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Subpart VID
Chapter
78
International – Europe
United Kingdom
Louella Vaughan, MBBS, MPhil, DPhil, FRACP
Dylan Jenkins, MBBS
Emergency Medicine (EM) services in the United
Kingdom (UK) have supported high-quality
Observation Medicine (OM) for many years.
However, the context of OM is internationally
unique, with UK Emergency Departments (EDs)
being subject to complex national performance
targets and the recent development of Acute
Medicine as a subspecialty branch of General
Medicine that deals solely with the first 12–72 hours
of care of the medically unwell patient (see
Chapter 21 Acute Medicine in the United Kingdom,
Chapter 16 Extended and Complex Observation and
Chapter 17 Extended Observation Services). This
chapter will provide a brief overview of EM in the
UK and describe the development of a new model
of care.
Overview
The structure and functioning of EDs in the UK
has been heavily influenced over the past decade
by the need to meet governmental performance
targets.
1
The ‘four hour rule’ was introduced in
2003/2004 and this mandated that 98% of patients
presenting to an ED must be seen, treated, and
then admitted or discharged in under 4 hours. As
a result, many EDs have ED-led Observation
Units (OUs) or Clinical Decision Units (CD Us).
However, the development of Acute Medicine
(AM) as a new specialty in the UK (see Chapter 21) has meant the task of Observational Medicine varies from hospital to hosp ital and is
dictated by local circumstances.
2
Decisions about
which area is most appropriate for any given
patient tends to be determined by considerations
regarding patient safety, rather than by given condition. Given that many EDs in the UK remain
relatively understaffed,
3
OUs and CDUs have
tended to be small and to take very well-defined
groups of low-risk patients.
St Thomas’ Hospital has one of the busiest
EDs in the UK, seeing about 170,000 patients each
year. The ED incorporates a 24-bed space, immediately adjacent to the main department. In the
past, this space was used as a CDU, which utilized
protocols to manage a range of diseases for
periods of up to 72 hours. Although the CDU
offered a high standard of care, its smooth functioning was often challenged by the demands of
the 4-hour target, with the CDU seen as an option
to avoid patients “breaching” their ED length
of stay target. This problem was compounded
by the relatively strict criteria for entry to the
unit mandated by the protocols, resulting in the
CDU being relatively underutilized or inappropriately utilized at times when bed demand was
otherwise high.
In July 2012, the model of care was changed,
with a focus on Goal Directed Outcomes (GDO),
for both admission and discharge. Eight beds
within the new Emergency Medical Unit (EMU)
are now dedicated to Goal Directed Therapy,
with the remainder for rapid Goal Directed Discharge. The approach within the EMU is multidisciplinary, with the EMU coordinating whatever
aspects of care are required to facilitate discharge.
Patients with conditi ons/ presentations that can
be assigned to a clear investigative or management pathway are identified as early as possible
within the main ED and are ideally referred to
the EMU within 2 hours. Although there are no
longer any rigid criteria for admission, patients
with low/intermediate risk chest pain, possible
pulmonary embolism, renal colic, pyelonephritis,
and biliary colic represent conditions where
expected outcomes and parameters for safe and
effective care are clear to both Emergency and
Speciality staff. The Goal Directed Therapy area
of the unit has monitored beds and will accept
more complex patients for stabilization before
inter-hospital transfer (certain specialities are
located on a second hospital site), admission to a
hospital ward, or discharge home. (See Chapter 16
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Extended and Complex Observation and Chapter 17 Extended Observation.) In all cases, the
aim is for the patient to have a stay of less than
12 hours.
The care of patients with sickle cell disease is
particularly well developed and suited to the ethos
of the new unit. Care is aimed at normalizing
physiology, reducing pain, and investigating to
exclude treatable precipitants of the crisis and/or
sinister complications (such as embolism). All
patients with sickle cell who regularly attend the
main ED have individualized care plans and are
managed in conjunction with the Hematology
Team and the dedicated Sickle Cell Nurse. This
substantially reduces the time that these patients
spend in the main department, improves their pain
management, and facilitates their early discharge.
The care plans and cooperative approach to management is being used as a model to develop services for other patient groups with relapsing
disease, such as inflammatory bowel disease, who
would usually be managed on a hospital ward.
Although there are no strict admission criteria, the EMU does not accept children (under
16 years) or violent/aggressive patients. For
patients between the ages of 16 and 18, suitability
depends on the individual patient and presenting
condition. Psychiatric patients are occasionally
accepted, although there must be a clear plan for
the patient’s management. (See Chapter 60 Psychiatric Patients.) The EMU will accept pregnant
patients under 20 weeks; patients over 20 weeks
go directly to obstetrics. (See Chapter 52 Hyperemesis Gravidarum.) The unit no longer accepts
patients from the main ED who are awaiting beds
in the hospital in order to avoid breaching performance targets.
The shift from the CDU to the EMU model of
care was accompanied by an increase in both
medical and nursing staff. There are two 12.5
hour long nursing shifts, with seven registered
nurses (RNs) during the day and six RNs and
one health care assistant (HCA) at night. There
are four junior (PGY2-3) and middle grade
(PGY4-8) doctors covering staggered shifts from
08:00 to 24:00 hours. Overnight, the unit has a
single junior doctor covering, supported by the
middle grade doctors in the main ED. There is a
consultant on the floor from 08:00 to 18:00 hours,
who conducts three ward rounds per day and
is responsible for the gateke eping of the EMU
during the day. There is an emphasis on the
maintenance of an appropriately high level of
skills-mix on the EMU at all times, with an intensive program of education focused on patient
safety and advanced skills. To facilitate the crossdisciplinary approach and support education, it is
intended that nursing staff will rotate with staff
from the main ED, as well as the Acute Medical
Admission Wards. The EMU has its own clerical
staff 12 hours per day.
The EMU is supported by excellent access to
diagnostics and support services. The main ED
hosts its own dedicated CT scanner and all EMU
requests are considered urgent. Further, scans for
certain conditions, such as possible head injury or
renal colic, can be approved by the senior radiographers, who are present permanently within the
department. The EMU is able to access the ED
pathology laboratory for rapid blood results and
also has its own point of care biomarker analyser
for troponins and brain natriuretic peptide
(BNPs). The EMU is visited twice daily by support outreach teams, including those from the
Respiratory and Elderly Care departments, and
these teams can be accessed quickly at other times.
The co-location of the Acute Physician service
and a surgical registrar (PGY4-8) within the main
ED means that advice from specialist services can
be quickly obtained. Medically unwell patients
can be referred from the EMU into a series of
“Hot Clinics” (e.g., General Medicine, Returning
Traveler, Falls/Syncope, Acute Chest Pain, etc.)
for review within 2–10 days of discharge, ensuring
robust patient follow-up.
Outcomes
The design and the increased staffing levels
resulted in rapid improvement in departmental
performance. The flow through the department
has increased from 15–20 patients per day to
30–35 patients per day, managing 40–45 patients
on days of high demand. The performance of the
main department has improved, with the department now consistently able to meet complex governmental targets and a substantial decrease on
the level of “access block” and overcrowding
within the department. The EMU also has positively impacted on the rest of the hospital, with
reductions in admissions by 15–20 patients per
day (i.e., 15–20%). Safety on the EMU has been
United Kingdom
083
21:38:53
improved, with a reduction in clinical incidents,
despite more and sicker patients being admitted.
Conclusion
The CDU at St Thomas’ functioned for many
years as a place to deliver effective and safe protocolized care. The shift from the CDU to EMU
model of care, with a focus on patient physiology
and multidisciplinary input, has resulted in better
care being delivered to a wider spectrum of
patients and considerable improvement in departmental and hospital performance.
References
1. Mason S. United Kingdom experiences of
evaluating performance and quality in
Emergency Medicine. Acad Emerg Med 2011;
18:1234–1238.
2. Goodacre SW. Role of short stay observation
ward in accident and emergency departments in
the United Kingdom. J Accid Emerg Med 1998;
15:26–30.
3. Paw RC. Emergency department staffing in
England and Wales, April 2007, Emerg Med J 2008;
25:420–423.
Louella Vaughan and Dylan Jenkins
083
21:38:53
Subpart VIE
Chapter
79
International – South America
Colombia
Carlos-Hernan Camargo-Mila, MD, EAES, ACEP
Observation Medicine at Fundacion
Cardio Infantil Emergency
Department
Fundacion Cardio Infantil Institute of Cardiology
is one of the main high-complexity teaching hospitals in Bogotá D.C. (Colombia, South America)
and a national and regional research and referral
center for Cardiology and Cardiovascular Surgery, Transplant Medicine, and Neurosciences. It
is a nonprofit private foundation.
Our Emergency Department (ED) provides
care to 110,000 patients a year, with an adult/pediatric ratio of 1.9 to 1. Initially, each patient comes in
contact with the Emergency Advisor (Nursing
Technician) who makes a quick visual assessment
and collects initial demographic data if the patient’s
condition allows it. The critically ill patients (Triage
1 and 2)
1
are treated immediately either in the
resuscitation room or in the Observation Unit
(OU). Stable patients arriving by ambulance
(Triage 3) are also treated directly in the OU. The
Emergency Advisor completes the initial assessment of walking patients (Triage 3, 4, and 5)
1
with a rapid interrogation and directs them to the
waiting room. From there, patients are called to
Triage consultation where they are assessed by a
General Physician. After this, with an initial diagnostic impression, part of the patients classified
Triage 4 or 5 are redirected to Priority Care Centers
(lower-complexity centers outside our hospital
managed by health insurance companies). The rest
(Triage 3 and some of 4 and 5) return to the waiting
room after completing administrative admission.
Then they are called to consultation rooms in
decreasing order of complexity (with the most
complex patients seen first). At this instance our
General Physician decides if the patient is discharged or continues to the OU where – after medical treatment, laboratory results, images and/or
specialist assessment – the patient is discharged,
admitted for hospitalization, or sent to another
institution for further definitive treatment.
(Figure 79.1)
084
21:39:15
Like in the rest of the world, Colombian
emergency services have to face daily the consequences of the lack of sufficient health networks
in primary care and the lack of opportunity in
outpatient care, which result in congestion at
the entrance.
2
This input overcrowding generally does not affect the OU and is faced with
diverse strategies that are not the subject of this
chapter.
3
Fifteen percent of our patients (24% of those
patients who are not redirected to a Priority Care
Center) are treated in the OU. Of the 16,500
patients observed each year, 86% are discharged
home and 14% are either hospitalized or referred
for hospitalization in another institution at the
same level of complexity.
As in all high-complexity EDs all over Colombia, the OU is directly attached to the ED
4,5
and its operation is organized in three main
shifts: morning, afternoon, and night, with some
additional coverage of peak situations. In our
OU each shift is managed by an Emergency
Specialist, two Internal Medicine Specialists,
two Pediatricians, and an Orthopedist, leading
the rest of the OU team composed by five
General P hysicians, an Internal Medicine resident, an Orthopedics resident, two Pediatrics
residents, five Nurses, and eight Nursing Technicians.
6
Our observation area has a capacity of
38 patients.
ThebiggestchallengeinourOU,commonto
all of Colombia, is the exit door (Output):
7
with
a shortage of h ospital beds throughout the country. Patients awaiting inpatient care stay in the
OUs, pending a hospital bed in the he alth network. This situation means that every day we
have between 45 and 60 patients (7 to 22 overcapacity) of which 40% to 50% have waited more
than 12 hours for a hospital bed. In the end, on
average 20% of patients with a hospitalization
order are discharged home directly from the
OU. (Figure 79.2). This situation shifted the
average stay in the OU from 4.8 hours to 8.1
hours in 2011.
In order to deal with it, we developed
strategies that increased our internal efficiency (throughput) and opened the exit door
(output):
Carlos-Hernan Camargo-Mila
084
21:39:15
In addition to normal rounds, we perform a
clinical-administrative round each shift by a team
composed of the ED Medical Coordinator, Physician and Nurse in charge of the patient, ED
Patient´s Service Coordinator, ED Quality Officer,
and ED Administrative Supervisor. This multidisciplinary team verifies clinical evolution and pending laboratory studies and procedures, contributes
in defining medical conduct earlier, detects and
manages any administrative problem, brings accurate and understandable information to the patients
and family about ED processes, and resolves any
doubt about the ED care of each patient.
We empower our team to manage ED patients
as much as possible without the consult of other
specialties, supported on clinical guid elines and
clinical pathways.
We manage special units inside the OU
based on a virtual model depending on the
demand: Chest Pain Unit (Average Door to
Needle time 37 minutes, average Door to Balloon
time 69 minutes),
8
Cerebrovascular Stroke Unit
(Average Door to Needle time 117 minutes) and
Hydration Unit.
9
We estab lish and constantly update service
agreements with the Laboratory and Imaging
Departments and Consulting Specialists, in order
to improve their response time.
We are improving mobile technology to support clinical records in real time.
We are working on monitoring technology
with direct connection and recording to the electronic medical record (EMR).
We recently completed the construction of a
Pneumatic Tube Transport System for laboratory
samples and blood products. This system has a
preferential pathway for ED and Intensive Care
Units (ICUs) controlled by radiofrequency (RF)
sensors. It was fully operational in April 2012. It
has reduced laboratory management time by
25 minutes per sample.
Our administrative team is permanently aware
of the management of the authorization of the
services and procedures involved in the OU care
process.
Once the decision of inpatient care is taken,
our strong Admission and Referral Depart ment
simultaneously begins the referral process, in
order to take the first open available hospital bed
for our patient either inside or outside Fundacion
Cardio Infantil.
10
As soon as possible we coordinate home care
with health insurance companies.
Fundacion Cardio Infantil is also working on
institutional strategies that could improve OU
performance. We just built a new tower that will
increase our current number of inpatient beds
from 340 to 400 and we are strengthening an
“early discharge task force” to improve the turnover of these beds.
References
1. Gilboy N, Tanabe P, Travers D
et al. Emergency Severity Index
(ESI): A Triage Tool for
Emergency Department Care.
AHRQ Publication No.
12-0014, 2012.
2. Trzeciak S, Rivers EP.
Emergency Department
overcrowding in the United
States: an emerging threat to
patient safety and public
health. Emergency
Medicine Journal 2003; 20:
402–405.
3. Asaro PV, Lewis LM,
Boxerman SB. The impact of
input and output factors on
emergency department
throughput. Academic
Emergency Medicine 2007;
14(3): 235–242.
4. Daly S, Campbell DA,
Cameron PA. Short-stay units
and observation medicine:
a systematic review. Medical
Journal of Australia 2003; 178:
559–563.
5. Graff L., 2. Principles of
Observation Medicine.
Observation Medicine:
TheHealthcareSystem’s
Tincture of Time. 2011.
www.iep.org/Our%20
Physicians/Journal%20
Club/Observation%20
Medicine%2002.03.11/
Observation%20Medicine.pdf
(Accessed January 2012).
6. Baugh CW, Graff L. 8.
Management – Staffing.
Observation Medicine: The
Healthcare System’s Tincture of
Time. 2011. www.iep.org/Our
%20Physicians/Journal
%20Club/Observation%20
Medicine%2002.03.11/
Observation%20Medicine.pdf
(Accessed January 2012).
7. Oldshaker JS. Managing
emergency department
overcrowding. Emergency
Medicine Clinics of
North America 2009; 27(4):
593–603.
8. Gabrielli L, Castro P, Corbalán
R, et al. Long term follow up of
patients consulting in a Chest
Pain Unit. Revista Médica
Colombia
084
21:39:15
Chilena 2010; 138(9):
1117–1123. Spanish.
9. Appendix 2: Types of
conditions most often
managed in observation
medicine units. Observation
Medicine Guidelines 2009.
Victorian Government
Department of Human
Services, Melbourne,
Victoria, Australia.
www.health.vic.gov.au/
emergency/obs09.pdf
(Accessed January 2012).
10. Olshaker JS, Rathlev NK.
Emergency Department
overcrowding and ambulance
diversion: the impact and
potential solutions of
extended boarding of admitted
patients in the Emergency
Department. Journal of
Emergency Medicine 2006;
30(3): 351–356.
Carlos-Hernan Camargo-Mila
084
21:39:15
084
21:39:15
Part
VII
Evidence Basis for
Observation Medicine
12:37:39
Part VII
Chapter
80
Evidence Basis for Observation Medicine
The Evidence Basis for Observation
Medicine in Adults Based on
Diagnosis/Clinical Condition
Christopher W. Baugh, MD, MBA, FACEP
Sharon E. Mace, MD, FACEP, FAAP
Margarita E. Pena, MD, FACEP
J. Stephen Bohan, MD, MS, FACEP, FACP
Abstract
This chapter deals with critical issues in observation medicine for adult patients based on
a given diagnosis or clinical condition, such as chest pain or asthma. A separate chapter deals
with critical issues in observation medicine based on age, for example, observation medicine
for pediatric and geriatric patients. The critical questions addressed in this chapter are:
1: In adult patients, when compared with inpatient treatment does the provision of
observation services, specifically in a dedicated, protocol-driven observation unit (OU),
improve patient outcomes, decrease length of stay (LOS), reduce costs, increase patient
satisfaction, and have other benefits, including (but not limited to) decreased
readmissions?
2: In adult patients, does the use of OU clinical and administrative methodology (by
aggressive early diagnostic and therapeutic management using tools such as protocoldriven therapy) produce equivalent or better results (e.g., patient outcomes, LOS, costs,
and adverse events) compared with routine inpatient care?
3: In the adult emergency department (ED), does use of an OU improve key measures of
department efficiency, such as decreases in ED LOS, door-to-doctor time, ambulance
diversion, and the left-without-being-seen rate?
Introduction
Recently, health care reform efforts have
renewed the international dialog surrounding
improving patient outcomes, cutting health care
costs, improving patient safety, and increasing
patient satisfaction. One of the largest drivers
of these factors is reducing hospital length of
stay (LOS), which results in decreased costs and
fewer patient errors due to decreased exposure to
the hazards of hospitalization and thus fewer
opportunities for patient errors or risks such as
falls and nosocomial infections. By decreasing
LOS and preve nting “avoidable admissions”
through dedicated and efficient observation
units (OUs) that use evidence-based protocols
of care, OUs can achieve all of these goals. This
chapter summarizes the extensive literature supporting wider use of OUs as a key strategy in our
health care system.
An important concept to understand about
observation care is that although observation
services may occur anywhere in a hospital, under
the care o f any physician, the best practice is to
provide observation services in a dedicated,
protocol-driven unit. These well-managed units
are very different from observation services
occurring in a bed elsewhere in the hospital ,
which most often do not employ the same
evidence-driven patient management strategies.
Rather, these dedicated units specialize in the
care of observation patients, using clinical and
administrative resources and methods to use
diagnosis and/or complaint-spec ific protocols,
typically achieving a LOS that is a fraction of
thetimeneededelsewhereforthesamepatient
populations.
The purpose of an observation stay is to
provide additional time, typically up to 24 hours
but sometimes longer, for additional monitor-
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