The Role of Emergency Department Observation Units

1. The Role of Emergency Department Observation Units Sultana Qureshi, PGY-2 Resident Grand Rounds December 14, 2006

2. Principles(ACEP Guidelines)6 • The ultimate goal is to improve the quality of medical care to patients through extended evaluation and treatment while reducing inappropriate admissions and health care costs. • There should be a focused goal of the period of observation. • The intensity of service needs should be limited and consistent with the staffing pattern of the unit • The patient's severity/complexity of illness should be limited. • The patient should have a clinical condition that is appropriate for observation

3. 4 models of OUs • The scatter bed model • The in-house defined unit model • The linked emergency department model (current) • Defined Unit • Technically the ideal model, with unit attached to ED • Under clinical and administrational management of ED

4. Evolution • Yealy. 19891 – First published on usefulness of OUs in EDs • Over past 15 years, interest and implementation have significantly increased due to changes in healthcare (i.e. ED overcrowding) • Observation Medicine official component of EM in U.S. • 1997 – “Core Content for emergency medicine” (AEM)2 • 2001 – “The model of the clinical practice of emergency medicine” (AEM)3 • 2001 - Observation Medicine Scope of Training Task Force of ACEP, SAEM, RRC, EMRA, CORD, ABEM4 • 2003 – “A national survey of observation units in the United States”5

5. Advantages7 • Allow additional time for patients requiring extensive ED care before discharge • Enlarge the emergency physician's scope of practice • Unique educational experience for medical students and residents • Reduce hospitalization and health care costs for some patients • Allowing a more comfortable area for patient care • More efficient flow of treatment plan

6. Advantages7 • Reduce the ED workload and improve patient flow • 60-90% of patients can be expected to be discharged home after their period of observation8-16 • Reduce physicians' liability risks by allowing more time to make difficult disposition decisions and, thus, allow more certainty of diagnosis (better risk management) • An avenue for clinical pathways • A marketing tool and improved public relations

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

8. Disadvantages7 • Many advantages become disadvantages if OU not operated properly • Decision making may be prolonged if no clearly defined admission criteria, policies and procedures • May become a "dumping area" • An inadequately staffed facility will overload the emergency staff • A carelessly organized and equipped unit will be unacceptable to the patient because of commotion and lack of privacy • Lack of continuity of care secondary to sign-over

9. Evaluation: Critical Diagnostic Syndromes Abdominal Pain Chest pain (low probability of myocardial infarction) Flank pain, rule-out renal colic GI bleed with initial evaluation Chest trauma, normal initial evaluation and chest X-ray Abdominal trauma, normal initial evaluation and lavage Drug overdose, clinically stable Syncope, negative initial evaluation Vaginal bleeding, threatened abortion Treatment: Emergency Conditions Allergic reactions Asthma Acute exacerbation of chronic CHF Dehydration Hyperglycemia, mild to moderate Hypertensive urgencies Selected infections (e.g., pyelonephritis) Seizure disorder requiring anticonvulsant loading Sickle cell pain crisis Transfusion of blood Clinical Indications: ACEP

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

11. Chest Pain Observation Units

12. Mid 90s – numerous studies showing effectiveness of managing “low risk” cardiac chest pain in CPU17-23

13. A Clinical Trial of a Chest-Pain Observation Unit for Patients with Unstable Angina (CHEER)Faroukh et al. NEJM. 1998; 339:1882-1888 • Prospectively, randomized intermediate risk patients to CPU vs hospital-admission • N=424 • Primary outcomes: • nonfatal myocardial infarction • death • acute congestive heart failure • Stroke • out-of-hospital cardiac arrest • Cost comparison

15. Criticism

16. Validation of a Brief Observation Period for Patients with Cocaine-Associated Chest PainWeber et al. NEJM. 2003; 348:510-517 • Conclusion: Patients with cocaine-associated chest pain who do not have evidence of ischemia or cardiovascular complications over a 9-to-12-hour period in a chest-pain observation unit have a very low risk of death or myocardial infarction during the 30 days after discharge.

17. A comparison of emergency department versus inhospital chest pain observation units Jagminas et al. Am J EM. 2005;23(2): • Retrospective Observational Study • Concluded EDOU more cost effective than IHOU

18. Chest Pain Unit • Current Cochrane Review of chest pain unit literature. • Berwanger, O; Polanczyk, CA; Rosito, GA. “Chest pain observation units for patients with symptoms suggestive of acute cardiac ischaemia.” Cochrane Database of Systematic Reviews. 4, 2006. • Objectives • Comparing chest pain observation units with routine emergency care in terms of morbidity and mortality • Also comparing rates of hospital stay, readmission, and cost benefits

19. In Summary, • Most studied and validated clinical condition for OU • So, why don’t we have one… • Ideally, would need to build one adjacent to ED • Would require extended hours for cardiology services (i.e. treadmill/chemical stress tests) to risk stratify and discharge

20. OU Management of Heart Failure

21. Diercks et al. Am J EM. May 2006 – identification of factors to predict OU appropriate cohort (SBP< 160, TnT neg) • Peacock et al. Ann EM. Jan 2006 – revised management protocol for HF in OU

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

23. Trauma Observation

24. Management of traumatically injured patients in the emergency department observation unitWelch R. Emerg Med Clin NA. 2001;19(2)

25. Management of traumatically injured patients in the emergency department observation unitWelch R. Emerg Med Clin NA. 2001;19(2)

26. Is it cost-effective? • Yes – by decreasing admission rate (most studies assume that for every admission to the OU an admission is saved) • Most studies assume that for admit to OU, an inpatient admission is saved • Most above prospective studies are diagnosis specific • Undetermined yet – need study on physician impression of suitability for OU vs actual patient disposition

27. An evaluation of emergency physician selection of observation unit patientsCrenshaw et al. AM J EM. 2006;24(3)

28. An evaluation of emergency physician selection of observation unit patientsCrenshaw et al. AM J EM. 2006;24(3) • “Selection of patients for observation was suboptimal; emergency physicians routinely identified patients as OU candidates who were not ultimately admitted, and they missed many admitted patients who might have been appropriate OU candidates.”

29. Conclusions and areas for discussion… • Do OUs improve patient care, outcomes? • Are OUs cost-effective? • Should CHR plan for OU in future? • What is more cost-effective – having more ED acute beds vs building OU?

30. Evaluation: Critical Diagnostic Syndromes Abdominal Pain Chest pain (low probability of myocardial infarction) Flank pain, rule-out renal colic GI bleed with initial evaluation Chest trauma, normal initial evaluation and chest X-ray Abdominal trauma, normal initial evaluation and lavage Drug overdose, clinically stable Syncope, negative initial evaluation Vaginal bleeding, threatened abortion Treatment: Emergency Conditions Allergic reactions Asthma Acute exacerbation of chronic CHF Dehydration Hyperglycemia, mild to moderate Hypertensive urgencies Selected infections (e.g., pyelonephritis) Seizure disorder requiring anticonvulsant loading Sickle cell pain crisis Transfusion of blood Clinical Indications: ACEP