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Part I
Chapter
5
Administration
Design
David Robinson, MD, MS, MMM, FACEP
Successful observation units (OUs) have several
features that have changed little since the late
1980s.
1,2
Since the majority of observable patients
are identified from the Emergency Department
(ED), a successful OU commonly fulfills the
following functions. An OU should augment the
clinical capacity of the ED.
1,3,4
Next, its design
and function should improve the quality of diagnostic and therapeutic care from the ED.
1,4,5
The
third and most compelling function is that an OU
should enhance the revenue cycle of a hospital by
delivering lower cost, more efficient strategies for
managing observable diagnoses.
3,5–8
If the third
function cannot be achieved, then the need for an
OU comes into question.
3,6,7,9
OUs are designed to serve as a bridge for those
patients requiring extended care beyond what is a
reasonable time for the ED or similar outpatient
setting, but not requiring the resources or intensity
of services found in an inpatient service. Effective
observation care is delineated in many references
and is summarized by the following goals:
1,2,10,11
1. Improve the quality of the acute care patient
when a short-stay diagnostic or therapeutic
workup is planned.
2. Provide a designated physician and nurse who
shall be responsible for the patient’s
observation care.
3. Establish a dedicated location for this
observable care.
4. Provide written protocols and procedures
established by the hospital and medical staff
that clearly delineates the type of care, the
methods from which observation care will be
performed, qualifying criteria to and from the
unit, and criteria for discharge from the OU
or admission to the hospital.
5. Provide a documented, ongoing quality
review process.
Successful OUs also share several design features
that follow the three ‘Ps’ of hospital unit design:
Proximity, Personnel, and Process. The choice
of hospital OU location is largely dependent on
the available resources, space, training, and hospital budget. There are 4 types of OUs based on
two variables (Table 5.1).
12
The first variable is
whether or not the personnel are specifically
trained in observation care and are familiar with
the care protocols and processes. The second variable is if the unit is physically located in one
location, preferably in close proximity to the ED,
or if the observation patients are scattered
throughout the hospital. The most effective units
are those managed by trained personnel in a location where all observation patients are concentrated (type I OU).
2,4,9,12
(Note: This is similar
to the Types of Observation Units in Table 1.1
in Chapter 1 where protocol driven is similar to
trained personnel and dedicated unit is similar
to unit in one location.)
Table 5.1 Types of Observation Units
Type Trained Personnel
Familiar with Protocols and Processes
Unit in One Location
Ideally near ED
Efficiency
I Well informed Yes Most efficiency
II Well informed No Intermediate efficiency
III Generally informed Yes Intermediate efficiency
IV Generally informed No Least efficiency
008
20:18:34
The location of the OU significantly benefits the
unit’s operations and is a primary driver of its
clinical and operational effectiveness. OUs with
specific identifiable hospital locations improve
long-term hospital costs by reducing redundant
equipment costs, administrative workload, and
transfer times from the ED.
10,12,13
There is no specific requirement for an OU to be located in a
specific location although most hospital-based
OUs are generally located near or adjacent to
the ED
11
and nearly one-third of all hospitals now
have an existing OU.
9,11
OUs located next to the ED
permit seamless, integrated care pathways originating from the ED, have and can share resources such
as staffing (phlebotomy and ECG technicians, nursing, clinicians) and equipment.
3,11,12
OUs located
far from the ED must provide separate resources
and nursing. Care protocols may be different when
personnel and location varies, resulting in redundant test ordering and increased cost. Unfortunately, the creation of a new OU is often a capital
budget consideration that is in direct competition
with other ED expansion projects.
3,6
Room size is a factor in many OU expansion
projects. With miniaturization of telemetry
systems and electronic records, and smaller computers with flat screen monitors, a modern OU
room may require as little as 120 square feet per
room.
14
Since a primary func tion of an OU is to
complete a diagnostic workup, one must consider
what diagnostic tools the OU will require before
considering room size. For example , if a Chest
Pain OU is considering performing bedside cardiac echocardiography or portable radiography,
would the rooms accommodate these devices?
Toilets, showers, televisions, and sleeper chairs
may provide additional comfort for patients and
guests. As an extended-stay room for patients,
OUs deploying standard hospital inpatient beds
may require rooms of 150 to 160 square feet.
14
Regulations vary from state to state, but room
size and amenities such as the requirement for
windows are generally more liberal for OUs
than for inpatient beds, making it easier to convert inpatient beds to observation beds, rather
than vice-versa.
Estimating the unit size requires three metrics:
the anticipated ED volume, the expected nurse
ratio for staffing, and the average time for processing the observable patient. In general, 5–10% of
the ED volume might be suitable observation
patients.
3,9
Most resources suggest that OU staffing
is best suited for 4:1 to 6:1 nursing.
12,15
Ahospital
with an anticipated ED volume of 60,000, therefore, might expect to have 3,000–6,000 qualified
observation patients. Using 12 hours (0.5 days)
for an average protocol completion time (including transfer or discharge time), then the calculation of OU estimated size is (0.5 [bed-days/
patient] × 3,000–6,000) / 365 days, or 4 to 8 beds.
A 5- or 10-bed unit with 5:1 nursing would be a
reasonable estimate while still anticipating further
growth.
12,15
Personnel are a considerable factor in the oper-
ational efficiency and cost of an OU.
3
Acornerstone to efficient OU operations are highly trained
nurses and staff in protocol management.
16
OUtrained personnel managing an OU in a designated
area (Type I OU) results in better operational
efficiencies than an OU with concentrated patients
but without trained personnel (Type III).
10,12,17
There is no specific policy mandating that OUs
have specialized health care providers trained
in observation medicine, although systems with
trained OU personnel have reported better economic and noneconomic outcomes than OUs
without specific provider training.
3,6,12,18
OU systems employing nursing and ancillary
staff specifically trained and knowledgeable about
the clinical care pathways (e.g., chest pain protocols) can further be trained to manage the flow
of patient care.
16
All nurses and ancillary staff
(technicians, phlebotomists, and others) should
be familiar with each care pathway. Regulatory
billing guidelines outline specific documentation
requirements for observation services, but have
not mandated any specialty training in observation medicine as a prerequisite for establishing an
OU. As a result, there may be much variability
in the quality of training from the hospital’s physicians, nurses, and staff.
11
Units staffed by physicians, nurses, and staff who as part of their
practice, participate in observation services, and
have at least some knowledge of the processes of
observation medicine (e.g., risk stratification,
care pathways, and billing requirements) would
be considered ‘generally informed’ and occupy the
Type III or IV units. Physicians and nurses
who utilize goal-directed care pathways, are
specifically trained in observation processes, and
participate in the OUs quality assurance oversight, utilization review, and feedback are considered “well informed.”
10,12,17
These groups of
providers are found in Type I and II units. While
David Robinson
008
20:18:34
these descriptive classifications are useful, hospitals may modify a particular observation unit
type to better meet its patient care goals and needs
and particular institutional goals (Table 5.1).
Resources are available for observation medi-
cine training, design, and operations management,
including sample care-directed protocols. These
may be found from the American College of Emergency Medicine website (www.acep.org) or the
Society of Chest Pain Centers and Providers
(www.scpcp.org) and in Chapters 82–87 in
this book.
References
1. American College of
Emergency Physicians.
Emergency department
observation units. Ann Emerg
Med. 1988; 17:95–96.
2. American College of
Emergency Physicians.
Management of Observation
Units [policy resource and
education paper]. Approved
January 2008. www.acep.org
(Accessed February 20, 2016)
3. Baugh CW, Venkatesh AK,
Bohan JS. Emergency
department observation units:
A clinical and financial benefit
for hospitals. Health Care
Management Review. 2011; 36
(1):28–37
4. Ross MA, Naylor A, Compton
S. Maximizing use of the
emergency department
observation unit: A novel
hybrid design. Ann Emerg Med.
2001; 37(3):267–274.
5. Graff LG, Dallara J, Ross MA,
et al. Impact on the care of the
emergency department chest
pain patient from the Chest
Pain Evaluation Registry
(CHEPER) study. American
J Cardiology. 1997; 80:563–568.
6. Sieck S. Cost effectiveness of
chest pain units. Cardiol Clin.
2005; 23:589–599.
7. Robinson D, Woods P,
Snedecker C, et al.
A comparison trial for
stratifying intermediate risk
chest pain: Benefits of
emergency department
observation centers. Preventive
Cardiol. 2002; 5:23–30.
8. Roberts R, Graff L. Economic
issues in observation unit
medicine. Emer Med Clinics of
N America. 2001; 19(1):19–33.
9. Graff LG. In Observation
Medicine, The Healthcare
System’s Tincture of Time.
Update August 2011. Retrieved
March 28, 2012, from
American College of
Emergency Physicians website:
www.acep.org/Workarea/
DownloadAsset.aspx?id=45885
(Accessed February 20, 2016)
10. American College of
Emergency Physicians. Chest
Pain Units in Emergency
Departments. A report from
the Short Term Observation
Services Section. Aug. 8, 1994.
www.acep.org (Accessed
February 20, 2016)
11. Mace SE, Graff L, Mikhail M,
et al. A national survey of
observation units in the United
States. Amer J Emerg. Med
2003; 21(7):529–533.
12. Robinson DJ. Hospital based
observation unit design. In
Observation Medicine, The
Healthcare System’s Tincture of
Time. Update August 2011.
Retrieved March 28, 2012,
from American College of
Emergency Physicians website:
www.acep.org/Content.aspx?
id=46142&terms=observation
(Accessed February 20, 2016)
13. Cooke MW, Higgins J, Kidd P.
Use of emergency observation
and assessment wards:
Asystematicliteraturereview.
Emerg Med J. 2003; 20:138–142.
14. Huddy J. In: Huddy J, ed.
Emergency Department Design;
A Practical Guide to Planning
for the Future. Dallas, TX:
American College of
Emergency Physicians; 2002.
15. Graff LG. Observation unit
staffing. In Graff LG, ed.
Observation Medicine. Newton,
MA: Butterworth-Heinemann;
1993:89–98.
16. Emergency Nurses Association.
Observation Units/Clinical
Decision Units. [Position
Statement]. Revised Sept 1997.
17. Brillman J, Mathers-Dunbar L.
American College of
Emergency Physicians:
Management of observation
units. Ann Emerg Med. June
1995; 25:823–830.
18. Rotter T, Kugler J, Koch R,
et al. A systematic review and
meta-analysis of clinical
pathways on length of stay,
hospital costs and patient
outcomes. BMC Health Services
Research. 2008; 8 (265): 1–15.
www.biomedcentral.com/
472–6963/8/265 (Accessed
February 20, 2016)
Design
008
20:18:34
Part I
Chapter
6
Administration
Staffing Considerations
Christopher W. Baugh, MD, MBA, FACEP
J. Stephen Bohan, MD, MS, FACEP, FACP
While the staff needed to operate an Emergency
Department Observation Unit (ED OU) are no
different than those required for the ED proper,
the distribution of staff varies according to the
unique aspects of the individual institution and
can be modified depending on the location of the
unit relative to the ED. To ensure high-quality
patient care for this added service there must be
adequate dedicated personnel and oversight. Customarily, ED staffing is based on a combination
of visit volume, visit acuity, and the number of
treatment spaces or rooms; the ED OU is no
different.
Leadership
An ED OU should have clear physician and nursing leadership. This structure establishes accountability, training, oversight, and feedback. A clear
leadership structure encourages communication
and allows staff to elevate concerns. The most
important initial task of leadership is to develop
sets. ED OU-centric staff training, which includes
insights into the appropriateness of specific
patients for observation care,
1–3
maximizes the
potential of the unit. Clinicians need to understand patient characteristics that allow safe
and expeditious care with a high likelihood of
disposition to h ome within 24 hours. Finally,
leadership should develop a policy manual that
provides transparency as to the goals and available resources, update it regularly and make it
easily accessible.
4
Nurses
Observation units (OUs) are typically staffed by
registered nurses, who have the clinical skills and
experience to care for this patient population.
Ideally the nurses should be experienced ED staff
as they can carry the ED culture into the ED OU.
However, other non-ED nurses, if imbued with
the ED culture (e.g., rapid throughput), may be
utilized. Nurses are the only staff likely to be
present 24/7 in the ED OU, typically representing the highest operating cost. A survey of OUs
found that one nurse cares for a mean 4.2
patients.
8
One nurse is needed per shift for every
four to six patients in an OU. This vari es with
the institutional model, and whether Advanced
Practice Providers (APPs) are present. ED OU
patients tend to be more independent and less
acutely ill than their counterparts on the inpatient floors or those in an extended or complex
OU. Although the acuity of OU patients seems to
be increasing over the years,
5,6
nurses generally
care for fewer patients in the OU than is usual
on the inpatient floor in order to ensure faster
throughput and the “front loading” of diagnostics and therapy essential for an efficient OU to
ensure shorter length of stay (LOS). The OU
ratio of one nurse to four or five patien ts is
similar to and was derived from the nurse:patient
ratio for a stepdown unit. In the absence of an
APP, nurses can be given more autonomy and
can, for example, track down test results, thus
maintaining the aggressive throughput goals of
an EDU. In this model (operative at Cleveland
Clinic for about 20 years, S. Mace, personal
communication) nurses, with these additional
responsibilities, would generally care for fewer
patients, for example, a 1:4 ratio during the day
and a 1:5 ratio at night. Although more recently,
in order to further decrease OU LOS and for
some cost saving (e.g., APPs are less expensive
than emergency physicians), in the Clevela nd
Clinic model APPs have been added during the
day and some evening hours, with the OU nurses
continuing to fulfill their somewhat autonomous
role on the late evening and night shift (e.g., for
12 hours a day). Thus far, national guidelines for
nursing ratios have not specifically addressed the
observation setting. Usually an ED OU will have
a fixed number of beds, which will determine the
009
20:20:17
number of nurses needed based on the staffing
ratio above. For example, a typical 10-bed observation unit will be staffed by three nurses on the
day/evening shift and two nurses on nights (see
Figure 6.1).
Physicians
Payer requirements and quality standards generally dictate that an attending physician personally
perform both an observation admission and discharge assessment.
7
However, during the course
of the observation period, the attending physician need only be immediately available, not
physically present. This allows for cross coverage
of other areas in the hospital, including ED acute
care, but requires additional staff to support this
model. The number of patients assigned to any
single physician must recognize the demands of
both volume and complexity, taking provider
capacity into account, not just at the averages,
but also at peak times as well.
6
With the assistance of additional staff such as resident physicians or an APP, an uninterrupted minimum
of an hour is usually needed to round on a
typical 10-bed OU, but this does not include
the time needed to do a thorough history, physical examination, discuss plans with the prim ary
care physicians and consultants, with the patient
and family, and the OU nursing staff, as well as
write additional orders and complete the needed
documentation. Local conditions such as the
location of the unit and the presence of other
providers affect the amount of physician coverage. Resident physicians should not be counted
in any staffing model, although exposure to this
10 beds
1 Medical Assistant
1 Physician 1 Advanced Practice Provider
1 Unit Secretary
2 Nurses
Day/Evening Shift
1 Pharmacist 1 Care Coordinator
Figure 6.1 Staffing Model for 10-Bed Observation Unit
(Courtesy of Dr. C.W. Baugh, Dr. S.E. Mace and Center for Medical Art and Photography, Cleveland Clinic)
Staffing Considerations
009
20:20:17
growing aspect of practice is useful. (See Staffing
the Unit: Physicians from Chapter 1 Clinical
Issues.)
While there may be a demonstrated need for
an ED OU, the available space is not always
within or immedi ately adjacent to the ED. As
a result, institutions must determine the
staffing model that a ccounts for l ogistics to
allow the responsible physicians to be available
to the observation patients. For example, if an
ED OU is created on the opposite side of a
large hospital and results in long transit times,
it may not be practical to expect that physician
to be responsible for both locations simultaneously. However, a brief elevator ride may not
impose any significant obstacle to adequate
coverage.
Advanced Practice Providers
Many OUs are staffed by physician extenders,
such as Nurse Practitioners or Physician Assistants. These professionals, commonly used in the
United States and also called APPs, Advanced
Practice Clinicians or midlevel provider s, have
special training to function autonomously in
many clinical settings. These providers offer a less
expensive alternative to a direct physician presence in the OU. Stationed in the OU, an APP is
available to assess patients, respond to nursing
questions or suggestions, ensure results are
followed up and testing is completed. In some
institutions, the APP is also expected to “help
out” and adds coverage to the ED when they are
not busy in the OU.
Even with the use of an APP, a supervising
physician should be ultimately responsible and
available for each patient in observation. Critical
decisions, such as the overall management plan
and endpoints for discharge, are usually made by
the supervising physician and subsequently managed by the APP. If a patient decompensates or if
test results are concerning, the supervising physician is reengaged to intervene. However, mu ch of
the hands-on work needed to care for observation
patients can be safely handled by an APP. Some
institutions do not require all observation patients
to be personally seen by a physician if they rely on
experienced APPs for routine observation care.
However, there are implications for billing/reimbursement if this is the case, since the reimbursement may be less for an APP compared to the
physician.
Ancillary Staff and Consultants
A10-bedEDOUshouldbestaffedbyatleast
one medical assistant and one unit secretary.
Coverage may vary overnight, when patients
tend to be less active. Case management is
another crucial partner essential to be engaged
and present every day in an OU to assist with
safe and timely dispositions of observation
patients. In addition, a strong relationship with
consultant services is, as is the case in the ED,
essential to the success of the unit. Not surprisingly, the need for consultants tends to mirror
the most frequent types of complaints managed
in observation.
8
Consultations need to occur in
a timely manner and recommendations for
further diagnostics and treatments must consider the time frame and resources specific to
the ED OU. Finally, consultations are more
efficient when the consulting service has been
involved in the development of clinical
protocols.
References
1. Crenshaw LA, Lindsell CJ,
Storrow AB, et al. An evaluation
of emergency physician
selection of observation unit
patients. Am J Emerg Med 2006
May;24(3):271–279.
2. Burkhardt J, Peacock WF,
Emerman CL. Predictors of
emergency department
observation unit outcomes.
Acad Emerg Med 2005 Sep;12
(9):869–874.
3. Ross MA, Compton S,
Richardson D, et al. The use
and effectiveness of an
emergency department
observation unit for elderly
patients. Ann Emerg Med 2003
May;41(5):668–677.
4. Brillman J, Mathers-Dunbar L,
Graff L, et al. Management of
observation units. American
College of Emergency
Physicians. Ann Emerg Med
1995 Jun;25(6):823–830.
5. Greene J. Nurse groups,
administrators battle over
mandatory nursing ratios:
California law debated on
national stage. Ann Emerg Med
2009 September;54(3):31–33.
6. 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.
Christopher W. Baugh and J. Stephen Bohan
009
20:20:17
7. Centers for Medicare &
Medicaid Services (CMS). CMS
Manual System: Pub 100-04
Medicare Claims Processing.
2008 February 22nd;
Transmittal 1466.
8. Mace SE, Graff L, Mikhail M,
et al. A national survey of
observation units in the
United States. Am J Emerg
Med 2003 Nov;21(7):
529–533.
Staffing Considerations
009
20:20:17
Part I
Chapter
7
Administration
Nursing
Sharon E. Mace, MD, FACEP, FAAP
Karen Games, RN
Observation Unit Location: To Cohort
or Not Cohort Observation Unit
Patients
Whether to place observation patients scattered
throughout the hospital into inpatient units is a
common question. This practice should be discouraged for many reasons and is often a reason
why observation status (OS) fails.
“Observation is a mindset and a process, not a
location”; this quote of mine (Dr. Mace) empha-
sizes the importance of guidelines, protocols, policies, procedures, and other administrative and
organizational mechanisms coupled with the
observation unit (OU) physician and nursing
mindset that is focused on the timely, efficient
evaluation and/or treatment of patients and that
observation can be done anywhere, even in a designated area of the emergency department (ED).
However, cohorting OU patients has many
advantages. There is a precedent for grouping
like patients in a hospital. This is the case for
intensive care units, pediatric units, cardiology
telemetry or step-down units and other specialty
units, such as neurology. The advantages have
been well elucidated.
The OU should be viewed in a similar manner
as these other specialty units. The OU staff comprises a wide array of personnel in addition to
nurses: from unit secretaries or coordinators to
respirato ry therapists, technicians, housekeeping,
and others, depending on the setup of the OU.
Having a specific unit or area for OU patients
helps to develo p an esprit de corps and enhance
team building among the OU sta ff. They know
the tenets of t he OU, which are the efficient and
cost-effective diagnostic evaluation and treatment of patients with various illnesses and injuries. Cohorting OU patients fosters this mindset
and dist inguishes the OU patient from other
inpatients.
This also advances the OU concept through-
out the hospital. Other departments – for
example, cardiology, pulmonary, radiology,
and laboratory – can easily and quickly recognize the OU patient. When radiology calls the
unit to request it send a patient to the radiology
department for a CT scan, for example, they
likely will not b e aware of the patient being in
OS if the observation patients are sc attered
throughout the hospital. Even with color coding
of charts, color coding patient identification
bands, or signs on the patient’ s door, etc., the
respective department, such as radiology, may
not be aware of the patient’s OS until he or she
arrives in th e department for his or her test.
Being in a specific location readily lets everyone
throughout the hospital know that this patient is
an observation patient or a “high-priority”
patient. The OU could be likened to “an express
lane” at the supermarket where there is a quick
turnaround.
If OU patients are randomly placed in beds
throughout the hospital, then there must be a
mechanism for identifying the observation patient
as being unique or different from other patients
on the inpatient units. Various methods have
been used to distinguish the observation patient
from the other inpatients on the same inpatient
floor or unit. These include color coding the
patient’s charts, using different name bands for
OU patients, and color coding the room numbers
or signage on the patient’s door. Unfortunately,
unless other methods are used to identify the OU
patient, individuals may not be aware of the
patient’s OS until they arrive at the patient’s room
or bedside. Consider phlebotomy as one example:
unless their blood draw list identifies OU patients
and a system is set up to prioritize the OU
patients in the queue, they will not be automatically identified by the floor or area they are in, so
their blood draws would be the same as anyone on
010
20:20:16
a given floor and they would not be prioritized.
Other instances would be how to easily and
quickly identify OU patients in the daily list of
radiology patients for a CT scan or inpatients
having a stress test.
Not all hospitals are large enough to have a
distinct OU or can afford to build a separate OU.
However, OU patients can be grouped in a specific part of a given floor or consistently assigned
specific beds so they can be readily identified,
starting at the point of registration and throughout the entire process. Having OU patients dispersed throughout the hospital necessitates
developing and maintaining various mechanisms
for their identification, whether color coding, different charts, etc., which could be cumbersome
and time consuming.
These techniques do identify the observation
patient from other inpatients on the same floor.
However, by training and by good clinical practice, if there is another patient on the same inpatient floor who is “crashing” then there is the
possibility or even the likelihood that nursing
personnel and resources may be, justifiably,
diverted to the most seriously ill patients. When
faced with more seriously ill or, even occasionally,
critical patients, it is possible, even likely, that the
nurse, physician or other health care provider will
prioritize caring for the most seriously ill or
injured patient first and the OU patient will be
lower on the list.
Cohorting all observation patients in the same
location, whether an designated unit or a section of
a given inpatient floor, generally avoids this
“ranking” of patients by acuity since, by definition,
all the observation patients are at the same “low
acuity” ranking and are patients who do not need
intensive nursing or physician care. This grouping
of patients promotes the “rapid turnaround”
approach and the attitude that this is a “shortterm” unit or area in which patients can only be
diagnosed and treated for 24 hours or less, which
also makes it more explicit to the patients and
families, physicians, and other hospital personnel.
To summarize, this concept of “clustering”
like patients is similar to the grouping of other
types of patients, such as intensive care unit
patients or cardiac step-down patients, etc., and
engenders the same benefits as cohorting any
patient types. Nursing and other personnel are
part of a “specialized” unit that fosters an esprit
de corp and anyone, including ancillary services
such as laboratory or radiology, can readily identify these patients and the “short-term” rationale
for their care.
Observation Unit Staffing
Once the location of the OU is determined, then
another key issue in setting up an OU is personnel.
One mistake that dooms an OU to failure is not to
assign additional staffing hours and/or additional
personnel to care for OU patients when opening an
OU. This is true for physician or physician extenders, as well as for nursing and ancillary personnel.
In the zeal to start an OU, sometimes, personnel
especially from the ED are expected to take on the
additional responsibility of OU patients in addition
to the current demands of caring for ED patients.
When this happens, the OU patient is second on
the list after the ED patient, which defeats the
premise of the OU for prompt, efficient diagnostic
evaluation and treatment.
Additional nursing staff and/or nursing hours
and physician coverage or hours, and perhaps,
midlevel providers, will be necessary when opening
an OU. There should be consideration of staffing
as for additional inpatient beds. Generally, for the
nursing staffing of the OU, there is a 1:4 or 1:5
nurse to patient ratio.
1
This ratio may be decreased
slightly at night since some diagnostic testing, such
as stress tests, are not done at night; although
patients are still undergoing diagnostic testing
and therapy – such as cardiac monitoring, having
blood drawn and ECGs done – and receiving IV
fluids, treatments, and medications at night.
Additional physician coverage or a combination of midlevel providers with physician coverage is also necessary since there is continuing care
(including availability to review diagnostic testing
and discuss results with consultants) and ongoing
evaluation of patient response to treatment, and
so on, in addition to the initial evaluation (history,
physical examination, and OU plan of care) and
discharge planning (with reevaluation: history,
physical examination, medical course/decision
making). In some institutions, the ED evaluation
is transitioned into the initial OU evaluation when
the same physicians are responsible for the OU.
This is the case in our OU and to avoid any
concerns, our practice is to waive the emergency
fee and bill only for the observation fee(s) since
the same physicians are caring for the patient.
(This refers to the physician billing. Hospital
Nursing
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billing is different. See Coding and Reimbursement chapters: Chapter 62 for Physicians and
Chapter 63 for the Hospital.)
Depending on the number of observation
patients, the physician/midlevel provider staffing
may vary but additional hours and or providers
must be added, otherwise the observation patients
will end up waiting until the physicians or midlevel providers finish treating other patients in
the ED and only then are available to reevaluate
the observation patient, write additional orders
and determine a disposition (discharge or inpatient admission), which defeats the purpose of
observation.
Unlike nursing in which there are some suggested staffing ratios, there seems to be more
variation in physician/midlevel provider staffing
and the ideal physician/midlevel provider staffing
has not been determined. One suggested model as
used previously in our OU has one physician and
midlevel provider to care for all 20 patients in our
OU during the day shift, which is a 1:10 provider
to patient ratio. During the evening and nights,
the secondary ED coverage in the “ fast track” or
less acute areas may cover the OU, but again there
should be additional coverage especially in the
evening. (See Chapter 1 Clinical Issues.)
We are considering other staffing models,
including expanding the midlevel provider coverage to 24 hours a day with physician oversight. In
this model the midlevel provider and physician’s
first responsibility would be the OU patients,
making sure the initial evaluation/orders are complete, reevaluating patients on the evening shift
and documenting their findings with a progress
note ideally on every shift, and doing the discharge evaluation with an updated history, physical examination, clinical course, diagnosis, and
the discharge plan, which is different from and in
addition to the initial evaluation conducted when
the patient is placed in observation.
In addition to nursing and physician staffing,
other personnel should be considered, especially if
it is a large OU. The OU will need personnel
similar to that needed for running an equivalentsized inpatient unit. The question should be asked
“What personnel are essential for an inpatient unit
with the number of patients in your OU?” For
example, a 20-bed inpatient floor would have nursing staffing and physician/midlevel providers
plus a unit secretary, housekeeping, transport,
“technicians” or patient care assistants who assist
the nursing staff with various tasks (from doing
vital signs to transport, hygiene, nutrition, etc.).
One suggestion is to use the ancillary personnel
numbers for a general inpatient floor. For example,
if a 25-bed floor has four patient care assistants,
then a 12- bed OU should probably have two
patient care assistants. Other services, such as
housekeeping or transport, need to be assigned to
the OU as well.
Observation Unit Design,
Equipment, Supplies
The OU is unique in that it has characteristics of
both an inpatient unit yet is considered an outpatient service. (See Chapter 6 Observation Unit
Design.) When we started our OU over two
decades ago, there were no other OUs that we
could go and observe their setup, design, and
staffing. Since the unit was under the auspices of
the ED, our blueprints were similar to that for an
ED. Mentioning some of our early issues related
to design may help others avoid similar problems.
For example, rooms in the ED may have a
room with a sink, but do not generally have
showers in each room. Patients in observation are
expected to be there for a short time but may be
overnight, so in the morning patients waiting for
or returning from a stress test or other procedures
may want to take a shower. We did not put such
bathroom facilities in our OU so our creative
nurses invented “bath in a bed” to allow for morning hygiene, but shower facilities are desirable.
Initially, we did not have phone lines in every
patient room, so on day one, the few phone lines
assigned to the OU were overwhelmed by families
phoning in and patients phoning home so that the
consultants, and ancillary services calling for
patients to be transported to stress testing, etc.,
could not get through. Needless to say, we immediately put phone lines in every patien t room.
A small kitchen area to heat up patient meals,
etc., is also desirable.
I consider this the “4Ts” of patient amenities:
telephone, television, toileting (hygiene) and,
more recently, technology (internet access for
patients and families). While waiting for diagnostic testing or undergoing treatment, a television
and, currently, outlets and internet access for
patients and their fa milies are becoming essential
in every room . This is all fundamental to improving patient and family satisfaction.
Sharon E. Mace and Karen Games
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