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Part II
Chapter
11
Observation Medicine: Clinical Setting And Education
The Urban Community Hospital
Robert S. Bennett, MD
A community hospital is an ideal setting for an
observation unit (OU). Although many OUs
have been developed at large academic institutions to deal with issues of crowding in emergency departments (EDs) and inpatient units,
there are other compelling reasons to support
their presence in additional settings. In surveys
conducted between 2007 and 2008, approximately a third of all EDs in the United States
were found to have dedicated OUs. About
56% of these are administered through the
ED.
1,2
There is clearly an opportunity for expansion to the remaining facilities that do not yet
have dedicated OUs.
A community hospital ED may not have the
volume to fill a large OU. However, a small unit
(for example, ten beds or fewer) can provide flexibility to manage short-stay hospital patients or
extended-stay ED patients. The pressure on EDs
to complete full evaluations, including procedures
and radiology studies with limited availabil ity
(such as MRI), has resulted in longer stays. These
patients can be referred to an OU to decompress
the ED, with the OU functioning as a clinical
decision unit (CDU). There is growing evidence
that many “short-stay” patients managed on an
inpatient unit are similar to OU patients.
1
A community OU may be able to provide more
cost-effective and high-qual ity care to these
patients as well.
The key to the successful operation of a
community hospital OU is the cultivation of
strong relationships with diverse services. The
ED providers facilitate the referral of appropriate patients. Frequent interactions and feedback
regarding patient outcomes is essential. In
an environment that has become increasingly
regulated, availability of and collegiality with
utilization managers will assist with patient
selection. Geriatric services, which are becoming the focus of many EDs and OUs, should
follow suit. It is time-consuming to evaluate,
treat, and discharge an elderly patient presenting to the ED since many of their problems
are multidimensional. OUs can provide a less
hectic setting where more time can be taken to
evaluate the often complex set of circumstances
that led to an elderly patient’s arrival to the
hospital. Solid support from physical therapy
and social work consultants is vital in determining appropriate and safe disposition for
geriatricpatients.(SeealsoChapter55Geriatric
Observation Medicine and Chapter 81 AgeRelated Observation Care)
Most observation services include a large
census of patients with cardiac problems such
as chest pain, syncope or arrhythmias. Therefore,
it is worthwhile to nurture a collaborative relationship with the hospital cardiology department. Many patients with low-risk chest pain
require a noninvasive study. If the plan is to
perform t he study as p art of the OU stay, then
scheduling studies should be prioritized and
patients should be prepared with standardized
order sets (NPO, beta blockers held, and appropriate attire available). (see Chapter 89 Adult
Order Sets) Availability of testing o r consultation with a cardiologist early in the day can
optimize operational efficiency.
The presence of an OU in a community hospital can be a great asset. Institutions value the
additional revenues that can be produced with
high patient satisfaction and reduced lengths of
stay.
3
Patients are clearly satisfied with costeffective and efficient care. Forging and maintaining strong relationships with the many partner
services that support the OU is pivotal to the
success of any OU.
014
20:27:32
References
1. Wiler JL, Ross MA, Ginde AA.
National Study of Emergency
Department Observation
Services. Academic Emergency
Medicine 2011; 18:959–965.
2. Venkatesh AK, Geisler BP,
Gibson Chambers JJ, et al. Use
of observation care in US
emergency departments,
2001 to 2008. PLoS ONE 2011;
6(9):e24326. Doi: 10.1371/
journal.pone.0024326.
3. Baugh CW, Venkatesh AK,
Bohan JS. Emergency
department observation units:
a clinical and financial benefit
for hospitals. Health Care
Manage Rev 2011;36(1):
28–37.
Robert S. Bennett
014
20:27:32
Part II
Chapter
12
Observation Medicine: Clinical Setting And Education
Jonathan Glauser, MD, FACEP
Observation medicine started in the commu nity
setting as a way of working up certain discrete
problems that were quite common in the community setting and could be resolved within 24
hours: chest pain, asthma, COPD exacerbations,
and, slightly later, heart failure. These presentations were common in all emergency departments
(EDs), and lent themselves to standardized workups with treatment protocols. Moreover, since
patients often did not have to physically leave
the location of the ED, these workups could be
pursued expeditiously and more economically
than on an in-patient floor, and without delays
and interruptions while awaiting bed assignments, transfer of care to another service, or
transport upstairs.
Tertiary care hospitals work differently from
community hospitals in certain fundamental
ways. Patients with solid organ transplants, for
example, are seen nearly exclusively at transplant
centers, so that community hospitals seldom
manage transplant complications or even the routine emergency care of such patients when it is
not related to the transplan t itself. Similarly, tertiary referral centers treat patients with certain
chronic illnesses that may not present in the community setting at all because the underlying disease is rare, or because community primary care
physicians seldom are the major provider of these
patients’ care. Medical disorders such as primary
pulmonary hypertension, inflammatory bowel
disease, thrombocytopenic purpuras, leukemias,
myelofibrosis, gastroparesis, postural hypotension (POTS), refractory headaches (which historically do not clear with stan dardized therapy
for migraine), and other entities force patients
to come to tertiary centers exclusiv ely, including
for their emergency care.
It should be noted that a variety of urologic,
neurosurgical, colorectal and ENT procedures are
performed solely within a relative handful of
centers. Some patients therefore will be referred
from outside emergency departments to tertiary
care EDs. Many of these patients, while having
possibly rare illnesses, may not require a prolonged hospitalization, but simply an evaluation
by a consultant who is not available at all in a
community hospital. These patients may be
observed overnight pending an evaluation by a
consultant with unique expertise not found elsewhere in the city or even the state, and not necessarily present overnight at the tertiary center.
Patients with common problems typically
managed in the community setting may require
referral for care in a tertiary hospital, even if that
care can still be accomplished within 24 hours.
It is one thing to manage congestive heart failure
overnight with diuresis, education in diet, and
evaluation for acute coronary syndrome. It may
be a completely different matter in the patient
with an ejection fraction of 15%, who is already
on a transplant list, and with a course of therapy
maxed out on a regimen including diuretics,
aldosterone, beta blockers, and ACE inhibitors.
Tertiary care hospitals almost by definition are
in an urban setting, or at the very least require a
large catchment area to exist. A recent report
noted that hospitals with ED-managed observation units are more likely to be located in an
urban area and to have reported boarding in
the ED.
1
It is therefore reasonable to expect that
tertiary care hospitals in particular will derive the
aforementioned benefits of OUs to urban hospitals in terms of patient flow and in ameliorating
bed shortages upstairs. These are also medical
centers that tend to be larger, have more specific
admitting services, and therefore more complex
bed arrangements for specific categories of problems, with ensuing difficulties arranging the
proper floor and service for patients going
upstairs. The Crohn’s patient with a simple flare
will not go to the same floor or service as the one
with a collection on abdominal CT. The patient
with Goodpasture’s disease and hemoptysis may
015
20:27:38
not go to the same pulmonary service as the lung
transplant patient.
From a financial perspective, there is the
threat of audits of patients who “should have”
been admitted on observation stay by agencies
charged with recouping dollars, especially by the
nation’s largest health insurer, the Centers for
Medicare and Medicaid Services (CMS).
2
The
incentives for tertiary care centers to have or
establish OUs are self-evident, especially to any
emergency physician who has ever composed a
letter justifying why a hospital admission was
necessary as opposed to a less expensive observation stay. It should be self- evident that a recovery
audit contractor (RAC) who gets paid to extract
money from hospitals will not be impressed that a
patient who drove 300 miles to the ED had to be
fully admitted to the hospital so that he or she
could be seen by a specific consultant hematologist or urologist the next day. Given the interactions that emergency physicians have with
nearly every service in a complex institution, as
well as the time sensitivity inherent to the practice, emergency medicine may be uniquely situated to perform observation medicine in the
setting of the tertiary care ED.
3
The optimal size of a tertiary care hospital’s
OU has yet to be defined. Some may make the
case that the future hospital will be comprised of
intensive care beds and operating rooms, with the
remainder being divided among short-stay and
observation beds – in which case the future observation unit may need to be very large indeed.
There is ongoing pressure to accomplish imaging
more expeditiously as well. For example, keeping
an elderly patient with a negative X-ray who has
acute hip pain after a fall for an MRI is more
unacceptable than it was 10–15 years ago. Interventional radiology may be expected to perform
more interventions or tube placements immediately on patients staying in an OU when in the
past it would have been unthinkable to not formally admit them to the hospital. Since tertiary
care centers in general have more ready access to
technology and interventional services, it is reasonable to assume that the need for diagnostic
studies will enhance the value of the OU even
more in the tertiary referral medical center.
It will always be unacceptable for the emergency physician to not make accurate assessments
and diagnoses in any hospital setting. The
enhanced knowledge content, the availability of
technology at terti ary centers, and the immutable
fact that certain illnesses can only declare themselves after a period of time all ensure that observation medicine will become ever more critical to
the function and financial survival of these referral centers.
References
1. Wiler JL, Ross MA, Ginde AA.
National study of emergency
department observation
services. Acad Emerg Med
2011; 18(9): 959–965.
2. Terra SM. Regulatory issues:
recovery audit contractors
and their impact on
case management. Prof
Case Manag 2009; 14:
217–23.
3. Baugh CW, Venkatesh AK,
Bohan JS. Emergency
department observation units: a
clinical and financial benefit for
hospitals. Health Care Manage
Rev 2011; 36(1): 28–37.
Jonathan Glauser
015
20:27:38
Part II
Chapter
13
Observation Medicine: Clinical Setting And Education
Observation Medicine and the Hospitalist
David G. Paje, MD, FACP, SFHM
Peter Y. Watson, MD, FACP, SFHM
The concept of observation medicine (OM)
evolved from the same need for a more efficient
delivery of hospital-based services that gave rise to
the hospitalist movement. Whereas observation
was initially defined through specific government
directives, the early years of hospital medicine
were shaped in part by managed care forces.
1,2
Nonetheless, both were conceived to reduce cost
while improving the quality of care in the hospital
setting.
Since observation can be provided anywhere
on hospital premises, whether in a designated unit
or in a general unit, it is essential for the hospitalist to understand this new paradigm and to
recognize certain clinical and operational aspects
that distinguish observation from the usual inpatient care. This distinction starts with selecting the
right patients, and the key to this is properly
matching patients’ medical needs with the appropriate resources and level of care. Those placed in
observation are generally lower risk in terms of
severity of illness or likelihood for short-term
adverse outcomes. However, many of them present with diagnostic uncertainties for potentially
life threatening conditions, such as myocardial
infarction, serious arrhythmia or cerebral ischemia. The hospitalist must apply evidence-based
clinical algorithms and risk-stratification tools to
safely and efficiently identify patients who are
ideal candidates for observation.
When observation patients are placed in regular inpatient beds alongside admitt ed patients
who have more complex needs, the opportunity
to drive throughput may be lost in the overall unit
workflow. Formulating clinical pathways that are
goal-directed and clearly defining parameters for
disposition allow nurse-driven care and lead to
shorter lengths of stay. In addition, identifying
a dedicated hospitalist to round primarily on
observation patients should minimize the effect
of competing priorities from admitted patients
who are generally sicker. Alternatively, placing
all observation patients in a designated geographic area or unit would be ideal, and this has
been shown to have the potential to improve
efficiency and clinical outcomes.
3–5
Hospitalists must also be aware that the usual
routine in hospital operations, particularly with
regards to laboratory, imaging, testing and consultative services, may inadvertently delay the care
of observation patients. This is because staffing
and scheduling for these services are based on the
typical ebb and flow in demand that is mainly
influenced by inpatient ordering practices and
by traditional physician rounding times. Hospitalists need to collaborate with hospital leadership
and other key stakeholders to design a reasonable
expedited process specifically for observation
patients.
6
Also, hospitalists should adopt a scheduling model that ensures around-the-clock on-site
coverage, especially since observation patients can
be admitted or discharged at any time of the day,
and since some clinical conditions may need frequent and timely physician reassessments. Furthermore, these patients are best managed with a
mind-set that evaluates their progress in terms of
the hours rather than the days they have been in
the hospital.
For institutions that have observation units
(OUs) that are run by hospitalists, there may be a
temptation to accommodate patients with higher
acuity including admitted patients who are waiting
for inpatient beds. This is particularly true when
hospital occupancy is high and when the emergency department (ED) is busy. Nevertheless, routinely allowing this practice defeats the purpose of
a designated OU, that is, to drive throughput by
grouping together patients who have more predictable and shorter lengths of stay.
7
Keeping the
integrity of this cohort is crucial to the success of
the unit, which translates to increased bed availability and improved ED throughput.
8,9
In conclusion, providing observation ser-
vices is consistent with the hospitalist’smission
016
20:27:46
of optimizing resource utilization while at the
same time advancing the quality of care in the
hospital setting. However, the challenges and
demands of observation that differentiate it
from the usual inpatientcarerequirethehospitalist to adopt operational adjustments that
are directed at improving throughput and
efficiency.
References
1. Wachter RM, Goldman L. The
emerging role of “hospitalists”
in the American health care
system. N Engl J Med, 1996.
335(7): 514–7.
2. Medicare Benefit Policy Manual,
in Chapter 6 – Hospital Services
Covered Under Part B. Centers
for Medicare and Medicaid
Services, 2011.
3. Abenhaim HA, Kahn SR,
Raffoul J, et al. Program
description: a hospitalist-run,
medical short-stay unit in a
teaching hospital. CMAJ, 2000.
163(11): 1477–80.
4. Daly, S, Campbell DA,
Cameron PA. Short-stay units
and observation medicine: a
systematic review. Med J Aust,
2003. 178(11): 559–63.
5. Barsuk JH, Casey DE Jr, Graff
LG IV, et al. The Observation
Unit: An Operational Overview
for the Hospitalist. Society of
Hospital Medicine, 2007.
www.hospitalmedicine.org/
Content/NavigationMenu/
Publications/WhitePapers/
White_Papers.htm. Accessed
February 12, 2016.
6. Lucas BP, Kunapley R, Mba B,
et al. A hospitalist-run shortstay unit: features that predict
length-of-stay and eventual
admission to traditional
inpatient services. J Hosp Med,
2009. 4(5): 276–84.
7. Cooke MW, Higgins J, Kidd P.
Use of emergency observation
and assessment wards: a
systematic literature review.
Emerg Med J, 2003. 20(2):
138–42.
8. Krantz MJ, Zwang O, Rowan
SB, et al. A cooperative care
model: cardiologists and
hospitalists reduce length of
stay in a chest pain observation
unit. Crit Pathw Cardiol, 2005.
4(2): 55–8.
9. Leykum LK, Huerta V,
Mortense E. Implementation
of a hospitalist-run observation
unit and impact on length
of stay (LOS): a brief report.
J Hosp Med, 2010. 5(9):
E2–5.
David G. Paje and Peter Y. Watson
016
20:27:46
Part II
Chapter
14
Observation Medicine: Clinical Setting And Education
Training and Education – Residents
Pawan Suri, MD
Many academic and community Emergency
Departments (EDs) now have observation units
(OUs).
1
Emergency Medicine (EM) residents are
often exposed to these units during their training
and may be expected to manage patients in an
OU. Graff et al., in their paper on Observation
Medicine (OM) curriculum, state that managing
patients in an OU is governed by extended care
principles in contrast to the episodic care principles applied in the ED.
2
Thus, emergency physicians need to gain additional knowledge to
provide observation services. OM can be seen as
a bridge between emergency care and acute inpatient care. Following patients in an OU beyond
the acute presentation in the ED may allow residents to gain a deeper appreciation of the natural
history of disease and enable them to make better
disposition decisions. A structured OU rotation for
EM residents enhances the educational experience
in all areas of Accreditation Council on Graduate
Medical Education (ACGME) core competencies.
3
Other groups that may benefit from an OU rotation include medical students, midlevel providers,
internal medicine and pediatric residents, and
pharmacy residents.
Graff et al. divided the OU rotation curriculum into four topics: history of OM, types of
services, characteristics of services, and management of the ED OU. A model curriculum should
balance clinical experience with didactic teaching.
A fully developed rotation would ideally introduce the first-year resident to principles of OM
with incremental responsibilities under attending
supervision such that by the final year of residency, the resident feels comfortable managing
multiple patients in the OU. The didactic part
of the rotation should include core curriculum
lectures, a reading list pertaining to commonly
encountered observation diagnoses and review of
recent literature. Starting at the post-graduate
year (PGY)-1 year, residents can be introduced
to the basic principles of OM, existing proto cols
and understanding the global as well as diseasespecific exclusion and inclusion criteria for
patient selection. (See Chapter 82 on Clinical
Protocols.) As residents progresses to the PGY-2
level and beyond, they are encouraged to clinically
manage multiple patients, learn the administrative aspect of OM, help develop new protocols,
participate in quality assurance, (see Chapter 9)
and learn the nuances of observation billing and
coding (see Chapters 62 and 63). Prerequisites for
setting up a successful OU rotation start with
dedicated OU leadership with a commitment to
teach. There has to be institutional and departmental support that allows for faculty time to
develop teaching resources.
In 2008, the authors instituted a required rotation in OM for second-year EM residents at the
Virginia Commonwealth University’s ten-bed
OU. The residents have an 8-hour workday that
starts at 7 a.m. with signout from the overnight
midlevel provider. The structure of the rotation
mimics the ED multitasking approach. Residents
participate in work rounds with contemporaneous admissions and discharges. The approach is
disposition driven and yet allows for bedside
teaching. The residents participate in field trips
to various testing areas like nuclear medicine,
ECHO lab, stress testing, electrophysiology, and
endoscopy to get a behind-the-scene look and get
a chance to meet with consultants face to face.
Unlike in the busy ED environment, residents in
the OU get the opportunity to address patients’
social needs and communicate with primary care
physicians to ensure a safe discharge and minimize recidivism. In addition, we encourage residents to hone their skills in ancillary testing such
as bedside ultrasound to help management decisions. Residents are given reading assignments
and get a daily quiz. The response to our OU
rotations has been overwhelmingly positive.
3
017
20:28:00
Our situation is somewhat unique in that we have
two dedicated EM and Internal Medicine dualboarded physicians staffing the OU. In other academic departments where it may not be possible
to devote a full rotation to Observation Medicine,
it may be possible to combine OU experience with
an existing EM rotation, Ultrasound, Toxicology,
or Procedure elective.
References
1. Wiler JL, Glinde, AA. National
study of emergency
department observation
services. Annals of Emergency
Medicine, September 2010;56
(3) Suppl.: S142.
2. Graft LG, Dunbar L, Gibler
WB, et al. Observation
medicine curriculum. Annals of
Emergency Medicine, August
1992;21:963–966.
3. Coleman K, Aurora T, Kurz
MC, et al. Evaluating the
educational impact of an
observation unit rotation
for emergency medicine
residents on ACGME core
competencies. Academic
Emergency Medicine, May
2010;17(5), Suppl.
Pawan Suri
017
20:28:00
Part II
Chapter
15
Observation Medicine: Clinical Setting And Education
Training and Education – Medical
Students/Fellows
Margarita E. Pena, MD, FACEP
Incorporating observation medicine (OM) into
medical education is important. The incentives
to de crease a patient’s hospital length of stay and
provide more outpatient services have changed
the arena in which a medical student learns clinical medicine. As the number of patients placed
in a dedicated observation area increases, so does
the likelihood that a student physician will care
for patients in this setting. This trend is expected
to continue as the value and necessity of placing
patients in an observation unit (OU) versus an
inpatient unit in creases.
1–3
Fortunately, studies
suggest clinical teaching is not jeopardized in
short-stay areas.
4,5
OM education should ideally be introduced
during student physicians’ clinical rotations. In
this way they gain a general understanding about
the types of patients and conditions that they will
see in an observation setting and start to learn
about the factors that differentiate observation
versus inpatient care.
6
Medical students are likely to be exposed
to OM during those clinical rotations where
patients have the option of being placed in an
OU setting such as pediatrics, internal medicine,
surgery, and especially emergency medicine
(EM). This is for several reasons. Currently,
over half of U.S. hospitals with an OU are
administratively managed by ED staff.
1
In a
survey of EM residency programs, almost twothirds of all hospitals had o r were planning to
open an OU.
7
Therefore, in those hospitals
with EDOUs staffed by emergency physicians,
medical students learn from physicians knowledgeableinOM.Forexample,atthisauthor’s
institution, our 30-bed Clinical Decision Unit
(CDU) is a closed unit that is managed and
staffed by attending emergency physicians who
rotate their shifts between the ED and CDU.
Observation orders for patients are entered
electronically in the ED by attending and resident physicians. Our EM residents rotate in the
CDU starting their second year and have a
more dedicated month during their third year.
Lectures on OM topics are given on a regular
basis as part of the EM resident didactic lecture
series, which medical students are encouraged
to attend. Therefore, medical students rotating
in our ED learn about the science and clinical
aspects of OM firsthand by working with
EM attendings and residents experienced in
caring for patients in a dedicated OU setting.
There is also an opportunity for fourth year
medical students to do a 1-month OM elective
where they receive additional didactic teaching
and work directly with the attending CDU
physician.
Interestingly, for medical students planning
to interview for an EM residency position, the
Emergency Medicine Residents Association website encourages familiarity with the practice of
observation.
8
Fellowships in OM provide an opportunity
after reside ncy training to gain expertise and
prepare for a directorship. Current programs
offer board certified or prepared emergency
physicians 1- to 2-year EM OM Fellowships that
focus on clinical, administrative, and research
training and the possibility to earn a degree in
business administration or public health during
the fellowship.
Although there is currently no consensus curriculum for OM fellowship training, the American College of Emergency Physicians (ACEP)
section of Observation Medicine and the Society
of Academic Emergency Medicine (SAEM) interest group are actively working to address this
need.
9
018
20:28:13
References
1. Wiler JL, Ross MA, Ginde AA.
National study of emergency
department observation
services. Acad Emerg Med
2011; 18(9):959–965.
2. Baugh CW, Venkatesh AK,
Bohan JS. Emergency
department observation units:
A clinical and financial benefit
for hospitals. Health Care
Manage Rev 2011; 36(1):
28–37.
3. Roberts R, Graff L. Economic
issues in observation unit
medicine. Emerg Med
Clin N Amer 2001; 19(1):
19–33.
4. O'Riordan DC, Ingram Clark
CL. Potential availability of
patients in a short stay ward for
medical student teaching. Ann
R Coll Surg Eng (suppl) 1997;
79:15–16.
5. Marks MK, Baskin MN,
Lovejoy FH Jr, et al. Intern
learning and education in a
short stay unit. A qualitative
study. Arch Pediatr Adolesc
Med 1997; 151(2):193–198.
6. Graff LG (ed). Observation
Medicine: The Healthcare’s
System Tincture of Time.
www.iep.org/Our%20
Physicians/Journal%20Club/
Observation%20Medicine%
2002.03.11/Observation%
20Medicine.pdf (Accessed
February 12, 2016)
7. Mace SE, Shah J. Observation
medicine in emergency
medicine residency programs.
Acad Emerg Med 2002; 9
(2):169–171.
8. EMRA website: Emergency
Medicine issues to know for
your interview. www.emra.org/
content.aspx?id=854 (Accessed
February 12, 2016)
9. SAEM website: Observational
Medicine interest group
objectives. www.saem.org/
observational-medicine-0
(Accessed February 12, 2016)
Margarita E. Pena
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