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The majority of patients in an OU are cardiac
patients: chest pain, heart failure, atrial fibrillation,
syncope, etc., and have cardiac monitoring ordered.
We made the mistake of not putting in cardiac
monitoring in every room so on day one we had
to find portable monitors until we could hardware
additional permanent monitors (at an expense).
Another consideration is the ability to include
patients with infections, such as pneumonia,
bronchitis, croup, bronchiolitis, gastroenteritis,
and diarrhea with dehydration, etc., in the OU.
This is a large group of patient s who can be cared
for in an OU so consideration for these “contagious” patients or patients with communicable
diseases should be included in the OU design.
Ideally, individual rooms, with doors instead of
curtains, etc., along with the usual standard infectious disease precautions will enable these patients
to be placed in the OU. (See administrative policy
on infectious diseases in Chapter 88 Administrative Policies.)
The OU needs to be stocked with the usual
inpatient supplies and equipment, such as linens.
Thought should be given to what medications to
include in the pharmacy stock or pixis in the OU.
Common medications that patients take daily may
need to be included since patients will need to take
their usual daily medications, in addition to various IV medications, etc., as used in the ED. The
OU is designed for low-acuity, low-risk patients so
the instances of resuscitations or “codes” should
be infrequent, although chest pain patients sometimes do rule in for a myocardial infarction.
2
Thus,
the pharmacy may need to stock both “routine
floor stock” as well as emergency medications.
The instances of intubations, resuscitations or
codes has been rare in the OU, although when we
had the first resuscitation in the OU, we had to go
to the ED to get a “crash cart”; fortunately the ED
was nearby, adjacent to the OU, but on review at
our monthly Observation Unit Meeting, a recommendation from quality improvement was to have
a “code cart” and an airway cart located in the OU
unit for easier and immediate access.
Observation Unit Census: “Time Lag
before the Observation Unit Is
Consistently Full”
Initially, it takes time, usually about 6 months to
a year, before everyone, especially the physicians
(and others including nursing), is comfortable
with the OU and placing patients in the OU.
This is true for the ED physicians as well as other
physicians throughout the hospital. If the physicians and/or midlevel providers are familiar
with the working of an OU, perhaps, having
worked in another OU or acquainted with observation medicine during their training/education,
this time lag before the OU is full may be
shorter. But in general, there is a delay before
the staff/personnel, especially the physicians, are
familiar with and understand the processes and
systems involved with the OU and are willing to
place patients in OS and the OU is consistently
full every day. This is to be expected and anticipated so staffing may need to be adjusted
or “ramped up” as the OU daily census grows
over time.
Observation Unit Staffing: Staffing
for the Daily and Hourly Census
in the Observation Unit
As mentioned, there may be a lag, usually 6–12
months, before the OU is consistently at full
census. There may also be variations in the daily
OU census so if there are “peaks and valleys”
and if a consistent pattern is identified, nursing
staffing may be adjusted appropriately. The observation census tends to follow the ED census, such
that when the ED is busy, the OU tends to receive
a lot of patients and be full. In our institution, the
ED census and, similarly, the OU census tend to
be lower on weekends so we decrease the nursing
staffing on weekends in the ED and the OU. (The
physician/midlevel provider staffing in the ED is
also decreased on weekends.) For pediatric EDs
and pediatric OUs, the ED census is likely higher
on weekends (and evenings) so staffing in the
pediatric ED and pediatric OU could take this
into consideration. However, if there is “flex”
nursing staffing, there may need to be an on-call
list or other avenues for increasing the nursing
staffing to meet the demand.
Generally, the highest influx of patients into
the OU is during the evening shift and the greatest
efflux or disposition of patients from the OU is in
the late morning and early afternoon. One possible solution to this hourly variation in the OU
census is to allow postprocedure recovery patients
be cared for in the OU since it is anticipated that
Nursing
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these patients will recover quickly (in 2–3 hours)
and be discharged around dinner time, thereby
freeing up the OU beds for the influx from the ED
on the busiest ED shift, the evening shift. We have
not allowed non-OU patients including postprocedure at our institution, but other institutions
have tried this practice.
This practice should be clearly differentiated
from the practice of putting admitted patients
into the OU until a bed opens up on an inpatient
floor. This is a dangerous practice and should be
avoided. The OU is not and should not become “a
holding unit.” The recommendation is not to put
admitted patients into the OU. This eliminates
beds for the true OU patients; in addition, this
creates excessive work by the OU nurses who have
to do nursing intake on an admitted patient and
then move the patient out to another floor where
the patient again sees another nurse. This practice
is also uncomfortable and unpopular with the
patients and families, and gives the appearance
of musical chairs or musical beds. This does not
give a very flattering view of the hospital to the
patient or their family. Needless to say, moving a
sick patient or someone in pain multiple times
from one bed to another until he or she reaches
his or her final inpatient location creates much
discomfort for the patient.
Assigning Observation Unit Nursing
and Other Personnel to Other Areas
and “Pulling Observation Unit
Staff/Personnel”
The purpose of the OU is the quick turnaround of
patients. If nurses are simultaneously assigned to
both the ED and the OU, the problem of dealing
with the most severely ill or highes t acuity
patients arises. By training and good clinical practice; clinicians, whether physicians or nursing
or ancillary personnel, will always prioritize the
sickest or most acute patients. Therefore, nursing
personnel should be assigned to the OU. Pulling
nurses from other units to respond when patients
are placed in the OU is a dangerous practice and
is to be avoided. It is difficult, if not impossible,
for a nurse who is caring for a given patient in the
ED or on an inpatient floor or other area of the
hospital to abruptly stop what he or she is doing
and transition to another area, the OU, to take
care a new patient placed in OS.
If OU nurse s are to be pulled from the OU,
then they should be assigned to an ar ea near the
OU since they can relocate quickly and they
should be caring for “short-term” patients. For
example, it may be easier for the nurse to assist
in the ED, especially in the “fast-track” area,
rather than the inpatient floors or even other
areas of the ED since these “fast-track” patients
are usually seen, evaluated and discharged very
quickly, freeing up the OU nurse to return more
rapidly to the OU.
It is preferable to staff the OU first and in
instances when the OU census is low, then
allowing the OU nurse to assist in the ED, with
the caveat that when a patient is placed in OS, any
patients that nurse is caring for in the ED are
immediately transitioned to another ED nurse so
the OU nurse can then begin caring for and
orienting the new OU patient to the OU. If the
OU nurses do work in the ED, then there should
be cross training so nurses from primarily the OU
or primarily the ED can work in the other unit, if
needed. Usually, nurses and other personnel who
work in a given unit prefer the type of patient care
specific to that unit so reassigning personnel to
other areas may create some dissatisfaction.
Balancing the demand of the OU for the ready
availability of staff to begin the patient’s management in order to ensure a rapid disposition and
quick turnover of OU patients with concerns over
cost, especially person nel costs, can be difficult.
Indeed, personnel costs, specifically nursing, are
the largest item in the OU budget. However,
factors that lengthen the OU stay are detrimental
to the efficiency of the OU and can have major
negative consequences in terms of patient outcome, quality of care, reimbursement, risk management, and patient/family satisfaction. A valid
cost analysis is likely to confirm the value of the
OU, and justify the personnel and other costs
involved. (See Chapter 68: The Business Case for
Observation Units.)
Administration of the Observation
Unit: Physician Medical Director
of the Observation Unit
There must be a physician medical director of the
OU. The physician me dical director has a dual
function: clinical and administrative. The physician medical director is responsible for ensuring
Sharon E. Mace and Karen Games
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quality patient care in the OU with the best possible patient outcomes. He or she oversees the
provision of medical care in the OU (for OS
patients). He or she is also the administrative
leader of the OU and works conjointly with the
nurse manager of the OU to foster the efficient
operation of the OU.
In order to fulfill the clinical and administrative responsibilities of the OU, the physician medical director of the OU should have protected
nonclinical administrative time.
1
There are many
varied complex roles performed by the medical
director of the OU, who has a leadership role for
the physicians and the entire OU. (See job
description for the physician medical director in
Chapter 88 Administrative Policies.)
Administration of the Observation
Unit: Nurse Manager of the
Observation Unit
No matter what the size – for example, number of
beds and thus, number of patients – there must be
a nursing administrator or nurse manager for the
OU just as there is a physician administrator
for the OU .
Whether the nurse manager is a full-time
administrator or part-time and works some clinical shifts may depend on the size and other
factors related to the OU as well as to the hospital.
As a general rule, it is usually good practice
for administrative personnel, whether nursing or
physicians, to work a few shifts or hours in the
OU and/or to be able to respond to clinical needs
and do “hands on” care for patients when the
need arises. This is a way to experi ence firsthand
the issues involved in caring for OU patients
and become knowledgeable about the details of
the day-to-day functioning of the OU, as well
as to gain credibility among the OU staff and
physicians.
If the OU is larger, or more specifically, a
“high-volume” unit, which has a large number
of patients, then there is like ly more than enough
for the nurse manager of the OU to do and the
OU probably deserves its own nurse manager, in
addition to the nurse manager of the ED, even if
the OU is under the auspices of the ED.
Summary
This chapter discusses some of the commonly
asked questions regarding the setup of an OU
with a focus on those issues that impact nursing
staffing. Based on our decades of experience, for
an OU to succeed, there must be the following:
personnel (clinical and administrative); resources
(space or location, equipment, supplies); specific
and general (clinical and administrative) guidelines, policies, procedures, order sets, and other
tools; a mandatory time frame; strong leadership
empowered to clinically and administratively
manage the OU with administrative support from
the hospital; and a multidisciplinary teamwork
approach.
References
1. Mace SE, Graff L, Mikhail M, et al. A national
survey of observation units in the United States.
Am J Emerg Med 2003; 21: 529–533.
2. Mace SE. Resuscitations in an observation unit.
Journal of Quality in Clinical Practice 1999; 19
(3):155–164.
Nursing
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Part I
Chapter
8
Administration
Risk Management
Gregory L. Henry, MD, FACEP
Introduction
Observation units have and will become a valuable tool for health care systems to manage both
patients and risk. With such units, physicians can
improve quality, and meet both patient and provider expectations. It is important to note that in
most emergency departments (EDs), the principle
complaints of patients have not changed over
the years. “I waited too long,” and “they never
told me anything,” are still common refrains
heard around ED waiting rooms. Complaints are
from frustration w ith unmet expectations. Such
frustration leads to anger, which, in America
today, leads to lawsuits. Risk management must
deal with causes of unmet expectations if it is to
mitigate the problems of the current medical/legal
quagmire. It is only from this broader approach
that better patient care and patient expectations
will be realized.
Insurance companies have become in some
ways the final arbiters of medical care, and they
never take risk; they spread risk. Insurance rates
will not go down until the actual risk goes down.
This will only be accomplished through planned
changes in the behavior of individuals, and more
importantly through changes in the system. If the
ED systems for evaluating patients leads to frustration, that is, long delays, poor service, etc.,
complaints and lawsuits can be expected. If the
ED systems for evaluating patients lead to bad
outcomes, that is, failure to diagnose serious disease, lawsuits are not just expected, but a certainty. The traditional ED system for evaluating
patients fails to diagnose a considerable number
of patients with acute myocardial infarctions and
releases them home with false reassurance. Other
serious conditions are similarly not reliably identified in the traditional ED. Observation units are
a tool to address many of these risk problems in
emergency medicine. More than that, they actually provide better care for less cost, which is a
laudable goal of the health care system. Observation units represent the new third pathway,
joining discharge and admission as outcomes
from an ED visit.
What Is Risk Management?
The actual definition of risk management has
varied over the years, but the traditional role
of risk management has been protection of the
institution, the health care workers, and the asset
base on which they function. Risk management
has carried a negative connotation not only for
the patients, but for the doctors. People from risk
management departments have been viewed
as meddling, non-physicians, or at least nonpracticing physicians, who have come to preach
as opposed to improve. Risk management has
been viewed as an office in the hospital bureaucracy rather than a way to practice. It may be that
the term “risk management” has outlived its usefulness. Patient safety is and should be the more
refined view of risk management.
Who Has the Real Risk?
The newer modes of risk management recognize
that the only real risk is to the patient. The people
who can truly be harmed by inadequate care are
the people receiving that care. The only way to
manage risk is to change the system and the care
that is given. A quality assurance program that
does not run hand and glove with a risk management program is doomed to failure. They are two
sides of the same coin. The function of risk management is to make certain that every patient
feels he or she has been handled in a correct and
humane manner. It is not just to manage claims
and complaints, but to have a continuous feedback loop into the care that is given so the problems are anticipated. The true effect of a risk
management program should be to help modify
the system. Perception is the only reality; the
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perception of care, as well as the care itself, is
critical to the intrinsic operations of any ED.
TheQualityofRiskManagementData
A tremendous problem in discussing risk management and quality assurance is that the information collected over the years has been spurious
at best. Most risk management departments
define their losses as failure to treat or failure to
diagnose, which rarely gets at the basic problems
involved. When considering an evaluation of
appendicitis, for example, the recorded claim is
always failure to diagnose. When in fact, with the
vast majority of such claims the patient did not
have the criteria on which the decision to operate
could be made. The real problem was in the
follow-up care, time interval for being seen again,
and the way in which the patient was instructed. It
is not that a diagnosis was not made, but that a
definitive diagnosis at that moment in time could
not be made and that further evaluation on a
time-structured basis was needed. This is a question of the quality of the discharge program and
the quality of system integration rather than a
simple failure to diagnose.
This type of overly broad and nonspecific data
collection is essentially useless when it comes to
improving the system. Humans only respond to
specifics. A physician and a system must know
exactly what behavior requires changing if they
are to act in a predictable manner. Risk management data in the future will need to be much more
carefully scrutinized and collected so that we actually understand the system, decision, or specific
action that requires change. Most human beings,
if handled correctly, can understand that medicine is complex. Instant decisions are often
impossible. Correctly constructed systems that
get the patient into health care, as opposed to into
the hospital, will be required in the future if costs
are to be controlled and patient safety assessed.
System Thinking
Just as Deming totally changed the manufacturing
world with his views of quality assurance, the
current medical system, which has grown up since
WWII, needs such an overhaul.
2
In the United
States, since the end of WWII, there has been
maximal money and minimal intelligence put
into asking serious outcome questions with
regard to health care outcomes. The questions of
“what do we want from a health care system?” and
“what should be the services provided by that
system?” have never been seri ously asked in a
structured format. If medicine is to be more than
a glorified magic show with the patient entertained by periods of incarceration in less-thansterile buildings with toys and gadgets, definitive
outlines of where we need to go must be drawn.
To this end, fundamental questions about the
function of hospital versus outpatient care will
need to be addressed. System thinking is defining
what outcomes will drive the health care system of
the future. This form of thinking must be done
as a partnership with those receiving the service.
The focus must not be on identifying good and
bad physicians, but on identifying good and bad
systems for providing defined medical service.
Ultimately, physicians alone will no t determine health care. A combination of scientific
input by physicians and the wants and desires of
the broader society will determine what services
will be given and in what settings. As resources
become more limited and the population continues to age at a rat e that has never before been
contemplated, the need to define what actual role
and outcome medicine can play is paramount.
Observation units cannot become holding units
for the diffident. They can’t be another place
to die. People can die at home for free. Risk
increases when the expectations of the general
society are not mirro red in its institutions. If the
expectation of the general society is that everyone
with abdominal pain is admitted to the hospital,
whether it has anything to do with their improved
health or not, failure to admit places extra risk on
health care providers. That is why serious discussion needs to be undertaken. Drive-through deliveries, drive-through mastectomies, termination of
life-support systems, and the like are not as much
scientific questions as they are sociologic questions. Risk management has been the interface
between technical and scientific knowledge that
has not yet become inculcated into societal beliefs.
Improved Communications
No discussion in a textbook of this generation
would be complete without genuflecting to the
intellectual god of communications. What people
think is greatly a function of what they are told. If
it is the norm that patients die at home, as it is in
many countries, there is no problem with a death
Risk Management
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at home. In the United States where death is
accompanied by sirens, ventilators, and transplants, communications with families becomes
critical. The decision to employ expensive inpatient, high-tech medicine to a defined end point will
more and more require the input of patients, their
families, and some true medical knowledge as to
the likelihood that such interventions would
restore meaningful life. It is often difficult to say
in one brief moment in the ED to what degree
family and patients understand the seriousness of
their disease and the likelihood of a return to
reasonable function. An often-overlooked function of observation units is not just for physicians
to monitor the course of a disease so as to be better
able to predict interventional outcomes, but for
families to become educated on the various
options and what might to be done with regard
to their loved ones. The real communication of
medical facts, as applied to the emotions of the ill,
is a milieu devoutly to be wished. Restructuring
the ED by adding a third disposition pathway,
observation, to the traditional dispositions of hospital admission or discharge empowers the ED
staff to have hours, rather than minutes, to spend
communicating with patients and their families.
But limitations are needed. The system fails when
the observation units become a step in the pathway from nursing home to funeral home.
Improved Cost-Effectiveness
The EDs of the United States are increasingly
becoming the arbiters of the application of science
to human problems. At any hour, day or night,
EDs are available throughout this country to process human misery and enter people into the health
care system. This need is not decreasing. Whether
the primary interests are social, such as the poor
and uninsured, or a mixture of medically and
financially important issues, such as in managed
care, a tempest in medical care exists in EDs. The
sorting out function has never been more important and has never required more skilled practitioners. It also requires wisdom. It is only in knowing
what to do and to whom, that we are able to
balance the three imperatives of access, quality,
and cost. There is an ill-defined sense that there
exists some linear relationship between the amount
of money spent on health care and the health of
society. Yet, some countries which spend less than
one-third that of the United States (on a gross
national product basis) on health care actually
produce better overall health outcomes. A third
disposition pathway (transfer to observation) prevents the ED staff from hasty decisions on hospital
admission and allows hours, rather than minutes,
before decisions must be made on committing a
patient to extensive, costly evaluation in a hospitalized setting. No one wants to talk about the fact
that the larger community need is not medical
observation units but psychiatric observation units.
In many locations effective care to medical patients
is being destroyed by overwhelmed and grossly
inefficient psychiatric systems.
Legal Issues
When providers and consumers cannot agree on
problems in risk management, resolution does not
occur in the medical world, but in the realm of
jurisprudence. The questions become of duty,
breach, harm done, and the proximate cause. The
relationship between these elements is the exclusive
arena of the law. Medical malpractice has been
present in English Common Law since at least
1290 AD. Since the case of Hill versus Chynault
in 1377, we have specific case law on which to base
future legal decisions. The concepts of health and
specific medical abilities in diagnosis and treatments have varied tremendously since the first
medical/legal cases. The concepts of physician as
assuming the role of healer have not changed in the
last millennium. In legal terms, the physician is
the retained agent and servant of the patient. The
degree to which we understand our servant role is a
measure of our maturity in medicine. By the same
token, physicians and the medical community are
health advisors to the individual. It is the interaction between the patient’srightsandthephysician’s duty where risk management is most
challenged. Into the future, as resources diminish,
the skilled physician is the one who can help the
society truly choose amongst options that will provide meaningful life with the most judicious use of
resources. Creating a system for selected patients to
receive prolonged observation with ED staff
enables emergency medicine to better meet both
its moral and legal obligations.
High-Risk Situations
EDs must come to grips with the fact that highrisk situations do exist. The role of observation
units should be in simultaneously increasing the
Gregory L. Henry
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quality of care, reducing the overall cost of care,
and providing the least disruption to patients’
lives. The options of either ED discharge or an
in-hospital admission must be supplemented by
the third choice of observati on. The third pathway
is often the most intelligent pathway with certain
types of conditions such as chest pain, abdomen
pain, headache, asthma, and change in mental
status.
Chest pain cases still constitute approximately
30% of all monies lost in emergency medicine
malpractice cases.
3
A physician who believes he
knows the exact cause of chest pain of every
patient after the initial history and physical is
often referred to by another name: Defendant
Physician. Chest pain is a constellation of diseases
in which the initial history and physical may
reveal nothing, while the patient actually has
incredibly severe disease. Only through proper
observation, retesting, and the application of certain test modalities will the question of chest pain
be resolved. It is the ideal example of that intermediate condition in which decisions can be
made without admission to the hospital, but often
require more than an initial history and a physical. Various TIA and stroke syndromes are
becoming the new norm for observation work-up.
Abdominal pain still constitutes a large percentage of money lost in emergency medicine malpractice.
4
The progression of disease may not be
clear. Abdominal pain can be sensitive, but highly
nonspecific. In those cases, in which time sensitive
management is required, the observation unit may
be ideal. Certainly many patients with abdominal
pain can go home and return in specifically stated
times for reevaluation. The observation unit is
ideal for those patients who have difficulty in logistics, transportation, understanding their disease, or
for those patients the physician has a high level of
concern about the presence of serious disease.
Resolution of head pain with therapy is no
indication that severe disease does not exist.
5
The performance of studies such as lumbar punctures, CT scans, and therapies with multiple drugs
may require a more prolonged ED evaluation. In
such cases, observation and treatment may be
essential in arriving at a diagnosis without missing potentially life-threatening disease.
The vast majority of diabetics who have mild
to moderate ketoacidosis can be managed with
aggressive fluids, insulin, and electrolyte therapy
and can be reversed without resorting to inpatient
care. Such patients often understand the nature of
their disease and how they got into trouble; actually admitting such patients, because it is an artificial situation, may prolong the time to stabilize and
enter them back into the usual outpatient world.
Asthmatics, as a group, constitute the largest
number of return visits to EDs.
6
This is frequently
because they are not using their medications correctly, are going back into contact with irritants,
or have not been properly stabilized before discharge. Observation/treatment units provide for
proper therapy and allow systematically administered steroids and other medications to stabilize
the condition of the patient prior to discharg e.
The quintessential ED patient is the alcoholic
with mild alteration of mental status who may or
may not have hit his head. Such patients are often
minimally confused and yet hospitals simply do
not have the resources to admit all such patients.
Observation units are where frequent repeat
examinations can be performed, and where community resources and family support can be
organized to facilitate the proper management of
such patients. Inpatient therapy offers little to
such patients who will then again return to the
streets. The coordination function with regard to
Risk Management Approach
Risk Management Goals
Improve service
Improve outcome
Help manage poor outcomes
Strategy to Decrease Risk
Patient feels handled correctly & humanely
Risk management data on system
On system function
On decisions
On actions
On outcomes
Observation to Redesign System
Improve communications
Improve cost-effectiveness
Observe High-Risk Patients
Chest pain patients
Abdominal pain patients
Headache patients
Asthma patients
Mental status patients
TIA
Risk Management
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such community and family services, which can
be carried out in a rapid treatment and decision
unit, are often overlooked. The availability of
resources for patients with altered mental status
and psychiatric disease is often tremendously constricted in nonregular work hours. It is frequently
the function of the ED to not only stabilize the
medical situation, but the social situation as well.
This may be best accomplished through a rapid
treatment and decision unit.
Conclusion
Risk management, in its older format of protecting the institution at all costs, is rapidly dying.
Risk management in the future will look at the
causes of risk and provide feedback and input into
the system to control such risks by improving
the care. The institution, the physician, and the
patient will all be at less risk if systems are broadly
understood by the people they serve. Some consensus as to what services will be offered and
where those services are best provided is needed
in this society. A total rethinking is necessary as to
the role of the in-hospital setting. The new role
of risk management in providing feedback to
improving the system, as well as communications
with patients and their families, will be critical as
we are more and more challenged to judiciously
utilize resources.
References
1. Henry G. Emergency Medicine
Risk Management:
A Comprehensive Review, 2nd
ed. American College of
Emergency Physicians, Dallas,
TX, 2001.
2. Deming, WE. Out of Crisis.
Massachusetts Institute of
Technology, Center for
Advanced Engineering Study,
Cambridge, MA, 1982.
3. Rogers JT. Risk Management in
Emergency Medicine. American
College of Emergency
Physicians, Dallas, TX,
1985.
4. Ibid.
5. Henry G. Headache, Emergency
Medicine Concepts in Clinical
Practice, 4th ed. Rosen/Barkan
et al., C.V. Mosby-Yearbook
Inc., St. Louis, MO, 1998.
6. Butz AM. Outcomes of
emergency room treatment of
children with asthma.
J Asthma. 1991;28(4):255.
Gregory L. Henry
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Part I
Chapter
9
Administration
Metrics and Performance Improvement
Patient Quality, Safety, and Experience
Sharon E. Mace, MD, FACEP, FAAP
Elaine Thallner, MD, MS, FACEP
Introduction
Quality improvement requires a method for
measuring and analyzing information about
a process, program, and/or system.
1
Tracking
metrics can be a valuable tool for assessment
of a system or benchmark.
2,3
Metrics are a first
step in a comprehensive Performance Improvement (PI)
4
or Continuous Quality Improvement
(CQI) program.
5
CQI has been defined as a continual process or methodology for positive change
or improvement in a system or program by
making system improv ements or modifying the
practice or procedure of how things are done.
In health care, the desired end result of any PI
or CQI process is to make a positive impact on
patient care, with the hope of improved patient
outcomes, which may include an array of results
ranging from a decreased length of stay (LOS) to
improved quality of life as well as a decrease in
morbidity and mortality.
6–8
More recently, another factor, cost, has been
added to this process. In addition to improving
patient care, there now needs to be a component
included that looks at the costs involved in providing quality care. So the equation has become
value = quality/cost whereby increased quality
and/or decreased cost increase value. This corresponds with the Centers for Medicare Services’
focus on transitioning from volume-based care
to value-based care.
Components of a comprehensive PI or CQI
program include quality, patient safety, and
patient experience.
9,10
Patient quality focuses on
improving patient care and achieving better outcomes by modifying processes and changing
and improving the system as well as monitoring
individual performance. The goal of patient safety
is to foster an environment that enhances the
identification of problems instead of ignoring or
concealing problems. The objective of a patient
experience program is to create the best experience
for everyone involved, especially the patient and
family, but also for the health care workers, as well
as including improved communication, patientcentered care initiatives and empowerment of
the patient.
Examples of “tools” in the PI “toolbox” or
approach include any number of forms from the
Toyota production mode (Demming approach),
the aviation flight team model, the plan/act/do/
check method, lean initiatives, and six sigma.
11
The Importance of Observation
Medicine
Numerous studies have documented the many
advantages of observation medicine in terms of
lower cost, decreased missed diagnoses, improved
risk management, fewer admissions, improved
quality of life, shorter length of stays, greater
patient satisfaction,
12
lower readmission rate, less
returns to the emergency department (ED),
improved efficiency of the ED, better patient care
and patient outcomes with fewer complications
and adverse events, and decreased morbidity and
mortality. Yet little has been published on CQI,
and even less on metrics for the observation unit
(OU), although CQI for the OU may be an asset
in identifying problems, saving money, improving efficiency, defining issues, developing new
processes, or making further improvements in
the system and processes.
5,13–15
Components of a CQI Program
Critical components for the OU to function optimally include policies and procedures, protocols,
standardized order sets, and clinical pathways. (See
Clinical Protocols Chapters 82–87, Administrative
Policies Chapter 88, Order Sets Chapters 89–96.)
Benchmarking against other OUs is a useful
methodology for ascertaining whether the OU is
performing at its full potential. Comparison with
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national or even international benchmarks or
standards can help determine how your specific
institution/OU is performing and if there is an
opportunity for improvement. Internal comparisons over a given timeframe (e.g., daily, monthly,
quarterly, or yearly) at your own institution/OU
can gauge whether issues are developing or if there
is progress toward a given goal.
Observation Unit Database
Information essential for an OU database begins
with the patients placed in observation status.
Such information is required for many purposes, in addition to metrics and the CQI program. Some of the reasons mandating an OU
database are communication among health care
providers and transitions of care including
patient care for referrals and follow-up; regulatory requirements whether local, state, or federal; meeting the standards for various
organizations, such as the Joint Commission
on Accreditation of Healthcare Organizations
(JCAHO or the “Joint”); for reimbursement
from government programs, health maintenance organizations, and other insu re rs/pa yer s;
in addition to training, education and research.
Of course, maintaining patient confidentiality
and meeting the Health Information and Portability Act (HIPPA) requirements, as with any
patient information, is mandatory.
Suggested data elements for individual OU
patients are listed in Table 9.1. Various components, such as mandatory patient identifiers such
as name and medical record number, are needed
for many reasons including follow-up on laboratory tests, procedures, and for referrals. At a minimum, the final diagnosis is essential clinical
information. Times are required in order to calculate LOS. LOS for the OU does not include the
time spent in the ED. Onset is from when the
order to place in observation is written and then
nursing acknowledges and documents the observation orders. LOS may be the most important
metric for an OU.
The specific procedures and the time required
for them is a requirement for the database since
the time out of the OU for various diagnostic or
therapeutic procedures, such as an endoscopy or
stress test, should be subtracted from the OU
time (e.g., time discharged from observation –
time placed in observation) in order to accurately
report the LOS for facility billing purposes. However, in some cases and depending upon the
payer, an average for a specific procedure may
be given. Although one should be able to determine or reiterate how this average was determined or calculated.
Suggested data elements useful for regular,
such as monthly and yearly, statistics, and for
designing metrics for the OU and evaluation
Table 9.1 Data Set for Individual Patients in the
Observation Unit (OU)*
I. Patient Identifiers
– Medical record number
– Name
II. Demographics
– Age
– Gender
– Ethnicity
III. Time
– Length of stay (LOS) in observation
– Date placed in observation**
– Time placed in observation**
– Date discharged from observation (or
admitted to an inpatient floor)
– Time discharged from observation (or
admitted to an inpatient floor)
IV. Disposition: admitted, (if yes, what floor or unit);
discharged, expired, other (give detail, e.g., left
against medical advice)
V. Clinical
Chief complaint(s)
Final diagnoses
Comorbidities
Procedures (list all)
Time for the procedure(s)***
Laboratory tests
Radiology tests
Consults
VI. Health Care Coverage/Insurance
* This is not an all-inclusive list, but one suggested data set
that can be tailored to the needs of your individual unit.
Insurance information may be in a separate data set from
the clinical parameters.
* This does not include such personnel information as
address, phone, emergency contact. Billing information such
as the insurer(s) may be in a separate data set.
** Needed to determine or calculate length of stay.
*** Facility requirements include subtracting procedure
times (time for a procedure and/or away from OU, as for a
stress test as an example) from overall OU length of stay.
Sharon E. Mace and Elaine Thallner
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