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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2721_Библиотеки_им_академика_М_И_Перельмана
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injury and negative CT
scan, managed in an
OU vs. discharged
home with monitoring
(N=1,408)
diff in deaths at 6
months
patients kept in
the hospital
were more
severely injured.
Observation
period was
much longer
than typical ED
OU evaluation
Menditto
et al.
69
2012
Prospective case series
of patients testing an
ED OU protocol
including a repeat CT
at 24h if initial head CT
normal in patients on
warfarin with minor
head injury (N=97)
%ofpatientsw/
intracranial lesions
after 24h of
observation
following normal CT
(N=87) was 6%
(N=5), with an
additional 2 patients
who had normal 2nd
CT developed bleed
(both had INR >3)
Small number II
MacLaren
et al.
70
1993
Case series of patients
with minor head injury
and variable access to
an OU, depending on
the day of the week
(N=405)
23.5% of patients
who met high-risk
criteria for further
observation were
sent home when
the unit was
unavailable
compared with only
9.9% when it was
an option
Study antedates
the most widely
used current
decision rules
for minor head
trauma (e.g.,
Canadian, New
Orleans criteria)
III
Congestive heart failure
Peacock
et al.
72
2005
Multicenter,
randomized controlled
study in ED OU
patients with CHF,
Nesiritide
patients had
fewer 30-day
Additional cost of
Nesiritide was
balanced by the
Nesiritide not
currently
recommended
I
451
085
21:45:54
Table 80.1 (cont.)
Author/
Year
Design Outcomes Limitations/
Comments
Class
Length of Stay
(LOS)
Cost Patient Satisfaction Other Metrics
Chest pain
looking at the impact
of Nesiritide on index
hospitalization, repeat
hospitalization at
30 days and other
outcomes (N=237)
readmits, with
shorter LOS
shorter LOS and
fewer readmits
for routine use
in CHF patients
Graff et al.
73
1999
Retrospective cohort
study of patients with
CHF in 12 hospitals to
identify patient
characteristics
associated with lowrisk for poor outcomes
(N=1,674)
Patients with 0 or 1
admission criteria
combined with
physician judgment
of safe outpatient
plan were low risk
Study helps
identify
potential ED OU
candidates, but
did not test ED
OU care
II
Storrow
et al.
74
2005
Prospective cohort
study of patients with
CHF managed
sequentially in an ED
OU and versus a
matched group on an
inpatient service
(N=64)
Mean ED OU
LOS 25.7h
vs. 58.5h for
inpatient
Use of ED OU
estimated to save
$3,600 per visit
2013 USD Savings
of $4,620 per visit
79% of ED OU
patients discharged
home. No
significant diff in
outcomes at
30 days between
ED OU and
inpatient groups
Not enough
power in study
to detect
outcome
differences
between groups
II
Peacock
et al.
75
2002
Case series of patients
before and after an ED
OU CHF protocol was
implemented in a
single hospital (N=154)
# 90-day ED revisit
rate for CHF by 56%
after ED OU; #90-day
readmit rate for CHF
by 64% after ED OU
Inclusion and
exclusion criteria
of ED OU
protocol
detailed in paper
III
Congestive heart failure
085
21:45:54
Burkhardt
et al.
76
2005
Case series of patients
with CHF exacerbation
in an ED OU protocol
(N=385)
74% of ED OU
patients discharged
home; BUN >30 mg/
dl significantly
predicted ED OU
management failure
III
Diercks
et al.
77
2006
Case series of patients
to determine which
factors are associated
with appropriate
patient selection for a
24h ED OU CHF
pathway (N=499)
Factors associated
with prolonged LOS
and 30-day adverse
outcomes were SBP
>160 m Hg at ED
presentation and
positive TnI
Actual study
patient
dispositions
varied; only
50 patients
managed in ED
OU, many more
identified as “OU
appropriate”
III
Collins
et al.
78
2009
Decision model of
alternative disposition
options for a low-risk
CHF patient presenting
to the ED: home, ED
OU, and inpatient
admission
ED OU costs were
$44,248 per QALY
and inpatient costs
were $684,101 per
QALY 2013 USD ED
OU costs were
$48,869 per QALY
and inpatient costs
were $755,539 per
QALY
Risk of readmission
if sent home
directly from ED
26% at 5 days and
74% at 30 days
ED OU shown to
be optimal
balance of cost
and risk versus
alternatives
III
Pyelonephritis
Schrock
et al.
79
2010
Retrospective cohort
study of patients,
before and after the
opening of an ED OU
(N=633)
Median ED OU
LOS was 22h,
median
inpatient LOS
was 3 days
72% of ED OU
patients discharged
home. Percentage
of patients
admitted to the
hospital dropped
from 35% to 26%
(p<.05) after the ED
OU opened
Uncontrolled
design
II
453
085
21:45:54
Table 80.1 (cont.)
Author/
Year
Design Outcomes Limitations/
Comments
Class
Length of Stay
(LOS)
Cost Patient Satisfaction Other Metrics
Chest pain
Israel et al.
80
1991
Case series of patients
with pyelonephritis
who underwent a 12h
ED OU protocol (N=87)
72% of patients
with confirmed
pyelonephritis
discharged home
Only about 80%
of patients sent
to the ED OU for
pyelonephritis
actually had the
disease
III
Ward et al.
81
1991
Case series of patients
with pyelonephritis
who underwent a 24h
ED OU protocol (N=44)
43 of 44 (98%)
patients discharged
home after two
doses of IV
antibiotics
Authors excluded
patients
retrospectively if
urine culture
from index visit
was negative
III
Cellulitis/soft tissue infections
Schrock
et al.
82
2008
Case series of patients
with skin and soft
tissue infections who
were managed in an
ED OU (N=179)
62% of patients
discharged home
after observation
stay; female gender
OR 2.33 and WBC
>15,000; OR 4.06
significantly
associated with
failure to discharge
III
Abdominal and general trauma
Conrad
et al.
83
1985
Case series of mixed
trauma patients who
underwent an ED OU
protocol (N=485)
Mean LOS was6hNearly 50% # in
cost vs. inpatient
stay
80% of patients
discharged home
after observation
stay
III
Pyelonephritis
085
21:45:54
Henneman
et al.
84
1989
Case series of mixed
blunt and penetrating
abdominal trauma
patients who
underwent 12h of ED
OU monitoring after a
negative initial DPL
(N=230)
Mean cost savings
of $224 2013 USD
Mean cost savings
of $869
81% of patients
discharged home
after observation
stay
DPL not
routinely used
today
III
Cowell
et al.
85
1998
Case series of mixed
trauma patients who
underwent a 24h ED
OU protocol (N=122)
80% of patients
discharged home
after observation
stay
III
Madsen
et al.
86
2009
Case series of mixed
trauma patients who
underwent an ED OU
protocol (N=364)
Mean LOS was
12h 46 minutes
88.5% of patients
discharged home
after observation
stay; at 30-day f/u,
there were no
significant missed
injuries
There were no
deaths,
intubations, loss
of vital signs or
other adverse
events
III
Toxicology/drug overdose
Hollander
et al.
88
1999
Case series of stable,
minimally symptomatic
or asymptomatic
patients in ED
observation with
potentially toxic
ingestions at two
hospitals (N=215)
167 (77%) patients
were deemed
medically clear after
only 2–4h of
observation
Findings suggest
asymptomatic
patients with
selected acute
intentional
ingestions can be
released from
observation in
<6h
III
Sivilotti
et al.
89
2005
Case series of
acetaminophen
overdose registry
patients modeled with
a 20h intravenous Nacetylcysteine protocol
(N=1,270)
20h protocol
versus 72h
protocol
Authors estimate
switching from
72h to 20h
protocol would
save 40,000
patient-days
annually in the
U.S., with an
Low-risk patients
may be identified
at the beginning
of therapy using
the published
nomogram,
given a 20h
course of
III
455
085
21:45:54
Table 80.1 (cont.)
Author/
Year
Design Outcomes Limitations/
Comments
Class
Length of Stay
(LOS)
Cost Patient Satisfaction Other Metrics
Chest pain
annual cost
savings of >$100
million
treatment, and
released without
further testing
Sztajnkrycer
et al.
90
2007
Case series of patients
with various toxic
exposures managed
under a new ED OU
protocol (N=6)
2 of 6 patients
required
subsequent
inpatient medical
admission
Very low number
of patients;
higher number
identified as
potential ED OU
candidates
III
Pneumonia
Chan et al.
91
2001
Case series of patients
with community
acquired pneumonia in
an ED OU (N=14)
Median ED OU
LOS 15h
71% of patients
discharged home
after observation
stay
II
COPD
Salazar
et al.
92
2007
Case series of patients
with COPD in an ED
short-stay unit (N=545)
Mean LOS 3.4d
for short-stay
unit vs. 12d for
inpatient
Short-stay unit
group had lower
mortality (1.7%) vs.
inpatient (8.1%) but
also higher hospital
readmission rate
(9.9% vs. 7%)
Study
performed in
Spain, where
concept of ED
OU is different
(LOS was over
3d); short-stay
patients were
significantly less
sick than
inpatients
III
Toxicology/drug overdose
085
21:45:54
ED efficiency
Baugh et al.
1
2012
Model of cost savings
of a single ED OU visit,
entire ED OU, and
potential national
savings from increased
ED OU use
Cost savings from a
single ED OU visit
was $1,572; annual
hospital savings
$4.6M, and national
savings of $3.1B
from increased ED
OU use
I
Hadden
et al.
93
1996
Retrospective cohort
analysis of 107 patients
managed in an
observation ward,
which was later closed
for administrative
reasons compared with
107 similar observation
patients subsequently
managed in inpatient
areas
99% of OU
patients
discharged
within 2 days, vs.
only 77% of
patients
managed in
inpatient areas
Number of
“investigations” of
OU patients was 1.3,
much lower than
for patients in
inpatient areas (3.3);
97% of OU patients
seen by senior
doctor within 24h
versus 71% for the
other group
II
Baugh
et al.
94
2008
Model of financial
value of an observation
visit using an optional
analysis framework and
considering indirect
benefits of observation,
such as freeing
inpatient beds, and
thus transfer capacity
Revenue created
by an average ED
OU visit was
$2,908; 40% of
which was indirect
value 2013 USD
Revenue of $3,314
II
Bazarian
et al.
95
1996
Before and after study
of an inpatient shortstay unit, which treated
4 types of patients:
asthma, chest pain,
sickle-cell crisis and
seizure
After short-stay
unit opened,
LOS for ED
boarders >8h #
from 9.6h to
2.3h, LOS for
treat and release
"13.4% in ED pro
billing after shortstay unit opened
# of ED patients left
without being seen
#42%
Mean LOS for
short-stay unit
was 2.4 days,
significantly
longer than the
target of a
typical ED OU
III
457
085
21:45:54
Table 80.1 (cont.)
Author/
Year
Design Outcomes Limitations/
Comments
Class
Length of Stay
(LOS)
Cost Patient Satisfaction Other Metrics
Chest pain
ED chest pain
patients #24%,
and #15% for
asthma patients
Kelen et al.
96
2001
Before and after study
of adding a remote ED
OU at a single academic
medical center
LWBS # from 10.1%
just prior to opening
of the ED OU to 5.0%.
Ambulance
diversion # from 6.7h
per 100 patients to
2.8h per 100 patients
III
Chandra
et al.
97
2011
Before and after study
of patient satisfaction
scores after adding an
ED OU at a single
academic medical
center
Mean overall PG scores pre-ED
OU was 75.2 and post-ED OU
was 80.2 (p<.05)
Other key
factors (i.e.,
physician and
nursing staffing,
wait times, etc.)
all remained the
same during this
period
III
Other
Cook et al.
99
2003
Systematic literature
review and critical
assessment of the
observation medicine
literature
14 studies
identified
showing shorter
LOS and more
rapid disposition
though OU use
5 studies across
various conditions
show lower costs
through OU use
3 studies showed higher
satisfaction in asthma and
chest pain patients
Included
pediatric studies
III
ED efficiency
085
21:45:54
Daly et al.
100
2003
Systematic literature
review of how shortstay observation units
(SOUs) affect the
efficiency of health
care delivery and the
quality of services
provided
no change,
another
1 showed
shorter LOS with
OU use
1 study in asthma
patients was
found to show
lower costs of care
through OU use
2 studies showed higher
satisfaction in asthma and
chest pain patients
2 studies showed
no change, 2 others
showed a decrease
in medical
admissions,
2 studies showed
equivalent clinical
outcomes with OU
use vs. routine care
III
Tempel
et al.
101
2006
Retrospective case
series of consecutive
patients with
decompression illness
presenting to a major
hyperbaric facility
(N=102)
42 patients (41.2%)
had neurological
sequelae requiring
further hyperbaric
oxygen treatments;
38 of these had
their treatments
completed within
24h, which is an
ideal OU time frame
Single center;
retrospective
analysis to see if
OU protocol
would have
been
appropriate
III
Ross et al.
102
2012
Historical overview of
the development of
OUs and literature
synthesis summarizing
the benefits of OU care
across many clinical
conditions
Cite numerous
studies showing
shorter LOS with
OU use
Cite numerous
studies showing
less cost with OU
use
Cite numerous studies
showing higher patient
satisfaction with OU use
Recent,
thorough, and
concise review
with helpful
supporting
information,
such as OU
management
strategies
III
459
085
21:45:54
Table 80.2 Evidentiary Table for Critical Question #2
Author/
Year
Design Outcomes Limitations/
Comments
Class
Length of Stay
(LOS)
Cost Patient
Satisfaction
Other Metrics
Other
Kerns
et al.
13
1993
Prospective cohort
study of ED low-risk CP
patients undergoing
immediate stress test
(N=32) vs. comparison
inpatient group (N=26)
LOS 5.5h
immediate stress
test group vs. 2
days for inpatient
group
Average patient charge
$467 ED protocol vs.
$2,340 inpatient
2013 USD $962 for ED
protocol vs. $4,821
inpatient
No diff in MACE at
6-month f/u: 0% ED
protocol and inpatient
Selection bias of low-risk
patients with atypical CP,
low pretest probability of
CAD and normal ECG;
inpatient group
retrospectively selected.
Downgrade for small
number of patients
II
Transient ischemic attack
Rothwell
et al.
42
2007
Population based
before and after
establishment of walk-in
clinic for evaluation and
treatment of TIA or
minor stroke (N=1,278)
Rate of stroke within
90 days after TIA or prior
minor stroke pre- vs.
post- intervention:
Before intervention
rate=10.3%, After
intervention 2.1%
Same-day diagnostics
and Rx, but clinic
mimics OBS; No
exclusions is a strength
as is large numbers
II
LuengoFernandez
et al.
43
2009
Before and after study of
patients referred to an
outpatient TIA clinic in
the UK; no appointment
needed in the second
phase (N=1,278)
Delay to assessment fell
from 3 days to less than
1; 90-day risk of
recurrent stroke fell by
80%
Implication that timing
of assessment
important implies role
for ED OU
II
Lavallee
et al.
44
2007
Case series of patients
to assess the impact of
an intervention (24/7
TIA clinic; N=1,085)
Rate of stroke within
90 days of attendance
at clinic (1.24%)
compared to expected
rate based on ABCD2
score (5.96%)
Not randomized and no
comparative group, i.e.,
measured against a
score; mimics rapid
assessment 24/7; large
numbers an asset
III
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21:45:54
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