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Some patients have pressing psychosocial
problems but cannot be admitted to the
hospital because of restricted admission
criteria.
The intensity of serv ice needs should be limited
and consistent with the staffing pattern of the
ward. This must be matched to the patient’s illness severity (which should be limited to one
organ system).
The severity of illness must not preclude the
expectation that the patient will be discharged
within established time limits. A time limit is very
important and should be carefully monitored and
strictly enforced.
Observation Ward Admission Paperwork
An admission note must be generated, detailing:
time admitted in EC
time admitted into Observation Ward
the reason for observation
the working diagnosis (and other possible
conditions needing exclusion)
treatment plan and aims
outstanding special investigations results
a clearly defined end point for patient
disposition
Documentation (both medical and nursing)
should be simple and goal driven.
All medical and nursing notes, drug cardex,
fluid charts and observation sheets should
transfer with the patient from the EC to the
Observation Ward; they should continue until
discharge.
There should be standardized designed
cover sheets, which only get completed
upon admission to the EC obs ward.
Segments should be kept simple and aim
driven.
1) Time admitted in EC
2) Time admitted in Observation Ward
3) Working Diagnosis (and other possible
conditions needed exclusion)
4) Outstanding special investigations resu lts
5) Treatment plan and aims
Suggested Admission Criteria
The following are ideal for Observation Ward
admission:
Diagnostic evaluation of haemodynamically stable
patients with:
Abdominal pain
Chest pain with low probability of myocardial
infarction (following a diagnostic pathway)
Flank pain (evaluation and pain management
of suspected kidney stones)
Gastrointestinal bleeding (with no evidence of
ongoing bleeding)
Chest trauma (normal initial evaluation
and CXR)
Drug overdose (clinically stable)
Syncope (negative initial evaluation following
diagnostic pathway)
Nonpregnancy related vaginal bleeding
awaiting Ultrasound/Gynaecological
evaluation
Trauma patients with minor injuries but
significant mechanism of injury
Mixed alcohol intoxication and minor head
injury
Short-term therapy of patients with:
Allergic reactions
Asthma/COPD
Acute exacerbation of chronic congestive
cardiac failure
Dehydration
Hyperglycemia
Hypertensive urgencies
Selected infections (e.g., pyelonephritis,
cellulitis, pneumonia with low CURB score,
etc.)
Blood transfusion
Seizure disorders requiring anticonvulsant
loading or observation
Meeting psychosocial needs of patients with:
Acute alcohol withdrawal
Depression with ongoing suicide ideation
(with documented risk assessment; after
discussion with Psychiatry)
All patients remain the responsibility of the EC.
Patients who should not be admitted:
The following patients SHOULD NOT be accommodated in Observation Ward bed:
Heather Tuffin and LA Wallis
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21:38:10
Patients referred to, or admitted to, an
inpatient speciality
Psychiatric patients at any point of their
admission
Patients for planned surgery
Postoperative patients
Patients admitted from outpatient clinics,
awaiting an inpatient bed
South Africa
076
21:38:10
Subpart VIB
Chapter
72
International – Asia
Singapore
Malcolm Mahadevan, MD FRCS (A&E), MRCP (Int Med), FAMS
Chew Yian Chai, MD, MCEM, FAMS
Introduction
Origins
It was in 1998 and early 1999 after reading the
first edition of Observation Medicine by Louis
Graff that the author was first intro duced to the
concept of observation medicine. This concept
was presented and the possibility explored with
the hospital administration of setting up such
a unit at the National University Hospital Singapore. With their blessing an application for a
scholarship under the human manpower development award was made and obtained. The
author (MM) successfully completed a fellowship
program in Observation Medicine with Louis
G. Graff, MD, FACEP at the University of Connecticut Medical School in Hartford, Connecticut. Subsequently the first formal observation
medicine unit in Singapore was approved and
set up in 2004 at the National University Hospital, and was named Extended Diagnostic Treatment Unit (EDTU) as a pilot project.
Challenges
The hurdles initially encountered in setting up
and running the unit included reimbursement
for observable conditions, acceptance by the local
hospital as a recognized site for continued care, as
well as establishing its role and utility in a hospital
system. For reimbursement there needed to be
approval from the government that patients could
utilize their medical savings (called medisave).
When the first protocols were being written
there was consultation with relevant specialties
related to the observed conditions. Examples
included cardiology for chest pain patients to rule
out myocardial injury. Utilizing repeat enzyme
testing was done by our unit, but the investigation
for possible coronary artery or ischemia by treadmill stress test, dobutamine echo or technetium
sestamibi scan was done by the cardiology service.
There had to be a meeting of minds as well as
agreement for continuity of care.
Following the National University Hospital,
most of the major restructured government hospitals in Singapore started developing their own
observation units (OUs). Also fostering the growth
of observation medicine in Singapore, two
additional physicians from Singapore completed
fellowships in observation medicine in Cleveland,
Ohio in 2006–2007 with the editor of this textbook, Dr. Mace. To date, six major hospitals offer
formal observation services. As all OUs are in
various stages of their development, hospital-tohospital variation occurs in terms of size, number
of protocols available, staffing ratio, and extended
services available; however, they all work on the
same fundamentals of observation medicine and
are largely protocol driven.
The National University Hospital’s EDTU
started with 8 beds and 8 protocols. Over the
years, we have expanded to 16 beds, and we now
have 32 protocols in place. We are still continuously seeking improvement and refining our
workflows and processes. Table 72.1 lists the
protocols we have in place.
Guidelines on Concept, Staffing
OUs are generally housed adjacent to the emergency department (ED) and are staffed and run by
ED physicians. Rounds are made twice daily. The
staffing ratio of nurses to patients is kept at 1:5,
thus allowing close monitoring of patients. In our
current model of care, no provision for additional
physician staff has been fa ctored in for running
the OU. This has limited the size of the units and
placed some strain on manpower. Moving forward there should be better rationalization of
needed resources to enable more efficient safe
care delivery.
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21:38:15
Unique Features of Observation
Medicine in Singapore
Our protocols are evidence based as far as possible.
On occasion we have discovered that there is a
dearth of evidence available and this has led us to
push the boundaries through research and publication of observable conditions. One example
would be the management of primary spontaneous
pneumothorax. We initially placed a normal bore
chest drain utilizing open dissection with the drain
being connected to an underwater seal. This was a
painful procedure and patients experienced discomfort with the drain. We then tried aspirating
and observing but soon realized that many
reaccumulated their pneumothorax. We then went
on to utilize a small bore drain inserted with a
seldinger technique and aspirated the pneumothorax after we which we connected to an underwater seal and observed the patients over 24 hours.
This has proven to be much more favorable, with a
39% reduction in insertion of chest tubes; 65% of
our patients were manag ed with mini chest tubes
and 56% of those admitted to our OU were successfully discharged within 24 hours.
The utility of our abdominal pain protocol
allows us to observe those with moderate probability of appendicitis (Alvarado score) hence
minimizing unnecessary CT scans of the
abdomen.
Table 72.1 EDTU Protocols, National University Hospital
Diagnostic
Conditions
Therapeutic Conditions Diagnostic & Therapeutic Conditions
Appendicitis Atrial fibrillation Dehydration
Chest pain Anaphylaxis Dyspepsia
Pneumothorax – Apical and rim Headache
Asthma Seizure
Back pain Stable head injury
Blunt chest trauma Syncope
Cellulitis Vertigo/Dizziness
Colorectal conditions
Congestive heart failure
Chronic obstructive pulmonary disease
(COPD)
Dengue
Deep vein thrombosis
Gastroenteritis
Gastrointestinal bleeding
Hyperglycemia
Hypoglycemia
Pneumonia
Renal or ureteric colic
Toxic smoke inhalation
Transient Ischemic attack
Urinary tract infection/pyelonephritis
Vertebral compression fracture
Singapore
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21:38:15
Our asthma and COPD pathways involved the
input and assistance of inpatient nurses specially
trained to assess and follow up with these patients
at home. This helps us discharge our patients
safely with timely follow-up. The management
of our COPD patients presenting to the ED in
the EDTU is part of a continuum of care, which
includes early recognition in ED for noninvasive
ventilation (NIV) (which we initiate) and has
shown a mortality reduction from 11.8% to
1.7%. This decision is based on postth erapy arterial blood gas. If the initial pH is below 7.25 then
NIV is initiated. If the patient has a pH of greater
than 7.25 posttherapy and is deemed suitable for
EDTU care, then he or she is admitted to the
EDTU for further treatment and assessment.
The advent of observation medicine in Singapore has also greatly helped limit our inpatient
admissions. As many of our facilities like those in
other countries have access block issues with bed
limitations, it has helped us as part of the hospital
system to cope better.
What is the Role of Observation
Medicine in the Health System?
The introduction of observation medicine has
seen increased merits in the health care system.
A review of the statistics over the past 2 years
shows that on the average, 444 patients in a
month are placed in our OU, which amounts to
4% of our ED volume. Discharge rates are as high
as 82%. This has greatly helped to reduce overall
length of stay in the hospital, thus freeing up
more inpatient beds for the needy and sicker
patients. In addition, patients admitted to the
OU get earlier access to short-term specialized
services such as cardiac stress tests, gastroduodenoscopies, abdominal ultrasound, electroencephalograms, and doppler ultrasounds (to exclude
deep vein throm bosis). Early follow-up can be
arranged in our early access clinics called “Hot
Clinics.” All these improve the continuity of care
and translate to overall high-quality patient care
in a cost-effective environment.
References
1. Wilder JL, Ross MA, Ginde
AA. National Study of
Emergency Department
Observation Services. Acad
Emerg Med 2011 Sep; 18(9):
959–965.
2. Venkatesh AK, Geisler BP,
Gibson Chambers JJ, et al. Use
of Observation Care in US
Emergency Departments,
2001 to 2008. PloS One 2011;
6(9):e24326.
3. Baugh CW, Venkatesh AK,
Bohan JS. Emergency
Department Observation
Units. A clinical and financial
benefit for hospitals. Health
Care Manage Rev. 2011
Jan–Mar; 36(1):28–37.
4. Graff L, Mucci D, Radford MJ.
Decision to hospitalize:
Objective diagnosis-related
group criteria versus clinical
judgement. Ann Emerg Med
1988; 17:943–952.
5. Ng CW, Lim GH, McMaster F,
et al. Patient satisfaction in an
Observation Unit: the
Consumer Assessment of
Health Providers and Systems
Hospital Survey. Emerg Med J.
2009 Aug; 26(8):586–589.
6. American College of
Emergency Physicians.
Management of Observation
Units. Ann Emerg Med 1988;
17:1348–1352.
7. Realdi G, Giannini S, Floretto P,
et al. Diagnostic pathways of the
complex patients: rapid
intensive observationin an acute
medical unit. Intern Emerg Med
2011 Oct; 6 Suppl 1:85–92.
8. Graff LG, Radford MJ.
Formula for emergency
physician staffing. Ann Emerg
Med 1990; 8:194–199.
9. Observation Medicine
Guidelines 2009. Victorian
Government Department of
Human Services, Melbourne,
Australia.
10. Graff LG. The observation
patient in the DRG era. Am
J Emerg Med 1988; 6:93–103.
11. Neville L, Rowland RS. Short
stay unit solves emergency
overcrowding. Dimens Health
Serv 1983; 60:26–27.
12. Kellerman A, Andrulis A,
Hackman B. Hospital and
emergency medicine
department overcrowding.
Results of a National Survey.
Ann Emerg Med 1990; 19:447.
Malcolm Mahadevan and Chew Yian Chai
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21:38:15
Subpart VIC
Chapter
73
International – Australia/New Zealand
Australia
John Burke, FACEM
Introduction
Observation Medicine has become an essential
adjunct to emergency medicine practice in
Australasia, and dedicated Observation Wards
(OW) are now featured in the design of most
modern metropolitan hospitals. While their function may vary according to local flow models and
resource constraints, their common focus is the
rapid turnover of selected patient groups for the
purposes of admission avoidance and early discharge. Successful implementation requires not
only well-defined operational parameters but also
a clear understanding of how the unit contributes
to overall patient flow.
Australasian Model of Care
While many international authors endorse an
expanded role for observation facilities, the
Australasian OW is typically based in the emergency department (ED) and does not provide care
for inpatients under normal circumstances. It
may, however, coexist with short-stay units
governed by internal medicine departments
(Emergency Medical Units, Medical Assessment
and Planning Units, etc.) that focus upon more
complex inpatient services. The different responsibilities (and governance) of each of these units
need to be explicitly stated to avoid confusio n.
Australasian OWs target specific patient
groups whose care may be augmented by early
intensive workup and/or treatment that falls
within the resources and skill set of Emergency
Physicians (EPs). These include:
Undifferentiated presentations that may
benefit from serial examination and/or further
diagnostic studies;
Stable patients who require a brief period of
specific therapy prior to outpatient
management;
Vulnerable or socially disadvantaged patients
who require additional supports in place prior
to discharge.
Boarding inpatients are not a preferred category
of OW patients and the use of the OW as a
holding unit compromises the efficiency of the
main department. For similar reasons, patients
who clearly require admission for > 24 hours
are unlikely to benefit from interim care in the
OW and their presence reduces the functional
capacity of the unit.
Minimum Requirements
A sustained improvement in patient flow outcomes is dependent upon several key features:
Geographical proximity to the Emergency
Department, which provides all medical/
nursing/allied health personnel. This
maintains the emphasis on regular review and
early decision making with respect to
disposition. Provision for optimal staffing is
normally made in the main departmental
roster, which ensures that personnel are
competent to perform duties in all areas.
Admitting rights for specialist emergency
physicians who retain clinical responsibility
and provide regular review. If the patient stays
beyond the end of a staff specialist’s shift, case
knowledge is handed over to ED -based house
staff who maintain care on behalf of the
admitting doctor.
Strict inclusion/exclusion criteria to identify
suitable patients. Some departments are more
prescriptive than others in their approach to
patient selection. As mentioned earlier,
patients whose trajectory may be changed or
improved by OW admission should be
considered, while those with a high chance of
eventual admission should be referred directly
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21:39:32
to inpatient services, particularly those
requiring specialized beds.
Well-defined assessment/management
plans with clear end-points. Further workup
should address a specific differential
diagnosis and revolve around simple
binary decision points. Management should
be limited to a single clinical problem w ith
clearly documented therapies and discharge
criteria.
Priority access to diagnostic services such as
pathology and medical imaging. Larger
departments typically have co-located
radiology services and early reporting.
Priority referral to allied health services. Poor
mobility and a need for social supports are
significant predictors of failed discharge
planning.
A nominal time limit (usually 24 hours)
enforced by an unambiguous transfer policy.
Inpatient review on the wards traditionally
occurs during once-daily rounds, meaning
that the inpatient length of stay (IPLOS)
tends to be measured in whole days once the
patient leaves the ED. Not only does the OW
offer an alternative pathway measured in
hours, but it identifies and discharges
diagnostic groups that are not funded for
longer stays under activity-based business
models.
Consistent management guidelines for the most
common diagnostic groups, such as:
: Chest pain for investigation
: Asthma
: Renal colic
: Overdose
: Cellulitis
: Pyelonephritis
: Minor head injuries
: Migraine, etc.
Impact of Observation Wards
In 2000 Williams et al.1reported on the ability of
Australasian OWs to reduce total length of stay
for certain diagnostic-related groups (DRGs) by
reducing ward admissions (at the expense of a
greater number of short-stay admissions). Since
that time there have been few prospective interventional trials examining the utility of Australian
OWs. The implementation of OWs is frequently
part of a greater structural and operational
redesign that makes it difficult to control for
confounders.
Local experience supports the commonly held
international view that OWs may safely reduce
LOS and inappropriate admissions, while increasing staff and patient satisfaction. Areas of uncertainty in the literature include the ideal size/
capacity of an OW and the overall financial benefit of observation medicine across a range of economic conditions.
Observation Medicine Culture
In order for any short-stay unit to improve the
performance of a hospital, its beds must function
as more than simply additional capacity – they
must add something of value that is not available
further along the patient journey. In this case, the
advantage is discharge facilitation via frontloaded senior expertise. This opportunity is lost
by passively allowing boarding inpatients to be
“held” in the OW, a practice that demonstrates a
lack of understanding of hospital bed dynamics.
In addition to clinical support, the OW model
of care requires the advocacy of emergency physicians, who can demonstrate the value of observation medicine by way of example. A proactive
approach to patient selection and early discharge
will prevent the OW from becoming an easy
target during times of economic hardship or bed
shortage.
Case Study – Royal Brisbane and Women’s Hospital
Royal Brisbane & Women’s Hospital
Brisbane, Queensland.
Hospital
Bed capacity (no Pediatrics)
Emergency admissions
Average inpatient LOS
Total beds ~ 850 Acute overnight beds ~ 600
~24,000
5.5 days
John Burke
078
21:39:32
References
1. Williams A, Jelinek G, Rogers I,
et al. The effect of establishment
of an observation ward on
hospital admission profiles. Med
Journal Aust 2000; 173:411–414.
2. Ross M, Graff L.. Principles of
observation medicine. Emerg
Med Clin Nth Am 2001; 19(1)
1–17.
3. Williams, A. Emergency
department observation wards.
In: Cameron et al. (ed).
Textbook of Adult Emergency
Medicine. 2nd ed. Churchill
Livingstone; 2004. pp. 710–712.
4. Cooke MW, Higgins J, Kidd P.
Use of emergency observation
and assessment wards: a
systematic literature review.
Emerg Med J 2003;20:
138–142.
5. Chan T, Arendts G, Stevens M.
Variables that predict
admission to hospital from an
emergency department
observation unit. Emerg Med
Aust 2008; 20: 216–220.
6. Lucas BP, Kumapley R.
A hospitalist-run short-stay
unit: features that predict
length-of-stay and eventual
admission to traditional
inpatient services. J Hosp Med
2009; 4(5): 276–283.
7. Clinical Epidemiology & Health
Service Evaluation Unit.
Models of care to optimise
acute length of stay – Short
Stay/Observation Unit (SOU),
Medical Assessment and
Planning Unit (MAPU),
Emergency Medical Unit
(EMU). Available from
www.royalmelbourne
hospital.org/project-reports/
w1/i1017258/ (Accessed March
2016).
Emergency Department
Annual ED presentations (adult) 74,000
Admission rate 32%
ED capacity Resuscitation + Trauma bays: 7
Acute cubicles: 27
Fast-track bays: 5 + Physiotherapy
Observation Ward
Bed capacity 18 (unmonitored)
Staffing (0800–1800 hours) 5 nurses, 1 Registrar, 1 Staff Specialist
Admissions ED ~ 8000 per annum (LOS 10 hours)
Inpatient (boarding) ~ 500 per annum (LOS 23 hours)
Discharge rate (ED patients) 86%
Top 10 DRGs Chest pain (15%)
Abdominal pain
Cellulitis
Pyelonephritis
Acute back pain
Headache
Syncope
Pharmaceutical overdose
Asthma
Renal colic
Chest pain pathway (protocol) ~ 1,000 intermediate risk patients (negative biomarkers and ECG)
0.2% admitted with positive markers at 6 hours
5% admitted with positive exercise stress test (EST)
Novel patient groups Post-aspiration of spontaneous pneumothorax
Snake bite*
Decompression illness (hyperbaric unit)**
Hospital in the Nursing Home*** (HINH)
LOS = length of stay
* Snakebites that do not produce clinical or biochemical envenomation are observed in the OW during a 12-hour serial
assessment and treatment program. (See snakebite protocols in Chapters 84 and 85)
** The hyperbaric patients are managed by a visiting hyperbaric specialist who admits to the OW under a special arrangement
with the hospital.
*** HINH = Hospital in the Nursing Home is a locally developed hospital avoidance program that features a team of ED specialists
and registered nurses who liaise with local aged care facilities. Many presentations to the hospital ED can be avoided by way
of nursing home visits, phone consultation, or brief ED assessment and OW management.
Australia
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21:39:32
Subpart VIC
Chapter
74
International – Australia/New Zealand
New Zealand
Michael Ardagh, ONZM, PhD, MbChB, DCH, FACEM
National Overview
In 2009 overcrowding of New Zealand (NZ)
emergency departments (EDs) prompted the
adoption of an ED length of stay (LOS) target.
The ‘Shorter Stays in Emergency Departments’
health target is one of six government health
priorities and is defined as follows: 95% of
patients will be admitted, discharged or transferred from an ED within 6 hours of arrival.
Admission, in this regard, includes admission to
an ED observation unit (OU). Consequently the
target has encouraged, among many other things,
the development of observation units.
ED LOS targets have the potential for both
good and bad consequences and an explicit part
of pursuing the target in NZ has been to discourage mere compliance and instead to encourage
changes which result in genuine improvements
in the quality of patient care.
1
To this end a
government sponsored advisory group, composed
mostly of Emergency Physicians and Emergency
Nurses, published a document
2
intended to
encourage the development of these units for the
right reasons. Specifically it states:
ED Observation Units are valuable for reasons of
efficiency, patient comfort and patient safety.
They allow prolonged ED care in a more conducive
environment (on a bed rather than a stretcher,
with less light and noise than the main ED), and
provide an alternative to either the admission of
patients to inpatient wards or the discharge of
patients when it may be unsafe or inappropriate
to do so (e.g., elderly patients at night).
ThedocumentsuggestsEDOUsshould
allow a short period of observation, further
treatment, or further investigation by ED staff;
be for patients who are perceived to be safe for
discharge at the end of that period;
be for patients for whom there is usually no
need, or an unlikely need, for input from
inpatient staff/teams;
have a duration of stay of usually 6 to 8 hours,
but up to a maximum of 24 hours.
It recommends that governance of an ED OU,
including resourcing, clinical management, standards, policies, and procedures, should be with the
ED. It goes on to define the circumstances under
which admission to an ED OU should allow
“stopping the clock” for the purposes of the
Shorter Stays in the ED Health Target, emphasizing that units should have dedicated staffing,
patients in beds rather than trolleys, and be
located in a dedicated space. Consequently, observation medicine in NZ is not intended to be
practiced in corridors or waiting rooms.
In early 2010 just over half of NZ EDs, including most of the busiest EDs, had an OU and
others are planning them.
3
In 2011, there was a
major earthquake in Christchurch, NZ so populations changed and services were affected. We are
now back to a reasonably stable state with services
resurrected.
An Example
Christchurch Hospital serves a population of
approximately 500,000 for secondary care and
provides tertiary services for much of the population of the South Island of NZ. In 2010, the ED saw
72,000 presentations per annum. Currently, the
ED sees in excess of 90,000 presentations per
annum. It has approximately 40 treatment cubicles
and 10 beds in a co-located OU. It is unable to
“divert” to other local EDs, and historically has
been prone to considerable peaks of demand and
episodes of overcrowding.
Observation beds have been operational since
1995, and in their current form since 2008.
Patients will be admitted to the unit under the
following conditions, according to the guidelines
for admission to the unit:
The patient has an 80 to 90% perceived chance
of discharge home from the observation unit.
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The patient will likely be ready for discharge
within 8 hours of admission to the OU
(although with the expectation that they will
stay overnight if the 8 hours finishes late
at night).
The patient will be under the care of ED
doctors and is unlikely to need input from
inpatient specialist teams.
The patient should have one of the following
conditions (or some other condition
consistent with the above criteria, at the
discretion of the senior doctor on duty):
- Clinically stable drug overdose
- Clinically stable allergic reaction
- Minor head injury (GCS 14 or 15) without
skull fracture or significant other injuries
- Acute alcohol intoxication with no other
significant illness
- Social disposition problem
- Mild asthmatic promptly responsive to
treatment
- Single seizures with full recove ry
- Hypoglycemia with full recovery
An increasing trend has been the overnight admission of elderly after falls or other presentations not
mandating hospital admission. An emergency
physician does a round each morning and a multidisciplinary team, consisting of social workers,
physiotherapists and occupational therapists, helps
facilitate discharge. A Psychiatric Emergency Service assesses relevant patients routinely in the
mornings or on call. A community-based “acute
demand” team, funded by the District Health
Board to provide a number of admission avoidance/discharge facilitation services, often will assist
with discharge arrangements.
Like most NZ OUs there is not a specific
pathway for rule out acute coronary syndrome
(ACS) in low-risk chest pain. This function tends
to be undertaken in the ED itself, or after referral
to Cardiology or Internal Medicine inpatient services. However, an accelerated pathway for rule
out of ACS in low–risk patients is the subject of
research
4
and the practice is likely to change in
the future.
In the calendar yea r of 2010 the Christchurch
Hospital ED OU admitted 5,154 patients, with an
average LOS of 7.3 hours (median of 6 hours)
and a su bsequent a dmission rate to hospital of
15%. Common diagnostic groups included deliberate self-poisoning, alcohol intoxication (often
associated with assault or falls with head and /or
facial injuries), elderly with falls or syncope
(often associate d with soft tissue injury or minor
fractures limiti ng mobility), minor head injur ies,
gastroenteritis requiring intravenous rehydration, renal colic, back pain, and constipation.
Summary
Observation medicine in NZ is active, but variable
and evolving. Our challenge is to ensure that the
growth of this service is guided by good reason.
References
1. Ardagh M. How to achieve
New Zealand’s shorter stays in
emergency departments health
targets. New Zealand Medical
Journal. 11 June 2010, Vol. 123
No. 1316; ISSN 1175 8716
www.nzma.org.nz/journal/
123–1316/4152/ (Accessed
March 2016).
2. Streaming and the use of
Emergency Department
Observation Units and
Inpatient Assessment Units.
www.hiirc.org.nz/page/18737/
guidance-statement-edobervation-and-inpatient/?
tab=4179&contentType=451&
section=9088
3. Ardagh M, Tonkin G,
Possenniskie C. Improving
acute patient flow and
resolving emergency
department overcrowding in
New Zealand hospitals—the
major challenges and the
promising initiatives. New
Zealand Medical Journal.
14 October 2011, Vol. 124 No.
1344; ISSN 1175 8716
http://
journal.nzma.org.nz/journal/
124–1344/4904/
4. Than M, Cullen L, Reid CM,
et al. A 2-h diagnostic protocol
to assess patients with chest pain
symptoms in the Asia-Pacific
region (ASPECT): a prospective
observational validation study
The Lancet. 26 March 2011, Vol.
377, No. 9771, Pages 1077–1084.
DOI: 10.1016/S0140-6736(11)
60310-3.
New Zealand
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