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Subpart VID
Chapter
75
International – Europe
France
Said Laribi, MD, PhD
Patrick Plaisance, MD, PhD
Context
Over the past 30 years there has been on average a
30% decrease in the number of hospital beds in
France from 11.1 to 7.7 per 1,000 inhabitants.
1
On the other hand, the number of Emergency
Department (ED) visits has doubled over the past
decade.
2
As an example, we used to receive in our
ED 52,000 visits in 2005, in 2011 we received
72,000 patients. Around 15% of our ED patients
are hospitalized. In this context, it was decided
20 years ago to create ED observation units
(OUs).
3
The initial aim of these units was to
admit patients in need of 24-hour hospitalization
either to do additional examinations or for surveillance/monitoring. In our ED, ~12,000 patients
(17% of the total visits) had to be hospitalized in
2011; half of these patients were directly admitted
to the hospital, the other half being admitted to
our ED OU. Around 8% of our ED patients are
more than 75 years old with a lot of comorbidities. Another specificity of our ED is that it is
located in a poor neighborhood of Paris. As a
consequence, we receive many patients with social
difficulties: the homeless, elderly patients without
relatives, etc. Of note, most of the hospitals
change their conventional hospital beds into beds
that can be used only during weekdays, (e.g.
Monday morni ng to Friday evening) which
decreases the beds available to the EDs on weekends. In this context, we are going to describe the
daily organization of our ED OU.
Emergency Department Observation
Unit organization
Our ED OU is composed of 13 beds with a possible
extension to 21 beds. It is located nearby the ED.
Patients admitted to this unit are in need of
24-hour surveillance/monitoring before discharge,
for example: psychiatric patients, patients who
wait for some specialized tests (MRI, scan, etc.),
and patients who need an inpatient bed when no
bed is available in the hospital. Two nurses are
dedicated to this unit 24/7. From 9 a.m. to 6 p.m.
a senior emergency physician and a resident in
emergency medicine are dedicated to this area.
Their work consists of an evaluation of all patients
admitted to this unit the previous night, doing
further examinations if needed and deciding the
best destination for each patient: going back home,
admission to an in hospital unit, or direct transfer
to a rehabilitation center, etc.
To help physicians and nurses achieve this
task, we have during the weekdays two dedicated
social workers. They help in the social evaluation
of the patients, especially the elderly and homeless
people. With their help, it is sometimes possible
to send back home some elderly patients. Our
social workers organize a nurse visit to these
patients in their home followi ng discharge. They
also are in contact with rehabilitation centers. If a
patient is too weak to go back home but doesn’t
need to be hospitalized, our social workers prepare a request to the rehabilitation centers. This
system allows us to keep the beds in the hospital
for the patients who need further exploration.
We also have the possibility of calling during
weekdays a geriatric mobile unit composed of a
physician and a nurse specialized in geriatrics.
4
They help the emergency ph ysician in the evaluation of some elderly patients with a lot of co morbidities. Rarely, it is possible to send back home
some of these patients with a geriatrics consultation organized at follow-up.
Another issue that emergency physicians have
to face is the care of patients with a chronic
disease in need of palliative care. Over the last
years we have had to keep these patients in our
OU until their death because no palliative bed is
available.
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21:38:46
Ideally the ED OU should be empty at the
beginning of the night shift: from 6 p.m. to 9 a.m.
Due to the shortage in inpati ent beds and the
overcrowding of our ED, elderly patients with
comorbidities are admitted to the ED OU.
5
We
have on a regular basis four to five patients that
spend more than 24 hours in our OU.
During the night shift, from 6 p.m. to 9 a.m, if
needed, the nurses call the emergency physician
on shift to see a patient or review a test result.
Perspectives
Our main objective is to maintain the length of stay
in the OU below 48 hours. To achieve this goal, we
work closely with the other departments of our
hospital so everybody in the institution knows that
our ED needs around 35 beds every 24 hours. We
also work with the other departments on the kind of
patients that they would like to take charge of. The
principle difficulty that persists concerns the elderly
patientsin need of a bed in the geriatric department.
Due to the lack of beds in the geriatric department
and the resistance of some of the other departments
to take charge of these patients, these patients may
spend more than 48 hours in our OU, increasing the
mean length of stay.
To conclude, the ED OU has become, over the
last few years, a mandatory tool to manag e
patients in need of hospitalization. The presence
of a senior emergency physician seven days a
week allows hospitalizing only the patients that
really need it. The presence of social workers
appears to be very helpful in our ED OU.
References
1. World Health Organization:
www.who.int/en/ (Accessed
March 2016).
2. French Society for Emergency
Medicine (SFMU). [Situation
of emergency departments in
France] (French)
www.sfmu.org/documents/
ressources/referentiels/
Aval_SU_SFMU_mai_
2005.pdf (Accessed
March 2016).
3. French Society for Medicine
Emergency on establishment,
management, use and
evaluation of ED observation
units (French):
www.sfmu.org/
documents/ressources/
referentiels/ref_uhcd.pdf
(Accessed March 2016).
4. Ross MA, Compton S,
Richardson D, et al. The use
and effectiveness of an
emergency department
observation unit for elderly
patients. Annals of
Emergency Medicine May 2003;
41(5):668–677.
5. Pines JM, Weber JA, Alkemade
AJ, et al. International
Perspectives on Emergency
Department Crowding.
Acad Emerg Med 2011;
18:1358–1370.
France
080
21:38:46
Subpart VID
Chapter
76
International – Europe
Germany
Martin Mockel, MD, PhD, FESC, FAHA
Julia Searle, MD, Phd
Background and Clinical Need
In Germany, of the adults with medical emergencies seen in the emergency department (ED),
around 10% of patients present with a chief complaint of chest pain. Of these, around 50% suffer
from an acute coronary syndrome (ACS), and an
acute myocardial infarction (AMI) is diagnosed in
roughly 20% of the chest pain patients.
1
It is one
of the most difficult challenges in Emergency
Medicine (EM) to identify chest pain patients
with or in acute danger of an AMI and those with
non-ischemic or non-cardiac underlying problems. Both the incorrect classification into the
high-risk group and the erroneous classification
into a low-risk group can have negative consequences for the patient as well as for the health
care system. The rate of patients who were mistakenly discharged from the ED with myocardial
infarction has been described to lie between 2 and
8% and the risk-adjusted mortality ratio for those
who were not hospitalized, as compared with
those who were, was significantly increased.
2
On
the other hand, the admission of chest pain
patients without ACS puts patients at risk of
inappropriate or unnecessary diagnostic testing
and treatment with the potential for side effects
from the treatment, and poses a burden to costs
for the health care system and resource availability in the ED . In summary, chest pain is a frequent
symptom in adults seen with a medical emergency
in the ED and can be caused by life-threatening
diseases, which need to be diagnosed or excluded
in a standardized patient workup.
TheEstablishmentofChest Pain Units
in Germany
Aware of the diagnostic challenges, specialized
observation units (OUs) or chest pain centers
(CPCs) have been set up in the United States
and the United Kingdom since the beginning of
the 1990s and clinical trials hav e shown their great
success in improving patient outcome as well as
economic resource utilization.
3,4
In Germany, the first Chest Pain Units (CPUs)
were established at the beginning of this century. In
2008, the Task Force CPU of the German Society of
Cardiology (Deutsche Gesellschaft für Kardiologie
[DGK]) defined minimal standard criteria for a
CPU and started a certification campaign to avoid
misuse of the term Chest Pain Unit and to guarantee a systematic approach.
5
The DGK standards
follow the Guidelines of the DGK for patients with
ACS
6,7
and include requirements regarding the
premisesof the CPU, technical equipment, diagnostic measures, therapeutic strategies, cooperating
partners, and institutions as well as training and
professional experience of staff.
5
Since the first certification in October 2008, 141 German CPUs have
been certified by the DGK (as of April 17, 2012) and
numbers are rising. The DGK estimates that
250 CPUs are necessary to cover the whole German
territory.
8
The Concept of a CPU
The overall aim of a CPU is to optimize the
diagnostic and therapeutic management process
for patients with acute chest pain whilst meeting
the requirements of current evidence-based
guidelines to improve patient outcome and
reduce costs. Figure 76.1 illustrates the standardized flowchart of patient management in a CPU.
It is important to stress that the starting point for
standardized patient care involves all patients
with all kinds of chest pain and not only patients
with ACS. Optimized care is delivered not only to
patients with ACS but also to those with nonischemic and extra-cardiac chest pain.
Important prerequisites to fulfill certification
requirements are the availability of a cardiac
catheterization laboratory 24 hours a day, 365 days
a year, a minimum of four monitored beds, and
081
21:40:15
Figure 76.1 Chest Pain Unit:1Chest pain of all kinds,2Angina pectoris equivalents. This could be dyspnea, atypical chest pain, or
other symptoms and needs to be judged individually. Suspicion of myocardial ischemia can also result from a series of events, e.g.,
arrhythmogenic syncope in a patient with a high-risk cardiac profile,
3
There are three categories of patients: STEMI, NSTEMI and chest pain patients without elevated cardiac markers or acute ST elevation
MI. STEMI and NSTEMI patients are monitored in a Coronary Care Unit. Stable chest pain patients without elevated cardiac markers or
acute ST elevation MI can be monitored in a chest pain unit.
ST-elevation myocardial infarction (STEMI). Patients with STEMI are treated according to current guidelines. Standard operating
procedures (SOPs) need to be available at a Chest Pain Unit (CPU) and regular training needs to be available,
4
Non-ST-elevation myocardial infarction (NSTEMI). Patients with NSTEMI are treated according to the current guidelines. Standard
operating procedures (SOPs) need to be available at a CPU and regular training needs to be available.Patients with NSTEMI are
monitored on a Coronary Care Unit (Intensive or Intermediate Care Unit).
5
Patients with typical complaints but without elevated cardiac markers (troponin) and without ST-elevation are immediately
transferred to the CPU.
6
Patients with atypical complaints are in most cases transferred to the CPU, unless myocardial ischemia is
extremely unlikely.
7
Cardiac markers.
Patients on a CPU should be tested for cardiac markers, preferably troponin, at admission and again after 6–8 hours; earlier time
points (e.g., 3h) are discussed with high-sensitive troponin assays,
8
Imaging. In addition to serial ECG and marker testing, imaging
techniques can be indicated (e.g., echocardiography, cardiac MRI, cardiac CT, SPECT).
9
Risk factors. Risk factors in this sense are refractory angina, diabetes mellitus, TIMI risk score > 3 points or GRACE-score > 140.10Stress
test. After exclusion of acute myocardial infarction, a stress test should be performed as soon as possible (bicycle stress test, stress
echocardiography, stress myocardial scintigraphy, stress-MRI).
11
Differential diagnosis. In case of a negative evaluation the differential diagnoses of the acute chest pain should be sought. The most
important diagnoses are pulmonary embolism, peri/myocarditis, and aortic dissection. Orthopedic correlates and gastrointestinal
diseases can mostly be evaluated in the primary care system.
Germany
081
21:40:15
24-hour availability of a laboratory as well as
availability of echoc ardiography, but also the
availability of computerized tomography (CT),
magnetic resonance imaging (MRI) and abdominal ultrasound for the evaluation of differential
diagnoses.
An important aspect of the CPU concept is to
create an environment that assures the implementation of evidence-based guidelines. Minimal
standard criteria of the DGK include the introduction of algorithms for STEMI (divided in preannounced and unannounced STEMI), NSTEMI,
stable and unstable angina pectoris, hypertensive
crisis, acute pulmonary embolism, acute aortic
syndrome, cardiogenic shock and resuscitation;
and recommendations for implementation of
additional standard operating procedures (SOPs)
and algorithms. Additionally door-to-balloon
times for patients with STEMI and NSTEMI have
to meet the guideline requirements.
5
The Effect of CPUs in Germany
A number of secondary data analyses and clinical
trials have shown the beneficial effect on patient
outcome and on resource utilization of patient
management in a CPU as opposed to management in a conventional inpatient setting in the
United States and the United Kingdom.
3,4
The
same is true for results of the evaluation of CPUs
in Germany. The University of Mainz was the first
institution with a certified CPU in Germany.
They retrospectively evaluated patient outcome
(combined endpoint of AMI, stroke, or death of
all causes within 1 year after the initial event),
length of stay (LOS) as a criterion for economic
benefit, and patient satisfaction in their institution, using patient data from before and after the
implementation of their CPU.
9–11
In the population of all patients with chest pain, no outcome
benefit could be shown. In the group of patients
with ACS though, treatment in a conventional ED
showed a significantly increased hazard ratio for
the combined endpoint and a reduced 1-year survival rate as compared to CPU treatment.
9
Likewise, the LOS of patients with ACS was
significantly shorter after CPU implementation
10
and patient satisfaction was markedly increased.
11
Conclusion
The concept of specialized Chest Pain Units in
Germanyisrelativelynewandnation-widecoverage still has to be achieved. Due to the dedicated
work of a Task Force of the German Society of
Cardiology and the certification process, the term
CPU is standardized and institutions have to meet
at least defined “minimal” requirements. Evidence
for the prognostic and economic benefit of German
CPUs has only been evaluated by retrospective data
analysis in one center. Large prospective controlled
clinical trials as well as the evaluation of guideline
adherence, management processes, and the economic benefit considering all patients with of all
kinds of chest pain are still lacking.
References
1. Mockel M, Searle J, Muller R,
et al. Chief complaints in
medical emergencies: do they
relate to underlying disease and
outcome? The Charite
Emergency Medicine Study
(CHARITEM). Eur J Emerg
Med 2012 Mar 1.
2. Pope JH, Aufderheide TP,
Ruthazer R, et al. Missed
diagnoses of acute cardiac
ischemia in the emergency
department. N Engl J Med 2000
Apr 20;342(16):1163–1170.
3. Farkouh ME, Smars PA,
Reeder GS, et al. A clinical trial
of a chest-pain observation unit
for patients with unstable
angina. Chest Pain Evaluation
in the Emergency Room
(CHEER) Investigators. N Engl
J Med 1998 Dec 24;339
(26):1882–1888.
4. Goodacre S, Nicholl J, Dixon S,
et al. Randomised controlled
trial and economic evaluation
of a chest pain observation unit
compared with routine care.
BMJ 2004 Jan 31;328
(7434):254.
5. Breuckmann F, Post F,
Giannitsis E, et al. Kriterien der
Deutschen Gesellschaft für
Kardiologie - Herz- und
Kreislaufforschung für “ChestPain-Units.” Kardiologe 2008
Sep 15;5(2):389–394.
6. Hamm CW. Guidelines:
Acute coronary syndrome
(ACS). II: Acute coronary
syndrome with ST-elevation.
Z Kardiol 2004 Apr;93
(4):324–341.
7. Hamm CW. [Guidelines:
acute coronary syndrome
(ACS). 1: ACS without
persistent ST segment
elevations]. Z Kardiol 2004
Jan;93(1):72–90.
8. Post F, Gori T, Senges J, et al.
Establishment and progress of
the chest pain unit certification
process in Germany and the
local experiences of Mainz.
Eur Heart J 2012 Mar;33
(6):682–686.
Martin Mockel and Julia Searle
081
21:40:15
9. Keller T, Post F, Tzikas S, et al.
Improved outcome in acute
coronary syndrome by
establishing a chest pain unit.
Clin Res Cardiol 2010 Mar;99
(3):149–155.
10. Keller T, Tzikas S, Scheiba O,
et al. The length of hospital stay
in patients with acute coronary
syndrome is reduced by
establishing a chest pain unit.
Herz 2011 Nov 5.
11. Tzikas S, Keller T, Post F, et al.
Patient satisfaction in acute
coronary syndrome.
Improvement through the
establishmentofachestpainunit.
Herz 2010 Sep;35(6):403–409.
Germany
081
21:40:15
Subpart VID
Chapter
77
International – Europe
Italy
Salvatore Di Somma, MD, PhD
Angelo Ianni, MD
Cristina Bongiovanni, MD
Emergency Me dicine is deputed to manage clinical
emergencies. At the end of this process the Emergency Department (ED) physician must decide for
final disposition: discharge or admission of the
patient. Today, ED overcrowdin g represents an
international crisis that may negatively affect the
quality and the access to health care and is associated with an increased risk of in-hospital mortality.
1,2
As a consequence of the lack of available beds
for acute patient’s hospitalization and the request
of more appropriate disposition, the ED mission
gradually changed from “Adm it to work” to
“Work to admit,” indicating the need to create a
new filter system for hospital admission.
3
The Observation Unit (OU) is the third
opportunity for ED physicians to manage clinical
emergencies, in an attempt to avoid the risk of
inappropriate discharge and/or hospitalization. In
Italy, observation practice in the ED is very
common and widespread, trying to face off the
problem of the acute patient’s long length of stay
(LOS) in the ED, waiting for bed allocation, with
consequent ED overcrowding.
4
According to Ital-
ian data, about 5 to 7% of patients referring to the
Figure 77.1 The OU ward in Sant’Andrea Hospital, Rome.
082
21:38:55
ED need to be observed for a time, requiring care
for 24–36 hours. Of these patients, 10 to 30% are
admitted, while 70–90% are discharged.
3
In the 1990s, the National Health System
(NHS) decided to introduce in Italy observation
medicine (OM) with the aim to impact the inhospital admission decision. The Italian Presidential Decree of March 27, 1992, enhanced the
power of the local regional government in terms
of public health activities planning, funding,
organization, and control.
5,6
In this document
the activation of OU wards was introduced with
the objective to ameliorate the decision for hospital admission from the ED, through an intensive and accurate stabilization of critical patients
who often do not need subsequent hospitalization. This project was also coupled with a
common teaching process for ED doctors and
nurses to better use the emergency "evidence
based medicine." The proper use of the OU was
aimed to:
7
– decrease the risk of medical mistakes
through accelerated management protocols;
– reduce inappropriate admissions by
improving the function of the filter;
– decrease the LOS;
– reduce the costs;
– improve the quality of health care perceived
by users.
Systematic guidelines were created and approved
in the attempt to unify the different approach of
every Italian region to OU management.
8
These
guidelines introduced the all-comprehensive daily
reimbursement, of the value of 220€/patient not
hospitalized after observation in ED. Exceptions are
Region Lazio (275€),
9
Region Veneto (200€),10and
Region Alto Adige (250 €).
11
In the OU, accelerated management protocols
allow facilitation of patient care for selected ED
patients and improve the observation quality
of patients at “low risk” for complications.
8
The
Figure 77.2 Proposed protocol for the management of patient care in emergency department.
Italy
082
21:38:55
LOS in the OU is usually not less than 6 hours
and not more than 24 hours, with exceptions
arising from the requirements of individual
regions or specifically of the single hospital (maximum of 36 hours).
9,12,13,14
From a structural point of view, the OU is a
dedicated area nearby the ED, providing the same
services as the ED. In particular, there must be
available a fair and appropriate (relative to inpatient beds), highly skilled, dedicated, 24-hour nursing staff, support staff, and medical staff; a
laboratory providing for quick laboratory tests with
an ability to respond 24 hours a day; and a conventional radiology and CT scan for the total body
24 hours a day with real time x-ray responses. All
medical and nursing activity must be computerized
and available: there should be a clinical diary for
each patient and, at discharge time, a brief report
for the general practitioner must be delivered.
Depending on the existing buildings, there are
two different possible settings: 1) an open space
with center console and 2) individual rooms or
compartments with central monitoring. The
number of beds in each OU is identified using
two equivalent criteria: 2% of the hospital’s total
number of beds or one bed for every 4,000–8,000
access to the ED. A portion of beds, on average
50%, must be provided with hemodynamic and
respiratory monitoring with pulse oxime ter. Each
bed should be provided with oxygen and vacuum
and at least one monitor defibrillator/pacer, one
noninvasive mechanical ventilator able to work
in PSV/PEEP mode, one multidisciplinary ultrasound, one electrocardiograph, an appropriate
number of glucometers, of sphygmomanometers,
of infusion pumps, and intubation/CPR staff.
4
(See Chapter 5 on Obse rvation Unit Design)
In particular, in Sant’Andrea Hospital, Rome,
the OU is provided with eight multiparametric
monitored beds divided into two rooms with a
central core working station. (Figure 77.1) Pointof-care laboratory system test for blood gas
analysis, troponin, brain natriuretic peptide
(BNP), neutrophil gelatinase-associated lipo cain
(NGAL), and urine drug abuse test are included.
Furthermore, point-of-care ultrasound equipment are available for abdominal, thoracic, and
cardiac disease dedicated protocols. Moreover,
a continuous data recording system for EKG
(24 hours) is provided for detecting complex cardiac arrhythmias and an online system allows
the prompt visualization of x-ray imaging and
reports. Ventilator systems for invasi ve and noninvasive ventilation are also provided.
In Italy differences exist between each regional
state on the lists of diseases eligible for OU admission (but these lists should be interpreted with
some flexibility). In every hospital and in particular in every ED dedicated structure, appropriate
diagnostic and therapeutic paths are drawn for
more common diseases, shared after the appropriate contextualization as the Guidelines
National Plan also provides.
8
(Figure 77.2)
Table 77.1 shows the most suitable conditions
for short observation admission in Italy.
8,15
Each
region has its own protocols for the management
of the listed acute conditions.
Monitoring the quality of care and service
delivery differs in each region, and it is important
for the development and implementation of “best
practice” models for OM.
References
1. Bernstein SL. The effect of
emergency department
crowding on clinically oriented
outcomes. Acad Emerg
Med. 2009 January; 16(1):1–10.
2. Kellermann AL. Crisis in the
emergency department. N Engl
J Med. 2006 September 28; 355
(13):130.
3. Ministero della salute:
documento commissione
urgenza-emergenza 2008.
Available at: www.salute.gov.it/
imgs/C_17_pubblicazioni_
856_ulterioriallegati_ulterio
reallegato_0_alleg.pdf
(Accessed March 2016).
4. Hoot NR. Systematic review of
emergency department
crowding: causes, effects, and
solutions. Ann Emerg Med.
2008 August; 52(2):126–36.
0–3.
Table 77.1 Conditions for Admission to OU
Asthma, COPD
Abdominal pain
Renal colic
Chest pain
Infections
Allergic reactions
Dehydration
Headache
Deep vein
thrombosis
Hypertensive crisis
Paroxysmal atrial
fibrillation
Intoxication
Congestive heart failure
Syncope
Transient ischemic
attack
Vertigo
Minor head trauma
Minor chest trauma
Hypo/Hyperglycemia
Salvatore Di Somma, Angelo Ianni, and Cristina Bongiovanni
082
21:38:55
5. Il futuro della osservazione
breve intensiva e della
medicina d’urgenza. 2010.
Available at: www.simeu.it/
basilicata/convegnoOBi
Matera/2_Guerra.pdf
(Accessed March 2016).
6. DPR 27 marzo 1992. Atto di
indirizzo e coordinamento alle
Regioni per la determinazione
dei livelli di assistenza sanitaria
di emergenza pubblicato sulla
G.U. n. 76 del 31/3/92 - Serie
Generale. 1992. Available at:
www.118italia.net/lex/dpr
920327.asp (Accessed March
2016).
7. Section of Short Term
Observation Services (ACEP):
“Missed diagnosis and
observation”, vol. 12, no. 1,
April 2003; “Observation unit
lecture”, vol. 13, no. 1, August
2004.
8. Ministero della Sanità. Gazzetta
Ufficiale N. 114 Serie Generale
del 17 maggio1996. Atto di
intesa tra Stato e regioni di
approvazione delle linee guida
sul sistema di emergenza
sanitaria in applicazione del
decreto del Presidente della
Repubblica 27 marzo 1992.
1996. Available at:
www.ars.marche.it/nuovo/
html/download/emergenza/
documenti%20nazionali/
int1705_96.pdf (Accessed
March 2016).
9. DGR 946/07. Introduzione
dell’osservazione breve
intensiva nel Lazio dal
1 gennaio 2008: adempimento
rif.1.3.3 del piano di rientro
DGR 65/2007 e DGR 149/07.
2007. Available at:
www.asplazio.it/asp_online/
att_ospedaliera/files/file_
emergenza/obi/elenco_quadri_
clinici%20.pdf (Accessed
March 2016).
10. Borella L. L’osservazione breve
intensiva nel Veneto. Available
at: www.simeu.it/download/
convegni/2010/Relazioni_
Congresso_SIMEU_2010/
Osservazione%20Breve%
20Intensiva/L.Borella_
Osservazione%20Breve%
20Intensiva%20nel%20veneto
.Pps (Accessed March 2016).
11. Linee guida per la rilevazione
delle prestazioni di specialistica
ambulatoriale, di diagnostica
strumentale e di laboratorio
(SPA) e linee guida per la
procedura informativa “scheda
di pronto soccorso” (SPS)
Available at: www.provincia
.bz.it/oep/download/unione_
SPS_PS.pdf (Accessed March
2016).
12. Proposta di linea guida
istituzionale per l’Osservazione
Breve in Abruzzo. 2004.
Available at: www.simeu.it/
abruzzo/PropostaLineaGuida
.pdf (Accessed March 2016).
13. Piemonte e Valle d’Aosta.
Osservazione Breve. 2006.
Available at: www.simeu.it/
piemonte/OBI_finale.pdf
(Accessed March 2016).
14. DGR 24/05 Regione Emilia
Romagna. Approvazione linee
guida regionali per la funzione
di osservazione breve intensiva
(obi). Determinazione della
tariffa di remunerazione
dell’attivita’ e definizione degli
adempimenti correlati ai flussi
informativi. 2005. Available at:
http://utenti.unife.it/giampaolo
.garani/OssBreveIntensiva/
OssBreveIntensiva-24-2005ERevidenziato.doc (Accessed
March 2016).
15. ACEP (American College
Emergency Physicians) Policy
Statement: Management of
observation units, July 1994;
Emergency Department
Observation Unit, Oct 1998;
Management of observation
Units. Ann Em Med 1998, 17;
1348–1352; Emergency
Care Guidelines, September
1996.
Italy
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