The Role of The Role of Emergency Emergency Department Department Observation UnitsObservation UnitsSultana Qureshi, PGY-2Sultana Qureshi, PGY-2

Resident Grand RoundsResident Grand Rounds

December 14, 2006December 14, 2006

PrinciplesPrinciples(ACEP Guidelines)(ACEP Guidelines)66

The ultimate goal is to improve the quality of medical The ultimate goal is to improve the quality of medical care to patients through extended evaluation and care to patients through extended evaluation and treatment while reducing inappropriate admissions and treatment while reducing inappropriate admissions and health care costs.health care costs.

There should be a focused goal of the period of There should be a focused goal of the period of observation. observation.

The intensity of service needs should be limited and The intensity of service needs should be limited and consistent with the staffing pattern of the unit consistent with the staffing pattern of the unit

The patient's severity/complexity of illness should be The patient's severity/complexity of illness should be limited. limited.

The patient should have a clinical condition that is The patient should have a clinical condition that is appropriate for observation appropriate for observation

4 models of OUs4 models of OUs The scatter bed modelThe scatter bed model

The in-house defined unit modelThe in-house defined unit model

The linked emergency department The linked emergency department model (current)model (current)

Defined UnitDefined Unit Technically the ideal model, with unit Technically the ideal model, with unit

attached to EDattached to ED Under clinical and administrational Under clinical and administrational

management of EDmanagement of ED

EvolutionEvolution

Yealy. 1989Yealy. 198911 – First published on usefulness of OUs in – First published on usefulness of OUs in EDsEDs

Over past 15 years, interest and implementation have Over past 15 years, interest and implementation have significantly increased due to changes in healthcare significantly increased due to changes in healthcare (i.e. ED overcrowding)(i.e. ED overcrowding)

Observation Medicine official component of EM in Observation Medicine official component of EM in U.S.U.S.

1997 – “Core Content for emergency medicine” (AEM)1997 – “Core Content for emergency medicine” (AEM)22

2001 – “The model of the clinical practice of emergency 2001 – “The model of the clinical practice of emergency medicine” (AEM)medicine” (AEM)33

2001 - Observation Medicine Scope of Training Task Force of 2001 - Observation Medicine Scope of Training Task Force of ACEP, SAEM, RRC, EMRA, CORD, ABEMACEP, SAEM, RRC, EMRA, CORD, ABEM44

2003 – “A national survey of observation units in the 2003 – “A national survey of observation units in the United States”United States”55

AdvantagesAdvantages77

Allow additional time for patients requiring extensive Allow additional time for patients requiring extensive ED care before dischargeED care before discharge

Enlarge the emergency physician's scope of practice Enlarge the emergency physician's scope of practice

Unique educational experience for medical students Unique educational experience for medical students and residentsand residents

Reduce hospitalization and health care costs for Reduce hospitalization and health care costs for some patientssome patients

Allowing a more comfortable area for patient careAllowing a more comfortable area for patient care

More efficient flow of treatment planMore efficient flow of treatment plan

AdvantagesAdvantages77

Reduce the ED workload and improve patient flowReduce the ED workload and improve patient flow

60-90% of patients can be expected to be 60-90% of patients can be expected to be discharged home after their period of discharged home after their period of observationobservation8-168-16

Reduce physicians' liability risks by allowing more Reduce physicians' liability risks by allowing more time to make difficult disposition decisions and, time to make difficult disposition decisions and, thus, allow more certainty of diagnosis (better risk thus, allow more certainty of diagnosis (better risk management)management)

An avenue for clinical pathwaysAn avenue for clinical pathways

A marketing tool and improved public relationsA marketing tool and improved public relations

Potential benefitLevel of

evidence

Clinical outcome

Improved —

No change I4,5

Worsened —

Length of stay

Increased —

No change II-214

Decreased I8

Efficiency of emergency department

Improved II-19

No change —

Decreased —

Medical admissions Level of Level of EvidenceEvidence

Increased —

No change I,4 II-112

Reduced I,7 II-16

Cost effectiveness

More costly than routine care

—

Cost neutral —

Less costly than routine care

I5

Patient quality of life

Improved I5

No change —

Decreased —

Patient satisfaction

Higher satisfaction I5,16

Equivalent satisfaction

—

Lower satisfaction —

Daly et al. Short stay units and observation medicine: a systematic review. MJA 2003; 178 (11): 559-563

DisadvantagesDisadvantages77

Many advantages become disadvantages if Many advantages become disadvantages if OU not operated properlyOU not operated properly Decision making may be prolonged if no clearly Decision making may be prolonged if no clearly

defined admission criteria, policies and defined admission criteria, policies and proceduresprocedures

May become a "dumping area" May become a "dumping area"

An inadequately staffed facility will overload the An inadequately staffed facility will overload the emergency staffemergency staff

A carelessly organized and equipped unit will be A carelessly organized and equipped unit will be unacceptable to the patient because of unacceptable to the patient because of commotion and lack of privacycommotion and lack of privacy

Lack of continuity of care secondary to sign-overLack of continuity of care secondary to sign-over

Clinical Indications: Clinical Indications: ACEPACEP

Evaluation:Evaluation: Critical Critical Diagnostic SyndromesDiagnostic Syndromes Abdominal PainAbdominal Pain Chest pain (low Chest pain (low

probability of myocardial probability of myocardial infarction)infarction)

Flank pain, rule-out renal Flank pain, rule-out renal coliccolic

GI bleed with initial GI bleed with initial evaluationevaluation

Chest trauma, normal initial Chest trauma, normal initial evaluation and chest X-rayevaluation and chest X-ray

Abdominal trauma, normal Abdominal trauma, normal initial evaluation and lavageinitial evaluation and lavage

Drug overdose, clinically Drug overdose, clinically stablestable

Syncope, negative initial Syncope, negative initial evaluationevaluation

Vaginal bleeding, threatened Vaginal bleeding, threatened abortion abortion

Treatment:Treatment: Emergency Emergency ConditionsConditions Allergic reactionsAllergic reactions AsthmaAsthma Acute exacerbation of Acute exacerbation of

chronic CHFchronic CHF DehydrationDehydration Hyperglycemia, mild to Hyperglycemia, mild to

moderatemoderate Hypertensive urgenciesHypertensive urgencies Selected infections (e.g., Selected infections (e.g.,

pyelonephritis)pyelonephritis) Seizure disorder Seizure disorder

requiring anticonvulsant requiring anticonvulsant loadingloading

Sickle cell pain crisisSickle cell pain crisis Transfusion of blood Transfusion of blood

Table 1.   Common Diagnostic Syndromes in the Observation Unit, 1996 to 1998

Chest pain 1,629 (22) 1450 (89) 83–93

Asthma 1,409 (19) 1169 (83) 83–84

Cellulitis 625 (8) 531 (85) 83–87

Diabetic emergencies 518 (7) 466 (90) 87–94

Substance abuse‡ 425 (6) 370 (87) 82–87

Pneumonia 350 (5) 266 (76) 74–78

Abdominal pain 242 (3) 201 (83) 80–88

Pyelonephrits 216 (3) 156 (72) 69–74

Enteritis/dehydration 140 (2) 113 (81) 77–84

Congestive heart failure

124 (2) 98 (79) 62–83

Sickle cell crisis 123 (2) 82 (67) 59–76

Seizures 84 (1) 70 (83) 74–89

Other 1,622 (22) 1362 (84) 77–88

Total 7,507 (100) 6334 (85) 84–87

Admission to OU N (%) Discharge Home within 23 hours

Martinez et al. Am J EM. 2002;110(4):

Chest Pain Chest Pain Observation UnitsObservation Units

Mid 90s – numerous studies Mid 90s – numerous studies showing effectiveness of managing showing effectiveness of managing “low risk” cardiac chest pain in “low risk” cardiac chest pain in CPUCPU17-2317-23

A Clinical Trial of a Chest-Pain A Clinical Trial of a Chest-Pain Observation Unit for Patients with Observation Unit for Patients with

Unstable Angina (CHEER)Unstable Angina (CHEER)

Faroukh et al. NEJM. 1998; 339:1882-1888Faroukh et al. NEJM. 1998; 339:1882-1888 Prospectively, randomized intermediate Prospectively, randomized intermediate

risk patients to CPU vs hospital-risk patients to CPU vs hospital-admissionadmission

N=424N=424 Primary outcomes:Primary outcomes:

nonfatal myocardial infarctionnonfatal myocardial infarction deathdeath acute congestive heart failureacute congestive heart failure StrokeStroke out-of-hospital cardiac arrest out-of-hospital cardiac arrest

Cost comparisonCost comparison

Criticism

Validation of a Brief Observation Period Validation of a Brief Observation Period for Patients with Cocaine-Associated for Patients with Cocaine-Associated

Chest PainChest Pain

Weber et al. NEJM. 2003; 348:510-517Weber et al. NEJM. 2003; 348:510-517 Conclusion:Conclusion: Patients with cocaine-associated chest pain Patients with cocaine-associated chest pain

who do not have evidence of ischemia or cardiovascular who do not have evidence of ischemia or cardiovascular complications over a 9-to-12-hour period in a chest-pain complications over a 9-to-12-hour period in a chest-pain observation unit have a very low risk of death or myocardial observation unit have a very low risk of death or myocardial

infarction during the 30 days after discharge.infarction during the 30 days after discharge.

A comparison of emergency department A comparison of emergency department versus inhospital chest pain observation versus inhospital chest pain observation

units units Jagminas et al. Am J EM. 2005;23(2):Jagminas et al. Am J EM. 2005;23(2):

Retrospective Observational StudyRetrospective Observational Study Concluded EDOU more cost Concluded EDOU more cost

effective than IHOUeffective than IHOU

Chest Pain UnitChest Pain Unit

Current Cochrane Review of chest pain Current Cochrane Review of chest pain unit literature.unit literature.

BerwangerBerwanger, O, O; ; PolanczykPolanczyk, CA, CA; ; RositoRosito, GA, GA. . ““Chest pain observation units for patients Chest pain observation units for patients with symptoms suggestive of acute cardiac with symptoms suggestive of acute cardiac ischaemia.” Cochrane Database of ischaemia.” Cochrane Database of Systematic Reviews. 4, 2006.Systematic Reviews. 4, 2006.

ObjectivesObjectives Comparing chest pain observation units with Comparing chest pain observation units with

routine emergency care in terms of morbidity routine emergency care in terms of morbidity and mortalityand mortality

Also comparing rates of hospital stay, Also comparing rates of hospital stay, readmission, and cost benefitsreadmission, and cost benefits

In Summary,In Summary,

Most studied and validated clinical Most studied and validated clinical condition for OUcondition for OU

So, why don’t we have one…So, why don’t we have one… Ideally, would need to build one Ideally, would need to build one

adjacent to EDadjacent to ED Would require extended hours for Would require extended hours for

cardiology services (i.e. cardiology services (i.e. treadmill/chemical stress tests) to risk treadmill/chemical stress tests) to risk stratify and dischargestratify and discharge

OU Management of OU Management of Heart FailureHeart Failure

Diercks et al. Am J EM. May 2006 – Diercks et al. Am J EM. May 2006 – identification of factors to predict identification of factors to predict OU appropriate cohort (SBP< 160, OU appropriate cohort (SBP< 160, TnT neg)TnT neg)

Peacock et al. Ann EM. Jan 2006 – Peacock et al. Ann EM. Jan 2006 – revised management protocol for revised management protocol for HF in OUHF in OU

Peacock et al. Observation unit management of heart failure. Emerg Med Clin NA.2001;19(1)

Trauma Trauma ObservationObservation

Management of traumatically injured patients Management of traumatically injured patients in the emergency department observation unitin the emergency department observation unit

Welch R. Emerg Med Clin NA. 2001;19(2)Welch R. Emerg Med Clin NA. 2001;19(2)

Management of traumatically injured patients Management of traumatically injured patients in the emergency department observation unitin the emergency department observation unit

Welch R. Emerg Med Clin NA. 2001;19(2)Welch R. Emerg Med Clin NA. 2001;19(2)

Is it cost-effective?Is it cost-effective?

YesYes – by decreasing admission rate – by decreasing admission rate (most studies assume that for every (most studies assume that for every admission to the OU an admission is admission to the OU an admission is saved)saved)

Most studies assume that for admit to OU, an Most studies assume that for admit to OU, an inpatient admission is saved inpatient admission is saved

Most above prospective studies are diagnosis Most above prospective studies are diagnosis specificspecific

Undetermined yetUndetermined yet – need study on – need study on physician impression of suitability for physician impression of suitability for OU vs actual patient dispositionOU vs actual patient disposition

An evaluation of emergency physician selection An evaluation of emergency physician selection of observation unit patientsof observation unit patients

Crenshaw et al. AM J EM. 2006;24(3)Crenshaw et al. AM J EM. 2006;24(3)

An evaluation of emergency physician selection An evaluation of emergency physician selection of observation unit patientsof observation unit patients

Crenshaw et al. AM J EM. 2006;24(3)Crenshaw et al. AM J EM. 2006;24(3)

““Selection of patients for observation was Selection of patients for observation was suboptimal; emergency physicians routinely suboptimal; emergency physicians routinely identified patients as OU candidates who identified patients as OU candidates who were not ultimately admitted, and they were not ultimately admitted, and they missed many admitted patients who might missed many admitted patients who might have been appropriate OU candidates.”have been appropriate OU candidates.”

Conclusions and areas for Conclusions and areas for discussion…discussion…

Do OUs improve patient care, Do OUs improve patient care, outcomes?outcomes?

Are OUs cost-effective?Are OUs cost-effective?

Should CHR plan for OU in future?Should CHR plan for OU in future?

What is more cost-effective – having What is more cost-effective – having more ED acute beds vs building OU?more ED acute beds vs building OU?

Clinical Indications: Clinical Indications: ACEPACEP

Evaluation:Evaluation: Critical Critical Diagnostic SyndromesDiagnostic Syndromes Abdominal PainAbdominal Pain Chest pain (low Chest pain (low

probability of myocardial probability of myocardial infarction)infarction)

Flank pain, rule-out renal Flank pain, rule-out renal coliccolic

GI bleed with initial GI bleed with initial evaluationevaluation

Chest trauma, normal initial Chest trauma, normal initial evaluation and chest X-rayevaluation and chest X-ray

Abdominal trauma, normal Abdominal trauma, normal initial evaluation and lavageinitial evaluation and lavage

Drug overdose, clinically Drug overdose, clinically stablestable

Syncope, negative initial Syncope, negative initial evaluationevaluation

Vaginal bleeding, threatened Vaginal bleeding, threatened abortion abortion

Treatment:Treatment: Emergency Emergency ConditionsConditions Allergic reactionsAllergic reactions AsthmaAsthma Acute exacerbation of Acute exacerbation of

chronic CHFchronic CHF DehydrationDehydration Hyperglycemia, mild to Hyperglycemia, mild to

moderatemoderate Hypertensive urgenciesHypertensive urgencies Selected infections (e.g., Selected infections (e.g.,

pyelonephritis)pyelonephritis) Seizure disorder Seizure disorder

requiring anticonvulsant requiring anticonvulsant loadingloading

Sickle cell pain crisisSickle cell pain crisis Transfusion of blood Transfusion of blood