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Subpart IVK
Chapter
54
Clinical – Pediatrics And Geriatrics
Pediatric Observation Medicine
at a Children’s Hospital
Aderonke Ojo, MBBS
Background
The concepts of observation medicine (OM) and
observation units (OUs) are not new; they continue to play a key role in patient flow in the
emergency de partments (EDs) to which they are
attached. In contrast to their longstanding role in
adult and community hospitals, pediatric OM and
pediatric OUs are relatively new. About 20% of
tertiary children’s hospitals have pediatric emergency department observation units (ED OUs)
(unpublished data from American College of
Emergency Physicians survey in 2007).
1
Adult
OUs provide optimal and safe care for patients
requiring a limited period of hospital care in
an outpatient setting; the same is true for the
pediatric OU.
As the name implies, pediatric OUs serve only
children (newborn to 18 or 21 years or younger,
depending on the policy of the unit). These
units may be designated as ED OUs (Emergency
Department Observation Units), RTUs (Rapid
Treatment Units), OUs or CDUs (Clinical Decision Units). These units are typically used to
manage or observe patients who require further
care for a definite and limited time period (usually
less than 24 hours), and also to determine who
may require inpatient admission du ring that
time.
2
Most pediatric OUs are located adjacent
or close to the ED. Some hospitals have specific
units on inpatient floors. A recent survey by Macy
et al. confirms that designated OUs are not
common in freestanding children’s hospitals, with
only 12 of 31 responding hospitals reporting
their presence. Even in the hospitals with established OUs, not all observation-status patients
are managed in these units; all 1 2 responding
hospitals reported providing some form of virtual observation care (in the ED or in an inpatient unit).
3
Most pediatric OUs are run by ED staff
members. However, they function as a separate
unit from the ED, serving the needs of other
services as well, in response to the limited and
decreasing number of inpatient beds.
What makes this an asset in a children’s hospital is the more complex and diversified conditions with which patients present. Following care
in the ED, most patients are discharged home;
15% or so are admitted; another 3– 4% are not
ready to be discharged, but are not sick enough to
be admitted.
4
Most of these patients (80–90%) are
eventually discharged home, but with both ED
and inpatient beds becoming increasingly scarce,
observing these children in either setting can
create problems. The end result is a vicious cycle:
limited inpatient beds, increased inpatient holding in the ED, prolonged ED wait times, increased
numbers of patients who leave without being
seen, and the list goes on. Pediatric ED OUs
benefit the hospitals they serve by reducing ED
overcrowding, limiting 1-day inpatient admissions, and improving patient satisfaction.
5
Types and Functions of a Pediatric OU
Pediatric medicine is inherently seasonal, with
influenza and other viruses peaking in the winter;
this may result in an OU that is full at certain
times of the year, while near empty at others. In
order to offset this problem, many pediatric OUs
have become hybridized. A hybrid unit is one that
serves other functions in addition to the primary
role of caring for the typical observation patients.
These functions may include administration of
scheduled blood transfusions, sleep studies, and
recovery from procedural sedation.
2
Some pediatric OUs also hold admitted patients awaiting
inpatient beds, particularly during the busier
winter season; however, this typically is not the
058
21:15:43
primary function of a pediatric OU. Carefully set
guidelines are needed to determine when holding
patients in the OU will be appropriate because it
can easily overtake the primary role of the OU.
Table 54.1 Texas Children’s Hospital – ED OU protocol for
patients with abdominal pain
Guidelines for the Management of Children
with Abdominal Pain in the ED OU
Time Frame:
Limit of 24 hours for observation and treatment
Appropriate Observation:
Stable vitals
Significant abdominal pain/right lower
quadrant pain
Ancillary signs and symptoms – anorexia,
nausea, vomiting, fever, leukocytosis
Normal or equivocal x-rays/ultrasounds or CT scans
Exclusion Criteria:
Unstable vitals (unexplained tachycardia, persistent
tachycardia despite resuscitation, tachycardia
> 95th percentile for age)
Surgical abdomen/presence of rebound
Immunocompromised patient
Confirmed appendicitis by diagnostic imaging
(patients with uncomplicated appendicitis
can be held in observation unit pending surgery)
Abnormal radiographic studies – except ileus
Observation Unit Intervention:
Keep NPO (nil per os) (nothing by mouth)_
Intravenous (IV) hydration
Serial exams and vital signs Q 4 hours
Repeat laboratory studies/radiographic study
Consultation
Disposition Criteria:
Home: symptomatic improvement of pain
Ability to take fluids/meds per os (PO)
(by mouth)
Deterioration
No improvement
Specific diagnosis identified requiring
hospitalization
Transfer to the pediatric intensive care
unit/pediatric clinical unit: Unstable vitals
(unexplained tachycardia, persistent tachycardia
despite resuscitation, tachycardia > 95th
percentile for age)
Table 54.2 Texas Children’s Hospital – ED OU protocol for
diabetic patients with hyperglycemia
Guidelines for the Management of Children with
Diabetes with Hyperglycemia in the ED OU
Timeframe:
Limit of 24 hours for observation and treatment
Appropriate Observation:
Acceptable/ stable vitals for age
No DKA (pH < 7.30, Plasma β-hydroxybutyrate
< 2.5 mMol/L, HCO3 < 15)
Initial evaluation completed in ED and formal
consultation of the endocrine service if
requested regardless of time of day
Joint agreement of the ED and Endocrine
Services for placement in the ED OU
ED OU and Endocrine Services can freely
communicate as the need arises
Exclusion Criteria:
DKA defined as glucose > 200 mg%, pH < 7.30,
HCO3 < 15, and plasma β-hydroxybutyrate
> 2.5 mMol/L
Unstable vital signs for age
Requiring subcutaneous insulin every 2 hours or
more frequently
Altered mental status/drowsiness
Requirement of an insulin drip
Plasma β-hydroxybutyrate > 2.5 mMol/L
New diagnosis of diabetes mellitus
Observation Unit Interventions:
Subcutaneous insulin
Serial exams
Finger stick blood glucose and β-hydroxybutyrate
every 2 hours or less frequently
IV hydration
IV glucose
Disposition
Home:
Acceptable/stable vitals for age
Tolerating PO fluids
β-hydroxybutyrate < 0.6 mM/L or trending near
0.6 mM/L
Reliable family
Clearance by Endocrine Services only required
for discharge if ED OU has questions or concerns.
Admit to the Hospital:
Persistent emesis
Unstable vitals for age
Persistent hypoglycemia
Persistent β-hydroxybutyrate > 2.5 mMol/L
Aderonke Ojo
058
21:15:43
Clinical Criteria
Pediatric OUs may have more diversified admission
diagnoses when compared to adult units. Common
diagnoses include gastroenteritis, asthma, croup,
cellulitis, abdominal pain, hyperbilirubinemia,
ingestions, seizures, urinary tract infections, renal
colic, headaches, and aseptic meningitis.
2,4,7–18
Patients are selected based on the guiding principles for all OUs: focused care goals and limited
duration and intensity of services, usually 24 hours
or less.
Management
Set standards (including admission criteria,
documentation, discharge criteria, length of stay,
chain of command and proper staffing) and
compliance with these standards is necessary to
thefunctionofapediatricOU.Priortoopening
such a unit, the goals and objectives of the unit
should be set based on the varying needs of the
institution. Most OUs in child ren’ shospitalsprimarily serve the ED, with other functions as
described earlier in the h ybrid units. A dmission
criteria are predetermined and are based on the
goals and objectives of the unit; discharge criteria and procedures are also predetermined (see
following p rotoc ol examples for abdominal pain
Table 54.1 and diabetes Table 54.2). The various
types of documentation and frequency of documentation should be clarified prior to setting up
a unit. The unit is a separate unit from the ED
and m ust therefore have appropriate staffing,
usually by acute care pediatric nurses. Physician
coverageisusuallyprovidedbyeitherEDphysicians (ideally separate from the physicians
actively working in the ED at any given time) or
hospitalists; some pediatric OUs have introduced
advanced practice clinicians (midlevel providers),
for example, nurse practitioners or physician
assistants who work under the guidance of the
supervising unit physician. Most children’sED
OUs are closed units; only ED physicians can place
patients in the unit.
Recurring utilization review is required to determine how well the unit is functioning, to prevent
inappropriate drain of ED healthcare resources, and
to limit health care costs. Data that should be collected for this purpose include total census, admission rates, and length of stay. An ongoing review of
patient care for adherence to standards and quality
of patient care follows admission rates, complaints,
unscheduled return visits within 48 hours of discharge from the OU, and adverse events including
codes and deaths in the unit.
4,12,19–23
OM in children’s hospitals typically operates
under the auspices of Emergency Medicine, rather
than as an independent section. It is currently not
included in the core pediatric curriculum for residents rotating in the ED, and so most of these
units have no pediatric residents/learners. However, this is not the case in non-ED settings,
especially on the inpatient floors.
Research in the field of OM is increasing, and
focuses primarily on resource utilization and the
various roles and functions of the OU. This
research continues to provide evidence that OUs
benefit the hospitals they serve, especially in the
areas of patient care, patient and physician satisfaction, ED flow, and cost-effectiveness. Future
areas of research include education of health care
providers about the various functions and benefits of OUs, standardization of outcome measures,
and quality improvement.
References
1. American College of
Emergency Physicians Survey.
Section of Observation
Medicine. Unpublished data
from 2007.
2. Zebrack M, Kadish H, Nelson
D. The pediatric hybrid
observation unit: Aanalysis of
6477 patients. Pediatrics 2005;
115: e535–e542.
3. Macy ML, Hall M, Shah SS,
et al. Differences in designation
of Observation care in US free
standing hospitals: are they
virtual or real. J Hospital Med
2011:1–7.
4. Graff LG. Observation
Medicine, 1st ed. Andover
Medical Publishers, 1993;6–40.
5. Rentz AC, Kadish HA, Nelson
DS. Physician satisfaction with
a pediatric observation unit
administered by Pediatric
Emergency physicians. Ped
Emerg Care 2004; 20:
430–432.
6. Greenberg RA, Dudley NC,
Rittichier KK. A reduction in
hospitalization, length of stay,
and hospital charges for croup
with the institution of a
pediatric observation unit. Am
J Emerg Med 2006; 24:
818–821.
7. Mace SE. Pediatric observation
medicine. Emerg Med Clin
North Am 2001; 19: 234–254.
8. Macy ML, Kim CS, Sasson C.
Pediatric observation units in
the United States: A systematic
Pediatric Observation Medicine at a Children’s Hospital
058
21:15:43
review. J Hospital Med 2010; 5:
172–182.
9. Mace SE, Graff L, Mikhail M,
et al. National survey of
observation units in the United
States. American Journal of
Emergency Medicine 2003; 21:
529–533.
10. AmWiley JF. Pediatric clinical
decision units: observation,
past present and future.
Clin Ped Emerg Med 2001; 2:
247–252.
11. Holsti M, Kadish HA, Sill BL,
et al. Pediatric closed head
injuries treated in an
observation unit. P Emerg Care
2005; 21: 639–644.
12. Mallory MD, Kadish H,
Zebrack M, et al. Use of
pediatric observation unit for
treatment of children with
Dehydration caused by
gastroenteritis. P Emerg Care
2006; 22: 1–6.
13. Alpern ER, Callello DP,
Windreich R, et al. Utilization
and unexpected hospitalization
rates of a pediatric emergency
department. P Emerg Care
2008: 24: 589–594.
14. Mierscier MJ, Nelson DS, Firth
SD, et al. Children with asthma
admitted to a pediatric
observation unit. P Emerg Care
2005; 21: 645–649.
15. Adekunle-Ojo AO,
Smithermann HF, Parker R,
et al. Managing well-appearing
neonates with
hyperbilirubinemia in the
emergency department
observation unit. P Emerg Care
2010; 26: 343–346.
16. Adekunle- Ojo AO, Craig AM,
Ma L, et al. Intussusception:
postreduction fasting is not
necessary to prevent
complications and recurrences
in the emergency department
observation unit. Pediatr Emerg
Care 2011; 27: 897–899.
17. Gouin S, Macarthur C, Parkkin
PC, et al. Effect of a Pediatric
observation unit on the rate of
hospitalization for asthma.
Ann Emerg Med 1997; 29(2):
218–222.
18. Scribano PV, Wiley JF 2nd,
Platt K. Use of an observation
unit by a pediatric emergency
department for common
pediatric illnesses. P Emerg
Care 2001; 17: 321–323.
19. Cooke MW, Higgins J, Kidd P.
Use of emergency observation
and assessment wards: a
systematic review. Emerg Med J
2003; 20: 138–142.
20. Burkhardt J, Peacock WF,
Emerman CL, et al. Predictors
of ED OU outcomes. Acad
Emerg Med 2005; 12: 869–874.
21. Mace SE. An analysis of patient
complaints in an observation
unit. Journal of Quality in
Clinical Practice 1998; 18(2):
151–158.
22. Mace SE. Resuscitations in an
observation unit. Journal of
Quality in Clinical Practice
1999; 19: 155–164.
23. Mace SE. Continuous quality
improvement for the clinical
decision unit. Journal for
Healthcare Quality 2004; 26(1):
29–36.
Aderonke Ojo
058
21:15:43
Subpart IVK
Chapter
55
Clinical – Pediatrics And Geriatrics
Geriatric Observation Medicine
Fredric M. Hustey, MD, FACEP
Background
The proportion of emergency department (ED)
visits made by older patients continues to increase
at a rate great er than any other demographic
group.
1
In the next 20 years, the proportion of
ED visits by patients age 65 years and older is
expected to rise from approximately 15% to 25%.
1
This is likely to contribute to an increased
proportion of older patients being cared for in
observation units (OUs). While older ED patients
tend to be more complex, require more ED
resources, and have longer ED stays,
2
in many
cases these patients may be appropriate for EDbased OU care.
Many of the conditions typically managed in
OUs are much more common in the older population.
3
Examples of these include chest pain
where myocardial infarction is being ruled out,
4
syncope, congestive heart failure, transient ischemic attack evaluation (TI A),
5
atrial fibrillation,
6
and COPD.3As the principles of evaluation and
management of these conditions are covered elsewhere in this text, this chapter will focus on conditions that are likely to have special issues more
unique to the geriatric population. These include
falls and injury, altered mental status, and acute
abdominal pain.
Discussion
Falls and Injury
ED visits for falls with related injuries are not
uncommon in older patients. While many of
these patients can be discharged home after a
thorough evaluation, some may warrant observation care.
Inclusions
Patients sustaining falls with subsequent injury
may have difficulty with mobility. Mobility may
be impaired by pain resulting from injury or by
the underlying etiology that precipitated the
fall (such as lightheadedness). (See Chapter 37
on Dizziness). All older patients for whom ED
discharge is being considered should be observed
arising and ambulating unless there is a contraindication to do so (such as known or suspected
hip fracture). In those patients for whom it
is unclear as to whether they will be able to
ambulate safely, observation admission may be
warranted.
In addition, there is a small subset of patients
for whom high-risk fractures cannot be ruled out
in the ED. The classic example of this is the older
patient with significant hip pain after a fall who
undergoes plain radiographs that do not show hip
or pelvic fracture. Patients who are discharged
with missed femoral neck fractures are at risk
for subsequent fracture displacement and avascular necrosis of the femoral head. It is important to
exclude hip fracture via obtaining advanced
imaging, ideally using MRI.
7
Given the difficulty
in obtaining an MRI in the time frame of an ED
visit, these patients may also be candidates for OU
admission.
Management and Outcome
For patients whose mobility is significantly
impaired due to pain, the goal is analgesia. While
intravenous opioids may be necessary initially,
ideally these should be weaned to oral medications that the patient can use at home. If pain is
well-controlled and the patient is able to ambulate
safely they may be subsequently discharged. In
some cases, however, additional resources may
be required that are not immediately available
in the ED. In these patients physical therapy
assessment and training with ambulatory assistive
devices (such as a walker) in the OU may be
beneficial. Home health care resources may
also be arranged with the assistance of social
services when necessary to prevent unne cessary
hospitalization.
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21:22:13
For patients whose mobility is significantly
impaired due to a simple underlying medical condition, the goal is to achieve gait stability through
condition management. Patients with orthostatic
instability may requi re an observation stay for
continued intravenous hydration and or medication adjustment. In some cases instability may be
due to dizziness caused by new medications or
medication interactions (especially those with
anticholinergic side effects). In patients who have
limited home support and are at risk for subsequent falls, medication adjustments can be made
followed by observation admission with reassessment of gait prior to discharge. Assessment by a
geriatric consult team, if available, may also be
beneficial for some patients in this group.
In cases where hip fracture is suspected but
not evident on initial radiographs, the goal is to
rule out fracture with advanced imaging while
attempts are made at pain control. Ideally this
should be done with MRI unless there is a contraindication.
7
Once hip fracture has been ruled out,
a trial of ambulation should be done with the use
of assistive devices as necessary. Patients who can
safely ambulate and have adequate pain control
may then be discharged to home.
Exclusions
Falls are often a symptom of another underlying
process or processes in older patients. Prior to
referring these patients to the OU a reasonably
thorough ED evaluation should be completed to
look for underlying precipitants. While some
simple abnormalities may be managed in the ED
or OU, more significant problems may require
hospital admission. In addition, patients with significant preexisting mobility impairment (such as
those already walker dependent), limited home
assistance (live alone and no home health care),
and persistent severe uncontrolled pain after reasonable attempts in the ED at pain management
may be unlikely to progress to an ambulatory
state in the appropriate time frame. These patients
may require hospital admission directly from the
ED. This is confirmed by a recent study that
found that fraility was a significant predictor of
inpatient admission from the observation unit.
8
Altered Mental Status
Altered mental status is common in older ED
patients.
9
Delirium is a medical emergency requiring
emergent evaluation.
10
Previous research has
shown that unrecognized delirium is an independent predictor of mortality in older patients
seen in EDs and discharged home without admission. In one study by Kakuma et al., there was
a statistically significant association between
unrecognized delirium and mortality after adjustment for age, sex, functional level, cognitive
status, comorbidity, and number of medications
for the first 6 months of follow-up (hazard ratio =
7.24, 95% CI = 1.62–32.35). This suggests that in
older patients with delirium who are being considered for discharge from the ED, placement in
observation status in an ED OU, may be a viable
alternative.
11
Inclusions
Most EDs admit patients with a new alteration in
mental status to the inpatient service, instead of
placing the patient in the OU. However, in view of
the onset of the “extended” or “complex” OU,
increasing numbers of geriatric patients, and ED
crowding, specific criteria for placing patients
with delirium into an OU may be considered.
(See Chapters 16 and 17 on extended or complex
observation.)
Patients with mild delirium who are being
considered for ED discharge may alternatively
benefit from evaluation in the ED OU in order
to clearly identify or confirm the cause of their
delirium and to institute treatment if possible. In
addition, patients with mild delirium with a single
simple etiology or etiologies identified that is/are
potentially correctable during a brief observation
stay may be ideal candidates for care in the ED
OU. Examples include new medication(s) causing
side effects or medication interactions, dehydration with or without mild electrolyte abnormality,
drug or alcohol intoxication, or otherwise uncomplicated infection (such as urinary tract).
10
It is important to remember that delirium is
often multifactorial in etiology,
10
and several
factors may need to be addressed during observation care. In addition, it is not uncommon for
patients with dementia to develop delirium due to
a single precipitant.
Management
Management is targeted towards treating precipitating factors. In patients with preexisting dementia it is often only a single additional precipitant
requiring management. In others there may be
Fredric M. Hustey
059
21:22:13
multiple issues requiring intervention. Correcting
dehydration and electrolyte deficiencies, treating
infection, and managing medications may all play
a role depending on the circumstances. Neuroi
maging is often not helpful unless other factors
point towards a primary central nervous system
(CNS) precipitant (such as new focal neurologic
deficits, recent head trauma, or concern for
CNS infection).
It is important to establish the patient’s base-
line mental status and to assess for resolution of
delirium prior to discharge to home. Family,
friends, or caregivers in frequent contact with
the patient should be interviewed to establish the
baseline. Current mental status is best assessed
using a structured tool for delirium such as the
Confusion Assessment Method (CAM)
12
or the
Confusion Assessment Method for the ICU
(CAM-ICU)
13
in addition to a standard short
mental status assessment such as the Short Orientation Memory Concentration Test.
14
Both of
these tests can be completed in a matter of minutes in the ED and in the OU.
15
Patients should be
assessed at a minimum while in the ED, upon
admission to the OU, and prior to considering
OU discharge. Those individuals who have
returned to baseline mental status may be considered for discharge to home. Assessment in the
OU by a geriatric consult team, if available, may
also be beneficial for some patients in this group.
Exclusions
Patients for whom safety cannot be maintained
due to behavioral issues (such as those who are
severely agitated or combative) should not be
referred for observation care. Severe CNS depression (obtundation due to hypoactive delirium) is
unlikely to resolve during an OU stay and should
be admitted elsewhere. Patients with severe metabolic abnormalities, potentially life-threatening
withdrawal syndromes (alcohol, benzodiazepines,
barbiturates), new focal neurologic deficits, and
those for whom CNS infection is suspected but
has not been ruled out are also not appropriate for
OU care.
Acute Abdominal Pain
Acute abdominal pain is a common presenting
complaint for older ED patients.
16–17
Those
patients with potentially life-threatening etiologies
pose a particular challenge in that the diagnosis is
often unclear in the ED. Older patients in general
tend to have more delayed presentations, vague
histories and physical examination findings, and
"unimpressive" laboratory results (such as a lack
of leukocytosis).
15
In nearly 1 in 5 older patients,
the initial ED diagnosis may be inaccurate.
15
Up to
14% of older patients discharged from the ED after
presenting with acute abdominal pain may return
to the ED within 2 weeks.
15
Given these challenges,
a subgroup of older patients with acute abdominal
pain may be suitable for care in the ED OU.
Inclusions
Patients who do not have a clear diagnosis at the
end of the ED evaluation, those who have moderately poor pain control, or those who are unable
to adequately tolerate per os (po) (by mouth) may
be candidates for observation-based care. In addition, patients who possess a lack of significant
history or physical examination findings but have
concerning, nonspecific laboratory findings (such
as a marked leukocytosis) may also warrant observation admission for serial abdominal examinations. As cholecystitis is often missed in this
population,
15
stable patients for whom the diagnosis is suspected but who have had an unremarkable ED workup (nondiagnostic ultrasonography
and unremarkable laboratory findings) may also
be candidates for observation. However, this decision should be made in consultation with a surgeon when there is a very high suspicion for the
diagnosis. Finally, patients for whom there is a
concern for acute coronary syndrome should
undergo observation to exclude this possibility if
this diagnosis is still in question at the end of the
ED visit.
Management
Management is tailored towards providing supportive and symptomatic treatment, careful
observation, and serial exami nations and further
testing as indicated based on the suspected differential diagnosis. For example, patients admitted
with a diagnosi s of gastroenteritis may receive
intravenous fluids, antiemetics, and antidiarrheals, while also undergoing serial abdominal
examinations and further diagnostic testing given
the relatively higher rate of misdiagnosis in this
subgroup. Patients with suspected cholecystitis
should receive symptomatic and supportive treatment as well as undergo a hepatobiliary iminodiacetic acid (HIDA) scan if the initial ultrasound
Geriatric Observation Medicine
059
21:22:13
was not diagnostic. Patients for whom there is
concern for acute coronary syndrome should
undergo rule out of myocardial infarction with
serial cardiac enzymes and electrocardiograms
(ECGs). For those patients in which myocardial
infarction has been ruled out, cardiac stress
testing may also be indicated prior to discharge
based on history, physical examination, and ECG
findings.
Exclusions
Patients who are hemodynamically unstable, have
serious acute metabolic derangements, or severe
uncontrolled pain after ED treatment are not candidates for OU admission. In addition, patients
for whom there is a very high suspicion for an
acute surgical process in spite of nondiagnostic
test results (e.g., those with guarding and rigidity
on abdominal examination or patients for whom
there is a very high suspicion for mesenteric
ischemia in spite of nondiagnostic abdominal
CT) should undergo surgical consultation in the
ED prior to any consideration of OU admission.
Summary
Older ED patients are typically more complex
than younger counterparts. While they generally
require more time and resources in the ED, in
many cases these patients can be appropriately
managed in the OU. While OUs have been caring
for older patients for years, there is a lack of
evidence regarding OU outcomes for these conditions that are more unique to the geriatric population. Nonetheless appropriate use of the OU in
these circumstances may help to avoid unnecessary hospital admissions and ED recidivism for
many of these patients.
References
1. Wilber ST, Gerson LW, Terrell
KM, et al. Geriatric emergency
medicine and the 2006 Institute
of Medicine reports from the
Committee on the Future of
Emergency Care in the U.S.
health system. Acad Emerg Med.
[Review]. 2006 Dec;13(12):
1345–1351.
2. Strange GR, Chen EH. Use of
emergency departments by
elder patients: a five-year
follow-up study. Acad Emerg
Med. [Research Support, NonU.S. Gov’t]. 1998 Dec;5(12):
1157–1162.
3. Ross MA, Compton S,
Richardson D, et al. The use
and effectiveness of an
emergency department
observation unit for elderly
patients. Ann Emerg Med.
[Comparative Study]. 2003
May;41(5):668–677.
4. Madsen TE, Bledsoe J, Bossart
P. Appropriately screened
geriatric chest pain patients in
an observation unit are not
admitted at a higher rate than
nongeriatric patients. Crit
Pathw Cardiol. [Comparative
Study]. 2008 Dec;7(4):
245–247.
5. Stead LG, Bellolio MF,
Suravaram S, et al. Evaluation
of transient ischemic attack in
an emergency department
observation unit. Neurocrit
Care. [Clinical Trial Research
Support, Non-U.S. Gov’t].
2009;10(2):204–208.
6. Decker WW, Smars PA,
Vaidyanathan L, et al.
A prospective, randomized trial
of an emergency department
observation unit for acute
onset atrial fibrillation. Ann
Emerg Med. [Randomized
Controlled Trial Research
Support, Non-U.S. Gov’t]. 2008
Oct;52(4):322–328.
7. Chana R, Noorani A, Ashwood
N, et al. The role of MRI in the
diagnosis of proximal femoral
fractures in the elderly.
Injury. 2006 Feb;37(2):
185–189.
8. Zradzinski MJ, Phelan MP,
Mace SE. Impact of fraility and
sociodemographic factors on
hospital admission froman
emeregency department
observation unit. AJMQ
(accepted for publication
2016).
9. Hustey FM, Meldon SW, Smith
MD, et al. The effect of mental
status screening on the care of
elderly emergency department
patients. Ann Emerg Med.
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10. Inouye SK. Delirium in older
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Geriatric Observation Medicine
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Subpart IVL
Chapter
56
Clinical – Surgical Evaluation
Abdominal Pain
Mark G. Moseley, MD, MHA, FACEP
Miles P. Hawley, MD, MBA
Introduction
Abdominal pain is a frequent cause of emergency
department (ED) visits. In many cases the etiology
for the pain is unclear. This often requires an
extensive evaluation in the ED. In other cases,
the cause of the abdominal pain is clear and the
focus of the visit is controlling the symptoms. In
some cases, patients with differentiated abdominal pain may be placed in the observation unit
(OU) for management of their symptoms.
Patients with differentiated abdominal pain
can be successfully treated in an OU. The primary
goal in this patient population is symp tom control. The cause of their symptoms should already
be established and therefore observation is used to
determine if symptoms can be controlled enough
for the patients to be discharged. In some cases,
these patients may require some diagnostic
workup to determine the severity of their illness.
For example, a patient with a Crohn’s disease flare
may require an abdominal CT scan to determine
the extent of the inflammation. A postendoscopy
patient with abdominal pain may require an
abdominal plain film to rule out perforation.
However, in general the primary focus should be
on symptom control.
Discussion
Patients frequently present to the ED with an
established source of abdominal pain. These
patients may include patients with chronic
abdominal pain, Crohn’s disease, ulcerative colitis, postoperative patients with known ileus and
postprocedural patients with abdominal pain.
Many of these patients have had frequent evaluations for their pain in the past. Postoperative and
postprocedural patients may have had recent
inpatient evaluations or outpatient testing. It is
unclear exactly how and where to treat this patient
population. There is very little evidence to guide
their management and no guidelines exist. There
is a subset of these patients who are appropriate for
observation care and respond well to treatment in
the observation unit. Patient selection is critical in
establishing which patients with differentiated
abdominal pain are appropriate for treatment in
the OU. It is very important to define clear goals
and discharge criteria in this population. Chronic
abdominal pain without new findings is probably
not appropriate for the OU. However, acute on
chronic abdominal pain (e.g., acute exacerbation
of chronic abdominal pain) may be appropriate. It
is very important that this patient population has
good outpatient follow-up. Patients with no previously established primary care physician or specialist may benefit from inpatient treatment rather
than observation. Symptoms often reoccur and
without good follow-up this population will end
up back in the ED.
Patient Criteria
Patient selection is critical in this population.
Patients must have a good chance of discharge
in 24 hours. In addition, there must be clear goals
and treatment objectives.
Inclusion Criteria
Patients who have a known cause of abdominal
pain and present with worsening of symptoms
may be appropriate for observation treatment.
These patients need to have a high likelihood
that the pain can be controlled in 24 hours.
Exclusion Criteria
Patients with a need for advanced testing such as
endoscopic retrograde cholangiopancreatography
(ERCP) to evaluate their abdominal pain usually
require inpatient admission. Patients with evidence
of a surgical abdomen require inpatient admission.
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