State of the art: emergency department observation units

Non-specific abdominal pain in elderly patients discharged from the emergency department: Frequency, outcomes and risk-factors for adverse events (EDEN-43 study)

OBJECTIVE

To determine the frequency of the diagnosis of NSAP among elderly patients discharged from EDs, investigate short-term outcomes and look for factors related to adverse outcomes.

OUTCOME MEASURES AND ANALYSIS

We included all patients 65 years or older diagnosed with NSAP and discharged home after ED care in 52 Spanish EDs during a one-week period. Outcomes consisted of 7-day and 30-day all-cause death, 30-day ED reconsultation and hospitalization, and 30-day combined adverse events (AEs) (ED reconsultation, hospitalization or death).

MAIN RESULTS

Among 25,557 elderly patients attended in EDs during the 1-week period, 19,026 were discharged home and 397 (2.1 %) had NSAP as the final diagnosis. The 7-day and 30-day mortality were 0. 3% and 1.5 %, respectively. The 30-day ED reconsultation was 21.9 % and the 30-day hospitalization was 16.4 %. Thirty-day combined AEs were recorded in 22.9 % of patients and were independently associated with comorbidity and functional impairment (Barthel index <100 points; 2.35, 1. 24-4.45), as well as the use of opiate (3.25, 1. 18-8.93) and non-opiate analgesia (1.77,0.101-(Powers and Guertler, 1995 3).11), and lack of laboratory (1.91, 1.02-(Powers and Guertler, 1995 3).58) and imaging (1.91, 1.02-(Powers and Guertler, 1995 3).58) studies in the ED during the index episode. Age, sex and extended ED observation were not associated with the risk of AEs.

CONCLUSIONS

A diagnosis of NSAP at ED discharge is frequent in elderly patients and carries a risk of adverse short-term outcomes. ED discharge of elderly patients with NSAP should be cautious, especially in comorbid patients with limited functional capacity, those needing analgesia, and patients discharged without laboratory and imaging studies.

Do Emergency Department Observation Units Help Prevent Revisits for Patients with Renal Colic?

INTRODUCTION

Renal colic is generally considered a diagnosis appropriate for discharge home once pain is adequately controlled and no other admission criteria are met. The increasing prevalence of ED observation units (EDOU) represent another disposition option for patients with renal colic. In this study, we sought to describe the rates of 14-day revisits for renal colic among patients placed in an EDOU as compared to those discharged from the ED.

METHODS

This is a retrospective observation study of ED patients with renal colic between 2016 and 2024. Adult patients 21 years and older with renal colic were included. Patients were excluded if they were admitted to the hospital during their ED visit. The cohort was divided into those who were discharged from the ED and those who were placed in an EDOU. The primary outcome was the rate of 14-day ED revisits for renal colic after discharge. We also describe the rate of 14-day "serious" ED revisits, defined as a revisit that required admission to the hospital or required urological intervention.

RESULTS

N = 1836 patients were included; 1376 in the ED discharge cohort and 460 in the EDOU cohort. Patients in the ED observation cohort were more likely to have a larger stone size (>5 mm), moderate-severe hydronephrosis, and a proximal stone location (ureteropelvic junction or ureteral) but were otherwise demographically similar. The overall rate of 14-day revisits in the cohort was 162 (8.8 %), 119 (8.6 %) in the discharge cohort and 43 (9.3 %) in the EDOU cohort (difference = -0.7 %, 95 % confidence interval -3.7 % to 2.3 %). The rate of serious 14-day revisits was 64 (3.8 %), 47 (3.4 %) in the discharge cohort and 17 (3.7 %) in the EDOU cohort (difference = -0.3 %, 95 % confidence interval -2.2 % to 1.7 %).

CONCLUSION

We did not identify a difference in 14-day revisits or serious revisits for patients with renal colic who were placed in an EDOU compared to those who were discharged from the ED. However, we found that patients placed in the EDOU had higher-risk stone features (size, location, degree of obstruction), and yet despite this, had similar rates for revisits.

Impact of the Implementation of a Short Stay Observation Unit Associated With Admitter-Rounder Model Onto Other Internal Medicine Units in a French University Hospital

INTRODUCTION

Few data on the impact of specific interventions against Emergency Rooms 'or Hospitals overcrowding are available in France.

METHODS

In the present report, we retrospectively investigated the impact of the implementation of a short-stay observation unit associated with the admitter-rounder model, especially onto the other in-patient internal medicine units in a French University Hospital.

RESULTS

During the first 100 days, 242 patients were admitted into the short-stay observation unit. The median length of stay (LOS) was 5 days, but it was lower during the first and third parts with the admitter-rounder model than during the second part without: 4 versus 6 days (p = 0.007). Internal medicine bed-spaced patients accounted for 19.5% of the bed-spaced patients during the study period versus 28.1% during the same period the previous year (p = 0.04). The median LOS increased significantly in two units of internal medicine: 10 versus 8 days (p = 0.005) and 10 versus 8 days (p = 0.01) during the study period versus the same period the previous year, respectively.

DISCUSSION

The reduced number of Internal Medicine bed-spaced patients, the reduced LOS of patients in short-stay observation unit when associated with the admitter-rounder model and the increase of LOS among some of the in-patient internal medicine units observed in this study should be evaluated elsewhere.

The feasibility of emergency department observation units in the management of mild to moderate hyponatremia

OBJECTIVE

To describe the feasibility of managing hyponatremia patients under outpatient observation status in an academic medical center, and compare outcomes based on the use of an emergency department observation unit (EDOU).

METHODS

This is a retrospective cohort study of emergency department hyponatremic patients managed in four hospitals within a large urban academic medical center over 27 months. All patients had an admit-to-observation order, ICD-10 codes for hyponatremia, and mild (130-135 mmol/L) to moderate (121-129 mmol/L) hyponatremia. Observation settings were divided into two groups: EDOU and Non-Observation Unit (NOU) inpatient beds. Severe hyponatremia (≤120 mmol/L) was excluded. Primary clinical outcomes were inpatient admit rate, length of stay (LOS), total direct cost, the rate of adverse events and 30-day recidivism.

RESULTS

188 patients were managed as an observation patient, with 64 managed in an EDOU setting (age 74.0 yr, 70.3% female) and 124 managed in a NOU setting (age 71.5 yr, 64.5% female). Patient subgroups were similar in terms of presenting complaints, comorbidities, and medication histories. Initial and final sodium levels were similar between settings: EDOU (125.1 to 132.6 mmol/L) vs NOU (123.5 to 132.0 mmol/L). However, outcomes differed by setting for observation to inpatient admit rate (EDOU 28.1% vs NOU 37.9%, adjusted effect 0.70), overall length of stay (EDOU 19.2 h vs NOU 31.9 h; adjusted effect -10.5 h and total direct cost ($1230 vs $1531; adjusted effect -$167). EDOU sodium correction rates were faster (EDOU 0.44 mmol/L/h vs 0.24 mmol/L/h; adjusted effect 0.15 mmol/L/h) and 30-day recidivism rate was similar (EDOU 13% vs NOU 15%). There were no index visit deaths or intensive care unit admissions.

CONCLUSION

Management of selected hyponatremia patients under observation status is feasible, with the EDOU setting demonstrating lower admit rates, shorter length of stay, and lower total direct costs with similar clinical outcomes.

Evaluating mental health decision units in acute care pathways (DECISION): a quasi-experimental, qualitative and health economic evaluation

Background

People experiencing mental health crises in the community often present to emergency departments and are admitted to a psychiatric hospital. Because of the demands on emergency department and inpatient care, psychiatric decision units have emerged to provide a more suitable environment for assessment and signposting to appropriate care.

Objectives

The study aimed to ascertain the structure and activities of psychiatric decision units in England and to provide an evidence base for their effectiveness, costs and benefits, and optimal configuration.

Design

This was a mixed-methods study comprising survey, systematic review, interrupted time series, synthetic control study, cohort study, qualitative interview study and health economic evaluation, using a critical interpretive synthesis approach.

Setting

The study took place in four mental health National Health Service trusts with psychiatric decision units, and six acute hospital National Health Service trusts where emergency departments referred to psychiatric decision units in each mental health trust.

Participants

Participants in the cohort study (n = 2110) were first-time referrals to psychiatric decision units for two 5-month periods from 1 October 2018 and 1 October 2019, respectively. Participants in the qualitative study were first-time referrals to psychiatric decision units recruited within 1 month of discharge (n = 39), members of psychiatric decision unit clinical teams (n = 15) and clinicians referring to psychiatric decision units (n = 19).

Outcomes

Primary mental health outcome in the interrupted time series and cohort study was informal psychiatric hospital admission, and in the synthetic control any psychiatric hospital admission; primary emergency department outcome in the interrupted time series and synthetic control was mental health attendance at emergency department. Data for the interrupted time series and cohort study were extracted from electronic patient record in mental health and acute trusts; data for the synthetic control study were obtained through NHS Digital from Hospital Episode Statistics admitted patient care for psychiatric admissions and Hospital Episode Statistics Accident and Emergency for emergency department attendances. The health economic evaluation used data from all studies. Relevant databases were searched for controlled or comparison group studies of hospital-based mental health assessments permitting overnight stays of a maximum of 1 week that measured adult acute psychiatric admissions and/or mental health presentations at emergency department. Selection, data extraction and quality rating of studies were double assessed. Narrative synthesis of included studies was undertaken and meta-analyses were performed where sufficient studies reported outcomes.

Results

Psychiatric decision units have the potential to reduce informal psychiatric admissions, mental health presentations and wait times at emergency department. Cost savings are largely marginal and do not offset the cost of units. First-time referrals to psychiatric decision units use more inpatient and community care and less emergency department-based liaison psychiatry in the months following the first visit. Psychiatric decision units work best when configured to reduce either informal psychiatric admissions (longer length of stay, higher staff-to-patient ratio, use of psychosocial interventions), resulting in improved quality of crisis care or demand on the emergency department (higher capacity, shorter length of stay). To function well, psychiatric decision units should be integrated into the crisis care pathway alongside a range of community-based support.

Limitations

The availability and quality of data imposed limitations on the reliability of some analyses.

Future work

Psychiatric decision units should not be commissioned with an expectation of short-term financial return on investment but, if appropriately configured, they can provide better quality of care for people in crisis who would not benefit from acute admission or reduce pressure on emergency department.

Study registration

The systematic review was registered on the International Prospective Register of Systematic Reviews as CRD42019151043.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/49/70) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 25. See the NIHR Funding and Awards website for further award information.

Rarely tested or treated but highly prevalent: Hypercholesterolemia in ED observation unit patients with chest pain

BACKGROUND

Hypercholesterolemia (HCL) is common among Emergency Department (ED) patients with chest pain but is typically not addressed in this setting. This study aims to determine whether a missed opportunity for Emergency Department Observation Unit (EDOU) HCL testing and treatment exists.

METHODS

We conducted a retrospective observational cohort study of patients ≥18 years old evaluated for chest pain in an EDOU from 3/1/2019-2/28/2020. The electronic health record was used to determine demographics and if HCL testing or treatment occurred. HCL was defined by self-report or clinician diagnosis. Proportions of patients receiving HCL testing or treatment at 1-year following their ED visit were calculated. HCL testing and treatment rates at 1-year were compared between white vs. non-white and male vs. female patients using multivariable logistic regression models including age, sex, and race.

RESULTS

Among 649 EDOU patients with chest pain, 55.8% (362/649) had known HCL. Among patients without known HCL, 5.9% (17/287, 95% CI 3.5-9.3%) had a lipid panel during their index ED/EDOU visit and 26.5% (76/287, 95% CI 21.5-32.0%) had a lipid panel within 1-year of their initial ED/EDOU visit. Among patients with known or newly diagnosed HCL, 54.0% (229/424, 95% CI 49.1-58.8%) were on treatment within 1-year. After adjustment, testing rates were similar among white vs. non-white patients (aOR 0.71, 95% CI 0.37-1.38) and men vs. women (aOR 1.32, 95% CI 0.69-2.57). Treatment rates were similar among white vs. non-white (aOR 0.74, 95% CI 0.53-1.03) and male vs. female (aOR 1.08, 95% CI 0.77-1.51) patients.

CONCLUSIONS

Few patients were evaluated for HCL in the ED/EDOU or outpatient setting after their ED/EDOU encounter and only 54% of patients with HCL were on treatment during the 1-year follow-up period after the index ED/EDOU visit. These findings suggest a missed opportunity to reduce cardiovascular disease risk exists by evaluating and treating HCL in the ED or EDOU.

Chest pain observation unit: A missed opportunity to initiate smoking cessation therapy

BACKGROUND

Emergency Department Observation Unit (EDOU) patients with chest pain have a high prevalence of smoking, a key cardiovascular disease risk factor. While in the EDOU, there is an opportunity to initiate smoking cessation therapy (SCT), but this is not standard practice. This study aims to describe the missed opportunity for EDOU-initiated SCT by determining the proportion of smokers who receive SCT in the EDOU and within 1-year of EDOU discharge and to evaluate if SCT rates vary by race or sex.

METHODS

We performed an observational cohort study of patients ≥18 years old being evaluated for chest pain in a tertiary care center EDOU from 3/1/2019-2/28/2020. Demographics, smoking history, and SCT were determined by electronic health record review. Emergency, family medicine, internal medicine, and cardiology records were reviewed to determine if SCT occurred within 1-year of their initial visit. SCT was defined as behavioral interventions or pharmacotherapy. Rates of SCT in the EDOU, 1-year follow-up period, and the EDOU through 1-year of follow-up were calculated. SCT rates from the EDOU through 1-year were compared between white vs. non-white and male vs. female patients using a multivariable logistic regression model including age, sex, and race.

RESULTS

Among 649 EDOU patients, 24.0% (156/649) were smokers. These patients were 51.3% (80/156) female and 46.8% (73/156) white, with a mean age of 54.4 ± 10.5 years. From the EDOU encounter through 1-year of follow-up, only 33.3% (52/156) received SCT. In the EDOU, 16.0% (25/156) received SCT. During the 1-year follow-up period, 22.4% (35/156) had outpatient SCT. After adjusting for potential confounders, SCT rates from the EDOU through 1-year were similar among whites vs. non-whites (aOR 1.19, 95% CI 0.61-2.32) and males vs. females (aOR 0.79, 95% CI 0.40-1.56).

CONCLUSIONS

SCT was rarely initiated in the EDOU among chest pain patients who smoke and most patients who did not receive SCT in the EDOU never received SCT at 1-year of follow-up. Rates of SCT were similarly low among race and sex subgroups. These data suggest an opportunity exists to improve health by initiating SCT in the EDOU.

The Impact of Virtual Care in an Emergency Department Observation Unit

STUDY OBJECTIVE(S)

We report the impact of telemedicine virtual rounding in emergency department observation units (EDOU) on the effectiveness, safety, and cost relative to traditional observation care.

METHODS

In this retrospective diff-in-diff study, we compared observation visit outcomes from 2 EDOUs before (pre) and after (post) full adoption of telemedicine rounding tele-observation (tele-obs) with usual care in control EDOU and care in a hospital bed in an integrated health system without tele-obs. Tele-obs physicians did not work at the control hospital. Outcomes were the length of stay, total direct costs, admission status, and adverse events (ICU and death). Difference-in-differences modeling evaluated outcomes with covariates including age, sex, payer type, and clinical classification software diagnostic category. Data from a system data warehouse and a cost accounting database were used.

RESULTS

Of the 20,861 EDOU visits, 15,630 (74.9%) were seen in the preperiod and 6,657 (31.9%) in control EDOU. Of 23,055 non-EDOU inpatient visits assigned to observation status (nonobservation unit), 76% were seen in the preperiod. Adjusted length of stay was not significantly different for tele-obs and control EDOUs (26.4 hours versus 23.5 hours), which remained lower than in hospital settings (37.9 hours). The pre-post diff-in-diff was not significant (P=.78). Inpatient admission status was similar for tele-obs and control EDOUs (20.9% versus 22.4.%) and lower than in hospital settings (30.3%). Prepost odds ratios for inpatient admission and adverse outcomes did not change significantly for all study groups. Adjusted costs increased over time for all settings; however, the prepost median cost change was not significantly different between tele-obs EDOUs and control EDOUs ($162.5 versus $235) and was lower than the change for control hospital settings ($783). Median tele-obs EDOU cost over both periods ($1,541) remained significantly lower than hospital costs ($2,413).

CONCLUSION

Using tele-obs to manage observation patients in an ED observation unit was not associated with significant differences in length of stay, admission status, measured adverse events, or total direct cost.

Impact of an Observation Medicine Educational Intervention on Residents' Confidence, Knowledge, and Attitudes: A Quasi-Experimental Study

OBJECTIVES

Driven by innovations in healthcare, observation medicine (OM) is expanding as a medical specialty. Despite exponential growth, education on OM remains underemphasized in the internal medicine (IM) residency programs. We assessed the impact of an educational intervention pairing didactic and experiential learning with an interdepartmental approach on IM residents' confidence, knowledge, and attitudes when providing observation care to patients with neuro-cardiovascular diseases in the hospital setting.

METHODS

Our multifaceted intervention incorporated OM's principles and practice in a flipped classroom with the team-, case-, lecture- and evidence-based learning model. Kirkpatrick's evaluation model was used to assess the educational intervention's effectiveness according to the first three levels, ie, reaction, learning, and behavior, using quantitative surveys. The surveys were completed pre-intervention, and immediately upon completion of the educational intervention.

RESULTS

Of 55 eligible residents, 55 (100%) participated in this intervention. Fifty (90%) completed the pre-intervention survey, and 21 (38%) completed the immediate post-intervention survey. Kirkpatrick's evaluation framework showed that the intervention had a positive impact on residents' motivational reaction (attention, relevance, confidence, and satisfaction [ARCS], M = 3.8, SD = 0.87), their knowledge of common observation diagnoses (pre = 49%, post = 63%), particularly on cardiac diagnostic workup and approach to patients with transient neurological symptoms (P < .05), and their behavior and self-assessment of core competency domains (pre-mean = 2.69, post-mean = 3.18, P < .001).

CONCLUSIONS

Our multimodal intervention provides a framework for a structured OM educational experience that can be incorporated into residency training, even without a formal observation unit rotation. The analysis also offers literary data on the current state of OM education in an IM residency program and supports the need to expand OM's educational resources to counteract the growth in hospital observation services. Future research should include an analysis of residents' knowledge and skills from a longitudinal OM experience and advancing the results to residency programs where observation care is as applicable as ours.

Blood Pressure Assessment and Treatment in the Observation Unit

PURPOSE OF REVIEW

To review the pathophysiology, diagnosis, and the management of hypertension. Given the paucity of literature regarding the role of the observation unit in the management of hypertension, we will provide our recommendations based on our experience working in an observation unit.

RECENT FINDINGS

Many patients have limited access to primary care, and hypertension diagnosis often relies on office-based measurements. We will describe situations where that is not necessary to make the diagnosis. We will discuss the current non-pharmacologic treatment guidelines, the education of which should be provided to patients both in the emergency department and observation units. We will provide the current recommendations on what anti-hypertension medications can be initiated in the emergency department and observation units. Hypertension is a leading cause of morbidity and mortality in the USA. The utility of an observation unit in the diagnosis and management of patients with hypertension is beneficial particularly for those with risk factors for atherosclerotic disease. An observation unit stay provides the opportunity to diagnosis hypertension, initiate lifestyle education and pharmacologic treatment if indicated, and help to arrange appropriate follow-up for ongoing management and treatment in individuals with limited access to care.

Observation unit use among patients with cancer following emergency department visits: Results of a multicenter prospective cohort from CONCERN

PURPOSE

Emergency department (ED) visits by patients with cancer frequently end in hospitalization. As concerns about ED and hospital crowding increase, observation unit care may be an important strategy to deliver safe and efficient treatment for eligible patients. In this investigation, we compared the prevalence and clinical characteristics of cancer patients who received observation unit care with those who were admitted to the hospital from the ED.

METHODS

We performed a multicenter prospective cohort study of patients with cancer presenting to an ED affiliated with one of 18 hospitals of the Comprehensive Oncologic Emergency Research Network (CONCERN) between March 1, 2016 and January 30, 2017. We compared patient characteristics with the prevalence of observation unit care usage, hospital admission, and length of stay.

RESULTS

Of 1051 enrolled patients, 596 (56.7%) were admitted as inpatients, and 72 (6.9%) were placed in an observation unit. For patients admitted as inpatients, 23.7% had a length of stay ≤2 days. The conversion rate from observation to inpatient was 17.1% (95% CI 14.6-19.4) among those receiving care in an observation unit. The average observation unit length of stay was 14.7 h. Patient factors associated ED disposition to observation unit care were female gender and low Charlson Comorbidity Index.

CONCLUSION

In this multicenter prospective cohort study, the discrepancy between observation unit care use and short inpatient hospitalization may represent underutilization of this resource and a target for process change.

The Changing Role of Chest Pain in the Emergency Department Observation Unit

BACKGROUND

This study objective was to describe changes in the utilization of a protocol-driven emergency department observation unit (EDOU) for chest pain over time.

METHODS

This is a retrospective serial cross-sectional study of data from a clinical data warehouse of a single integrated healthcare system. We estimated long-term trends (2009-2019) in EDOU visits at 4 system hospitals, using monthly proportions as the main outcome, and month of visit as the exposure variable, accounting for age and sex. Rate changes associated with compulsory use of the History, EKG, Age, Risk factors, Troponin (HEART) score in 2016 were analyzed.

RESULTS

There were 83,168 EDOU admissions among 1.3 million ED visits during the study interval, with an average admission rate of 5.9% of ED visits. The most common conditions were chest pain (41.2%), transient ischemic attack (7.8%), dehydration (6.3%), syncope (5.8%), and abdominal pain (5.2%). In each hospital, there was a temporal annual decline in the proportion of EDOU visits for chest pain protocols ranging from -7.9% to -2.8%, an average rate of -3.3% per year (95% CI, -4.6% to -2.0%) or a 54% (from 54% to 25%) relative decline in over the 11-year study interval. This decline was significantly steeper in younger middle-aged patients (ages 39-49). The HEART score intervention had a small impact on baseline decline of -3.1% at the 2 intervention hospitals, reducing it by -1.5% (95% CI, -2.2% to -0.8%).

CONCLUSIONS

Utilization of the EDOU for chest pain decreased over time, with corresponding increases in other conditions. This decline preceded the introduction of the HEART score.

Cancer-related Emergency Department Visits: Comparing Characteristics and Outcomes

Introduction

There is increasing appreciation of the challenges of providing safe and appropriate care to cancer patients in the emergency department (ED). Our goal here was to assess which patient characteristics are associated with more frequent ED revisits.

Methods

This was a retrospective cohort study of all ED visits in California during the 2016 calendar year using data from the California Office of Statewide Health Planning and Development. We defined revisits as a return visit to an ED within seven days of the index visit. For both index and return visits, we assessed various patient characteristics, including age, cancer type, medical comorbidities, and ED disposition.

Results

Among 12.9 million ED visits, we identified 73,465 adult cancer patients comprising 103,523 visits that met our inclusion criteria. Cancer patients had a 7-day revisit rate of 17.9% vs 13.2% for non-cancer patients. Cancer patients had a higher rate of admission upon 7-day revisit (36.7% vs 15.6%). Patients with cancers of the small intestine, stomach, and pancreas had the highest rate of 7-day revisits (22–24%). Cancer patients younger than 65 had a higher 7-day revisit rate than the elderly (20.0% vs 16.2%).

Conclusion

In a review of all cancer-related ED visits in the state of California, we found a variety of characteristics associated with a higher rate of 7-day ED revisits. Our goal in this study was to inform future research to identify interventions on the index visit that may improve patient outcomes.

Management of Minor Traumatic Brain Injury in an ED Observation Unit

Introduction

Traumatic intracranial hemorrhages (TIH) have traditionally been managed in the intensive care unit (ICU) setting with neurosurgery consultation and repeat head CT (HCT) for each patient. Recent publications indicate patients with small TIH and normal neurological examinations who are not on anticoagulation do not require ICU-level care, repeat HCT, or neurosurgical consultation. It has been suggested that these patients can be safely discharged home after a short period of observation in emergency department observation units (EDOU) provided their symptoms do not progress.

Methods

This study is a retrospective cross-sectional evaluation of an EDOU protocol for minor traumatic brain injury (mTBI). It was conducted at a Level I trauma center. The protocol was developed by emergency medicine, neurosurgery and trauma surgery and modeled after the Brain Injury Guidelines (BIG). All patients were managed by attendings in the ED with discretionary neurosurgery and trauma surgery consultations. Patients were eligible for the mTBI protocol if they met BIG 1 or BIG 2 criteria (no intoxication, no anticoagulation, normal neurological examination, no or non-displaced skull fracture, subdural or intraparenchymal hematoma up to 7 millimeters, trace to localized subarachnoid hemorrhage), and had no other injuries or medical co-morbidities requiring admission. Protocol in the EDOU included routine neurological checks, symptom management, and repeat HCT for progression of symptoms. The EDOU group was compared with historical controls admitted with primary diagnosis of TIH over the 12 months prior to the initiation of the mTBI protocols. Primary outcome was reduction in EDOU length of stay (LOS) as compared to inpatient LOS. Secondary outcomes included rates of neurosurgical consultation, repeat HCT, conversion to inpatient admission, and need for emergent neurosurgical intervention.

Results

There were 169 patients placed on the mTBI protocol between September 1, 2016 and August 31, 2019. The control group consisted of 53 inpatients. Median LOS (interquartile range [IQR]) for EDOU patients was 24.8 (IQR: 18.8 – 29.9) hours compared with a median LOS for the comparison group of 60.2 (IQR: 45.1 – 85.0) hours (P < .001). In the EDOU group 47 (27.8%) patients got a repeat HCT compared with 40 (75.5%) inpatients, and 106 (62.7%) had a neurosurgical consultation compared with 53 (100%) inpatients. Subdural hematoma was the most common type of hemorrhage. It was found in 60 (35.5%) patients, and subarachnoid hemorrhage was found in 56 cases (33.1%). Eleven patients had multicompartment hemorrhage of various classifications. Twelve (7.1%) patients required hospital admission from the EDOU. None of the EDOU patients required emergent neurosurgical intervention.

Conclusion

Patients with minor TIH can be managed in an EDOU using an mTBI protocol and discretionary neurosurgical consults and repeat HCT. This is associated with a significant reduction in length of stay.

Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department

This first Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-1) from the Society for Academic Emergency Medicine is on the topic: Recurrent, Low-risk Chest Pain in the Emergency Department. The multidisciplinary guideline panel used The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding eight priority questions for adult patients with recurrent, low-risk chest pain and have derived the following evidence based recommendations: (1) for those >3 h chest pain duration we suggest a single, high-sensitivity troponin below a validated threshold to reasonably exclude acute coronary syndrome (ACS) within 30 days; (2) for those with a normal stress test within the previous 12 months, we do not recommend repeat routine stress testing as a means to decrease rates of major adverse cardiac events at 30 days; (3) insufficient evidence to recommend hospitalization (either standard inpatient admission or observation stay) versus discharge as a strategy to mitigate major adverse cardiac events within 30 days; (4) for those with non-obstructive (<50% stenosis) coronary artery disease (CAD) on prior angiography within 5 years, we suggest referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (5) for those with no occlusive CAD (0% stenosis) on prior angiography within 5 years, we recommend referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (6) for those with a prior coronary computed tomographic angiography within the past 2 years with no coronary stenosis, we suggest no further diagnostic testing other than a single, normal high-sensitivity troponin below a validated threshold to exclude ACS within that 2 year time frame; (7) we suggest the use of depression and anxiety screening tools as these might have an effect on healthcare use and return emergency department (ED) visits; and (8) we suggest referral for anxiety or depression management, as this might have an impact on healthcare use and return ED visits.

The impact of emergency department observation units on a health system

IMPORTANCE

Protocol driven ED observation units (EDOU) have been shown to improve outcomes for patients and payers, however their impact on an entire health system is unknown. Two thirds of US hospitals do not have such units.

OBJECTIVE

To determine the impact of a protocol-driven EDOU on health system length of stay, cost, and resource utilization.

METHODS

A retrospective, observational, cross-sectional study of observation patients managed over 25 consecutive months in a four-hospital academic health system. Patients were identified using the "admit to observation" order and limited to adult, emergent / urgent, non-obstetric patients. Data was retrieved from a cost accounting database. The primary study exposure was the setting for observation care which was broken into three discrete groups: EDOUs (n = 3), hospital medicine observation units (HMSOU, n = 2), and a non-observation unit (NOU) bed located anywhere in the hospital. Outcomes included observation-to-inpatient admission rate, length of stay (LoS), total direct cost, and inpatient bed days saved. Unadjusted outcomes were compared, and outcomes were adjusted using multiple study variables. LoS and cost were compared using quantile regressions. Inpatient admit rate was compared using logistic regressions.

RESULTS

The sample consisted of 48,145 patients who were 57.4% female, 48% Black, 46% White, median age of 58, with some variation in most common diagnoses and payer groups. The median unadjusted outcomes favored EDOU over NOU settings for admission rate (13.1% vs 37.1%), LoS [17.9 vs 35.6 h), and cost ($1279 vs $2022). The adjusted outcomes favored EDOU over NOU settings for admission rates [12.3% (95% CI 9.7-15.3) vs 26.4% (CI 21.3-32.3)], LoS differences [11.1 h (CI 10.6-11.5 h)] and cost differences [$127.5 (CI $105.4 - $149.5)]. Adjusted differences were similar and favored EDOU over HMSOU settings. For the health system, the total adjusted annualized savings of the EDOUs was 10,399 bed days and $1,329,443 in total direct cost per year.

CONCLUSION

Within an academic medical center, EDOUs were associated with improved resource utilization and reduced cost. This represents a significant opportunity for hospitals to improve efficiency and contain costs.

Protocolized emergency department observation care improves quality of ischemic stroke care in Haiti

INTRODUCTION

In many low-income countries, Emergency Medicine is underdeveloped and faces many operational challenges including emergency department (ED) overcrowding and prolonged patient length of stays (LOS). In high-resource settings, protocolized ED observation unit (EDOU) care reduces LOS while preserving care quality. EDOUs are untested in low-income countries. We evaluate the effect protocolized EDOU care for ischemic stroke on the quality and efficiency of care in Haiti.

METHODS

We performed a prospective cohort study of protocolized observation care for ischemic stroke at a Haitian academic hospital between January 2014 and September 2015. We compared patients cared for in the EDOU using the ischemic stroke protocol (study group) to eligible patients cared for before protocol implementation (baseline group), as well as to eligible patients treated after protocol introduction but managed without the EDOU protocol (contemporary reference group). We analysed three quality of care measures: aspirin administration, physical therapy consultation, and swallow evaluation. We also analysed ED and hospital LOS as measures of efficiency.

RESULTS

Patients receiving protocolized EDOU care achieved higher care quality compared to the baseline group, with higher rates of aspirin administration (91% v. 17%, p < 0.001), physical therapy consultation (50% v. 9.6%, p < 0.001), and swallow evaluation (36% v. 3.7%, p < 0.001). We observed similar improvements in the study group compared to the contemporary reference group. Most patients (92%) were managed entirely in the ED or EDOU. LOS for non-admitted patients was longer in the study group than the baseline group (28 v. 19 h, p = 0.023).

CONCLUSION

Protocolized EDOU care for patients with ischemic stroke in Haiti improved performance on key quality measures but increased LOS, likely due to more interventions. Future studies should examine the aspects of EDOU care are most effective at promoting higher care quality, and if similar results are achievable in patients with other conditions.

Emergency department observation of mild traumatic brain injury with minor radiographic findings: shorter stays, less expensive, and no increased risk compared to hospital admission

OBJECTIVE

The management of mild traumatic brain injury (mTBI) with minor radiographic findings traditionally involves hospital admission for monitoring, although this practice is expensive with unclear benefit. We implemented a protocol to manage these patients in our emergency department observation unit (EDOU), hypothesizing that this pathway was cost effective and not associated with any difference in clinical outcome.

METHODS

mTBI patients with minor radiographic findings were managed under the EDOU protocol over a 3-year period from May 1, 2015 to April 30, 2018 (inclusions: ≥19 years old, isolated acute head trauma, normal neurological exam [except transient alteration in consciousness], and a computed tomography [CT] scan of the head with at least 1 of the following: cerebral contusions <1 cm in maximum extent, convexity subarachnoid hemorrhage, or closed, non-displaced skull fractures). These patients were retrospectively analyzed; clinical outcomes and charges were compared to a control cohort of matched mTBI hospital admissions over the preceding 3 years.

RESULTS

Sixty patients were observed in the EDOU over the 3-year period, and 85 patients were identified for the control cohort. There were no differences in rate of radiographic progression, neurological exam change, or surgical intervention, and the overall incidence of hemorrhagic expansion was low in both groups. The EDOU group had a significantly faster time to interval CT scan (Mean Difference (MD) 3.92 hours, [95%CI 1.65, 6.19]), P = 0.001), shorter length of stay (MD 0.59 days [95% CI 0.29, 0.89], P = 0.001), and lower encounter charges (MD $3428.51 [95%CI 925.60, 5931.42], P = 0.008). There were no differences in 30-day re-admission, 30-day mortality, or delayed chronic subdural formation, although there was a high rate of loss to follow-up in both groups.

CONCLUSIONS

Compared to hospital admission, observing mTBI patients with minor radiographic findings in the EDOU was associated with significantly shorter time to interval scanning, shorter length of stay, and lower encounter charges, but no difference in observed clinical outcome. The overall risk of hemorrhagic progression in this subset of mTBI was very low. Using this approach can reduce unnecessary admissions while potentially yielding patient care and economic benefits. When designing a protocol, close attention should be given to clear inclusion criteria and a formal mechanism for patient follow-up.

What is the impact of psychiatric decision units on mental health crisis care pathways? Protocol for an interrupted time series analysis with a synthetic control study

BACKGROUND

The UK mental health system is stretched to breaking point. Individuals presenting with mental health problems wait longer at the ED than those presenting with physical concerns and finding a bed when needed is difficult - 91% of psychiatric wards are operating at above the recommended occupancy rate. To address the pressure, a new type of facility - psychiatric decision units (also known as mental health decision units) - have been introduced in some areas. These are short-stay facilities, available upon referral, targeted to help individuals who may be able to avoid an inpatient admission or lengthy ED visit. To advance knowledge about the effectiveness of this service for this purpose, we will examine the effect of the service on the mental health crisis care pathway over a 4-year time period; the 2 years proceeding and following the introduction of the service. We use aggregate service level data of key indicators of the performance of this pathway.

METHODS

Data from four mental health Trusts in England will be analysed using an interrupted time series (ITS) design with the primary outcomes of the rate of (i) ED psychiatric presentations and (ii) voluntary admissions to mental health wards. This will be supplemented with a synthetic control study with the same primary outcomes, in which a comparable control group is generated for each outcome using a donor pool of suitable National Health Service Trusts in England. The methods are well suited to an evaluation of an intervention at a service delivery level targeting population-level health outcome and the randomisation or 'trialability' of the intervention is limited. The synthetic control study controls for national trends over time, increasing our confidence in the results. The study has been designed and will be carried out with the involvement of service users and carers.

DISCUSSION

This will be the first formal evaluation of psychiatric decision units in England. The analysis will provide estimates of the effect of the decision units on a number of important service use indicators, providing much-needed information for those designing service pathways.

TRIAL REGISTRATION

primary registry: isrctn.com Identifying number: ISRCTN77588384 Link: Date of registration in primary registry: 27/02/2020.

PRIMARY SPONSOR

St George's, University of London, Cramner Road, Tooting, SW17 ORE. Primary contact: Joe Montebello.

Impact of Emergency Department Tele-intake on Left Without Being Seen and Throughput Metrics

OBJECTIVES

More than 2 million patients present to a U.S. emergency department (ED) annually and leave without being seen (LWBS) due to delays in initiating care. We evaluated whether tele-intake at the time of presentation would reduce LWBS rates and ED throughput measures.

METHODS

We conducted a before-and-after study at an urban community hospital. The intervention was use of a tele-intake physician to triage patients from 11 am to 6 pm, 7 days per week. Tele-intake providers performed a triage history and physical examination, documented findings, and initiated orders in the medical record. We assessed the impact of this program using the domains of the National Quality Forum framework evaluating access, provider experience, and effectiveness of care. The main outcome was 24-hour LWBS rate. Secondary outcomes were overall door to provider and door to disposition times, left without treatment complete (LWTC), left against medical advice (AMA), left without treatment (LWOT), and physician experience. We compared the 6-month tele-intake period to the same period from the prior year (October 1 to April 1, 2017 vs. 2016). Additionally, we conducted a survey of our physicians to assess their experience with the program.

RESULTS

Total ED volume was similar in the before and after periods (19,892 patients vs. 19,646 patients). The 24-hour LWBS rate was reduced from 2.30% (95% confidence interval [CI] = 2.0% to 2.5%) to 1.69% (95% CI = 1.51% to 1.87%; p < 0.001). Overall door to provider time decreased (median = 19 [interquartile range {IQR} = 9 to 38] minutes vs. 16.2 [IQR = 7.8 to 34.3] minutes; p < 0.001), but ED length of stay for all patients (defined as door in to door out time for all patients) minimally increased (median = 184 [IQR = 100 to 292] minutes vs. 184.3 [IQR = 104.4 to 300] minutes; p < 0.001). There was an increase in door to discharge times (median = 146 [IQR = 83 to 231] minutes vs. 148 [IQR = 88.2 to 233.6] minutes; p < 0.001) and door to admit times (median = 330 [IQR = 253 to 432] minutes vs. 357.6 [IQR = 260.3 to 514.5] minutes; p < 0.001). We saw an increase in LWTC (0.59% [95% CI = 0.49% to 0.70%] vs. 1.1% [95% CI = 0.9% to 1.2%]; p < 0.001), but no change in AMA (1.4% [95% CI = 1.2% to 1.6%] vs. 1.6% [95% CI = 1.4% to 1.78%]; p = 0.21) or LWOT (4.3% [95% CI = 4.1% to 4.6%] vs. 4.4% [95% CI = 4.1% to 4.7%]; p = 0.7). Tele-intake providers thought tele-intake added value (12/15, 80%) and allowed them to effectively address medical problems (14/15, 95%), but only (10/15, 67%) thought that it was as good as in-person triage. Of the receiving physicians, most agreed with statements that tele-intake did not interfere with care (19/22, 86%), helped complement care (19/21, 90%), and gave the patient a better experience (19/22, 86%).

CONCLUSIONS

Remote tele-intake provided in an urban community hospital ED reduced LWBS and time to provider but increased LWTC rates and had no impact on LWOT.

The Case for Observation Medicine Education and Training in Emergency Medicine

BACKGROUND

Many hospitals have or will be opening an observation unit (OU), the majority managed by the emergency department (ED). Graduating emergency medicine (EM) residents will be expected to have the knowledge and skills necessary to appropriately identify and manage patients in this setting. Our objective is to examine the current state of observation medicine (OM) education and prevalence in EM training.

METHODS

In a follow-up to the 2019 Society for Academic Emergency Medicine (SAEM) OM Interest Group meeting, we convened an expert panel of OM physicians who are members of both the SAEM OM Interest Group and the American College of Emergency Physicians Section of OM. The panel of six emergency physicians representing geographic diversity was formed. A structured literature review was performed yielding 16 educational publications and sources pertaining to OM education and training across all specialties.

REPORT ON THE EXISTING LITERATURE

Only a small number of EM residencies have a required or elective OM rotation in an OU. An OM rotation in a protocol-driven ED OU gives residents experience managing patients in this setting and improves skills integral to EM and part of the EM milestones and Accreditation Council for Graduate Medical Education (ACGME) core competencies: reassessment, disposition decision making, risk stratification, team management, and practicing cost-appropriate care. Even without a formal rotation, multiple OM educational resources can be incorporated into EM resident education and didactics. Education research opportunity exists.

CONCLUSIONS

This panel believes that OM is an important component of EM that should be incorporated into EM residency as the knowledge and skills learned such as risk stratification, disposition decision making, and team management augment those needed for the practice of EM. There is a distinct opportunity for EM educators to better equip their trainees for a career in EM by including OM education and experience in EM residency training.

Hospital revisits within 30 days after discharge for medical conditions targeted by the Hospital Readmissions Reduction Program in the United States: national retrospective analysis

OBJECTIVE

To determine any changes in total hospital revisits within 30 days of discharge after a hospital stay for medical conditions targeted by the Hospital Readmissions Reduction Program (HRRP).

DESIGN

Retrospective cohort study.

SETTING

Hospital stays among Medicare patients for heart failure, acute myocardial infarction, or pneumonia between 1 January 2012 and 1 October 2015.

PARTICIPANTS

Medicare fee-for-service patients aged 65 or over.

MAIN OUTCOMES

Total hospital revisits within 30 days of discharge after hospital stays for medical conditions targeted by the HRRP, and by type of revisit: treat-and-discharge visit to an emergency department, observation stay (not leading to inpatient readmission), and inpatient readmission. Patient subgroups (age, sex, race) were also evaluated for each type of revisit.

RESULTS

Our study cohort included 3 038 740 total index hospital stays from January 2012 to September 2015: 1 357 620 for heart failure, 634 795 for acute myocardial infarction, and 1 046 325 for pneumonia. Counting all revisits after discharge, the total number of hospital revisits per 100 patient discharges for target conditions increased across the study period (monthly increase 0.023 visits per 100 patient discharges (95% confidence interval 0.010 to 0.035)). This change was due to monthly increases in treat-and-discharge visits to an emergency department (0.023 (0.015 to 0.032) and observation stays (0.022 (0.020 to 0.025)), which were only partly offset by declines in readmissions (-0.023 (-0.035 to -0.012)). Increases in observation stay use were more pronounced among non-white patients than white patients. No significant change was seen in mortality within 30 days of discharge for target conditions (-0.0034 (-0.012 to 0.0054)).

CONCLUSIONS

In the United States, total hospital revisits within 30 days of discharge for conditions targeted by the HRRP increased across the study period. This increase was due to a rise in post-discharge emergency department visits and observation stays, which exceeded the decline in readmissions. Although reductions in readmissions have been attributed to improvements in discharge planning and care transitions, our findings suggest that these declines could instead be because hospitals and clinicians have intensified efforts to treat patients who return to a hospital within 30 days of discharge in emergency departments and as observation stays.

Triage to Observation: A Quality Improvement Initiative for Chest Pain Patients Presenting to the Emergency Department

OBJECTIVE

The objective of this study was to evaluate the impact of a rapid admission protocol for chest pain patients presenting to the emergency department (ED) on ED length-of-stay (LOS). In this study, ED LOS was defined as the time from triage check-in until the time the patient physically leaves the ED. The purpose of this quality improvement study was to decrease ED crowding.

METHODS

This is a single-center prospective cohort study performed as a quality improvement initiative. This study implemented a rapid admission protocol for patients who were at moderate risk for a major adverse cardiac event based on the HEART score. When a patient presented to the ED through triage with a chief complaint of chest pain, this protocol allowed the provider-in-triage (PIT) to identify eligible patients for potential rapid admission to the hospital's clinical decision unit (CDU). The PIT would complete a rapid medical screening examination, initiate the patient's workup, and call the CDU providers to further evaluate the patient. By identifying these patients early, the lengthy ED chest pain workup contributing to longer ED LOS could then be completed in the CDU.

RESULTS

The total number of patients seen in the ED over the study period was 34,251. The total number of patients admitted to the CDU during the study period was 1,442. The PIT identified 13 patients for rapid admission to the CDU during the study period. These patients had a statistically significant reduction in ED LOS (P < 0.001). ED LOS was also adjusted to identify delays in patient movement resulting in a statistically significant difference (P < 0.001).

CONCLUSION

Implementation of a rapid admission protocol for chest pain patients at moderate risk for a major adverse cardiac event resulted in a reduction in ED LOS. Adjusted ED LOS was also significant, highlighting a delay in patient movement from the ED to the CDU indicating continued barriers affecting ED holding times.

Factors Affecting Length of Stay for Observation Patients

Objectives

The objective of this study was to determine whether the addition of a case manager and a physician advisor to the observation unit would decrease the length of stay (LOS) of observation patients.

Study design

This retrospective, observational study for observation patients was conducted in 2017.

Methods

At a tertiary-care, medium-sized, urban, community hospital, the LOS for all observation patients in 2017 (2, 981 clinical decision unit [CDU] patients and 1,248 non-cohort patients) was studied. Interventions studied were the addition of unit-based case manager and physician advisor to observation patient treatment teams.

Results

Patients assigned to the CDU had a shorter LOS than scattered patients, p < 0.0005. After the data was controlled for changes in LOS on inpatients using analysis of covariance (ANCOVA), none of the interventions resulted in statistically significant effects on LOS for CDU or scattered patients. Season, day of the week, the month of the year, and the presence of residents/medical students did not have any effect on LOS. Patients arriving at night had significantly shorter LOS than those arriving during the day or evening, p = 0.035 and p = 0.029, respectively.

Conclusions

Placing observation patients in a single unit is effective for decreasing LOS. The addition of case managers or physician advisors may not be an effective strategy to address the LOS. The presence of trainees does not hinder patient flow.

Emergency Department Observation Unit Utilization Among Older Patients With Chest Pain

BACKGROUND

Although some emergency department observation units (EDOUs) may exclude patients over 65 years old, our EDOU accepts patients up to 79 years old. We assessed the utilization of our EDOU by older patients (those 65-79 years old).

METHODS

We prospectively enrolled emergency department (ED) patients with chest pain. We gathered baseline data at the time of ED presentation and tracked outcomes related to the ED stay, EDOU, and/or inpatient admission. Our primary outcome included EDOU placement among older patients. Our secondary outcome was the rate of major adverse cardiac events [MACE: myocardial infarction, stent, coronary artery bypass graft, and death].

RESULTS

Over the 5-year study period, we evaluated 2242 ED patients with chest pain, of whom 19.4% (95% confidence interval, 17.8%-21.1%) were 65-79 years old. Older patients were more likely to be placed in the EDOU after the ED visit (45.8% vs. 36.6%; P = 0.001) and more likely to be admitted to an inpatient unit from the ED (31.8% vs. 17.9%;P < 0.001) than those under 65 years old. The overall MACE rate was similar between admitted older patients and those in the EDOU: 5.9% versus 4.3% (P = 0.57). Of the admitted older patients, 30.4% (95% confidence interval, 22.3%-39.9%) were low risk and there were no cases of MACE in this group.

CONCLUSIONS

In an EDOU that allows older patients, we noted substantial utilization by these patients for the evaluation of chest pain. The characteristics of admitted older patients suggest the potential for even greater EDOU utilization in this group.

Financial Viability of Emergency Department Observation Unit Billing Models

BACKGROUND

Outpatients receive observation services to determine the need for inpatient admission. These services are usually provided without the use of condition-specific protocols and in an unstructured manner, scattered throughout a hospital in areas typically designated for inpatient care. Emergency department observation units (EDOUs) use protocolized care to offer an efficient alternative with shorter lengths of stay, lower costs, and higher patient satisfaction. EDOU growth is limited by existing policy barriers that prevent a "two-service" model of separate professional billing for both emergency and observation services. The majority of EDOUs use the "one-service" model, where a single composite professional fee is billed for both emergency and observation services. The financial implications of these models are not well understood.

METHODS

We created a Monte Carlo simulation by building a model that reflects current clinical practice in the United States and uses inputs gathered from the most recently available peer-reviewed literature, national survey, and payer data. Using this simulation, we modeled annual staffing costs and payments for professional services under two common models of care in an EDOU. We also modeled cash flows over a continuous range of daily EDOU patient encounters to illustrate the dynamic relationship between costs and revenue over various staffing levels.

RESULTS

We estimate the mean (±SD) annual net cash flow to be a net loss of $315,382 (±$89,635) in the one-service model and a net profit of $37,569 (±$359,583) in the two-service model. The two-service model is financially sustainable at daily billable encounters above 20, while in the one-service model, costs exceed revenue regardless of encounter count. Physician cost per hour and daily patient encounters had the most significant impact on model estimates.

CONCLUSIONS

In the one-service model, EDOU staffing costs exceed payments at all levels of patient encounters, making a hospital subsidy necessary to create a financially sustainable practice. Professional groups seeking to staff and bill for both emergency and observation services are seldom able to do so due to EDOU size limitations and the regulatory hurdles that require setting up a separate professional group for each service. Policymakers and health care leaders should encourage universal adoption of EDOUs by removing restrictions and allowing the two-service model to be the standard billing option. These findings may inform planning and policy regarding observation services.

Postdischarge Unplanned Care Events Among Commercially Insured Patients With an Observation Stay Versus Short Inpatient Admission

STUDY OBJECTIVE

Observation stays are composing an increasing proportion of unscheduled hospitalizations in the United States, with unclear consequences for the quality of care. This study used a nationally representative data set of commercially insured patients hospitalized from the emergency department (ED) to compare 30-day postdischarge unplanned care events after an observation stay versus a short inpatient admission.

METHODS

This was a retrospective analysis of ED hospitalizations using the 2015 Truven MarketScan Commercial Claims and Encounters data set. Adult observation stays and short inpatient hospitalizations of 2 days or less were identified and followed for 30 days from hospital discharge to identify unplanned care events, defined as a subsequent inpatient admission, observation stay, or return ED visit. A propensity score analysis was used to compare rates of unplanned events after each type of index hospitalization.

RESULTS

Among the propensity-weighted cohorts, patients with an index observation stay were 28% more likely to experience any unplanned care event within 30 days of discharge compared with those with a short inpatient admission (20.4% versus 15.9%; risk ratio 1.28; 95% confidence interval [CI] 1.21 to 1.34). Specifically, patients in the observation stay group had substantially higher rates of postdischarge observation stays (4.8% versus 1.9%; odds ratio 2.60; 95% CI 2.15 to 3.16) and ED revisits with discharge (11.1% versus 8.8%; odds ratio 1.26; 95% CI 1.21 to 1.44) compared with those in the inpatient group, but were less likely to be readmitted as inpatients (6.4% versus 7.2%; odds ratio 0.90; 95% CI 0.83 to 0.96).

CONCLUSION

Commercially insured patients with an observation stay from the ED have a higher risk of postdischarge acute care events compared with similar patients with a short inpatient admission. Additional research is necessary to determine the extent to which quality of care, including care transitions, may differ between these 2 groups.

Providing high-quality fundamental care for patients with acute abdominal pain

PURPOSE

Globally, acute abdominal pain (AAP) is one of the most common reasons for emergency admissions, yet little is known about how this patient group experiences the delivery of fundamental care across the acute care delivery chain. The purpose of this paper is to describe how patients with AAP experienced fundamental care across their acute care presentation, and to explicate the health professional behaviours, reported by patients, that contributed to their positive experiences.

DESIGN/METHODOLOGY/APPROACH

A qualitative descriptive study, using repeated reflective interviews, was analysed thematically ( n=10 patients).

FINDINGS

Two themes were identified: developing genuine, caring relationships with health professionals and being informed about one's care. Patients reported that health professionals established genuine professional-patient relationships despite the busy care environment but perceived this environment as impeding information-provision. Patients were typically accepting of a lack of information, whereas poor professional-patient relationships were seen as inexcusable.

PRACTICAL IMPLICATIONS

To provide positive fundamental care experiences for patients with AAP, health professionals should establish caring relationships with patients, such as by using humour, being attentive, and acknowledging patients' physical pain and emotional distress; and should inform patients about their care, including allowing patients to ask questions and taking time to answer those questions.

ORIGINALITY/VALUE

This is the first Australian study to explore the experiences of patients with AAP across the acute care delivery chain, using a novel method of repeated interviews, and to demonstrate how fundamental care can be delivered, in clinical practice, to ensure positive patient experiences.

Evidence of Racial and Geographic Disparities in the Use of Medicare Observation Stays and Subsequent Patient Outcomes Relative to Short-Stay Hospitalizations

Purpose: To examine racial and geographic disparities in the use of—and outcomes associated with—Medicare observation stays versus short-stay hospitalizations.

Methods: We used 2007–2010 fee-for-service Medicare claims, including 3,555,994 observation and short-stay hospitalizations for individuals over age 65. We estimated linear probability models with hospital fixed effects to identify within-facility disparities in observation stay use, estimated in-hospital mortality, 30- and 90-day postdischarge mortality, return emergency department (ED) visits, and hospital readmissions as a function of placement in observation using linear probability models, propensity-score matching, and interaction terms.

Results: We identified racial and geographic disparities in the likelihood of observation stay use within hospitals (blacks 3.9% points more likely than whites, rural 5.4% points less likely than urban). Observation is associated with an increased likelihood of returning to the ED within 30 or 90 days and a decreased likelihood of readmission or mortality, but there are racial and geographic disparities in these outcomes.

Conclusion: While observation generally results in improved outcomes, disparities in these outcomes and the use of observation stays within hospitals are concerning and may be driven by clinical and nonclinical factors.

Are Geriatric Patients Placed in an Emergency Department Observation Unit on a Chest Pain Pathway More Likely Than Non-Geriatric Patients to Re-Present to the Hospital within 30 Days?

BACKGROUND

Emergency department observation units (EDOUs) are used frequently for low-risk chest pain evaluations.

OBJECTIVE

The purpose of this study was to determine whether geriatric compared to non-geriatric patients evaluated in an EDOU for chest pain have differences in unscheduled 30-day re-presentation, length of stay (LOS), and use of stress testing.

METHODS

We conducted an exploratory, retrospective, cohort study at a single academic, urban ED of all adult patients placed in an EDOU chest pain protocol from June 1, 2014 to May 31, 2015. Our primary outcome was any unscheduled return visits within 30 days of discharge from the EDOU. Secondary outcomes included EDOU LOS and stress testing. We used Wilcoxon non-parametric and χ² tests to compare geriatric to non-geriatric patients.

RESULTS

There were 959 unique EDOU placements of geriatric (n = 219) and non-geriatric (n = 740) patients. Geriatric compared to non-geriatric patients had: no significant difference in unscheduled 30-day return visits after discharge from the EDOU (15.5% vs. 18.5%; p = 0.31); significantly longer median EDOU LOS (22.1 vs. 20.6 h; p < 0.01) with a greater percentage staying longer than 24 h (42% vs. 29.1%; p < 0.01). Geriatric patients had significantly fewer stress tests (39.7% vs. 51.4%; p < 0.01), more of which were nuclear stress tests (78.2% vs. 39.5%; p < 0.01).

CONCLUSIONS

In this exploratory retrospective study, geriatric EDOU chest pain patients did not have an increased rate of re-presentation to the hospital within 30 days compared to non-geriatric patients. Geriatric patients had a longer EDOU LOS than non-geriatric patients. Geriatric patients in the EDOU had fewer stress tests, but more of those were nuclear stress tests.

[Asymmetries in the hospital treatment of acute ischemic stroke]

OBJECTIVE

To analyze the degree of implementation of the protocolized care for acute stroke in the Spanish emergency departments and to discuss the territorial differences in the treatment of stroke.

MATERIAL AND METHODS

Multicenter national survey conducted to evaluate the current treatment of ischemic stroke in emergency departments. The main variables analyzed were focused at evaluating the participation of ERs in the performance of thrombolysis, interventional treatment and destination of patients with stroke.

RESULTS

42 emergency services participated. 90.5% have stroke protocol. In 52.4% is identified an emergency physician referent in cerebrovascular pathology. In 2016 2090 thrombolysis were performed, we observe a great variability in the number of treatments per hospital [0-222]. 11.9% were admitted in the Observation area. Only one-third of the hospitals currently treat stroke with thrombectomy. 31% have a telemedicine service available.

CONCLUSIONS

Urgencies plays a fundamental role in the chain of care of stroke treatment. There is a worrying variability between centers in the management of the stroke.

Management of dyspepsia-The role of the ED Observation unit to optimize patient outcomes

BACKGROUND

Dyspepsia is a common complaint that can confer significant burden on one's quality of life and may also be associated with serious underlying conditions. The objective of this study was to determine if patients admitted to the emergency department observation unit (EDOU) for severe or persistent dyspepsia would have cost effective management in terms of investigations performed, length and cost of hospital stay. The secondary objective was to determine if any patient characteristics could predict a need for admission to the inpatient unit.

METHODS

Retrospective chart reviews of patients admitted to the EDOU under the Dyspepsia protocol between January 2008 and August 2014 were conducted. Baseline demographics, investigations performed, outcomes related to EDOU stay, admission and 30-day re-presentation outcomes were recorded.

RESULTS

A total of 1304 patients were included. Median length of stay was 1day. Cumulative bed-saved days were 38 per month. Two hundred eighteen (16.7%) patients required admission to the inpatient service for further management, while 533 (40.9%) and 313 (24.0%) patients underwent esophagogastroduodenoscopy and hepatobiliary ultrasonography, respectively. No major adverse events were attributed to the EDOU admissions or delays in treatment. No significant clinically relevant factors were associated with a need for admission from the EDOU to the inpatient unit. Median cost of the EDOU admission was approximately one-third that of a similar admission to the inpatient unit.

CONCLUSION

The EDOU is an appropriate setting to facilitate investigations and treatment of patients with dyspepsia with considerable bed-saved days.

Short-Term Outcomes and Factors Associated With Adverse Events Among Adults Discharged From the Emergency Department After Treatment for Acute Heart Failure

BACKGROUND

Although 80% of patients with heart failure seen in the emergency department (ED) are admitted, less is known about short-term outcomes and demand for services among discharged patients.

METHODS AND RESULTS

We examined adult members of a large integrated delivery system who visited an ED for acute heart failure and were discharged from January 1, 2013, through September 30, 2014. The primary outcome was a composite of repeat ED visit, hospital admission, or death within 7 days of discharge. We identified multivariable baseline patient-, provider-, and facility-level factors associated with adverse outcomes within 7 days of ED discharge using logistic regression. Among 7614 patients, mean age was 77.2 years, 51.9% were women, and 28.4% were people of color. Within 7 days of discharge, 75% had outpatient follow-up (clinic, telephone, or e-mail), 7.1% had an ED revisit, 4.7% were hospitalized, and 1.2% died. Patients who met the primary outcome were more likely to be older, smokers, have a history of hemorrhagic stroke, hypothyroidism, and dementia, and less likely to be treated in a facility with an observation unit. In multivariable analysis, higher comorbidity scores and history of smoking were associated with a higher odds of the primary outcome, whereas treatment in a facility with an observation unit and presence of outpatient follow-up within 7 days were associated with a lower odds.

CONCLUSIONS

We identified selected hospital and patient characteristics associated with short-term adverse outcomes. Further understanding of these factors may optimize safe outpatient management in ED-treated patients with heart failure.

Time delay to surgery for appendicitis: no difference between surgical assessment unit and emergency department

BACKGROUND

In Denmark, emergency departments (EDs) are replacing acute surgical and medical units. The aim of this study was to compare the trajectory of patients undergoing surgery on the suspicion of appendicitis in a surgical assessment unit (SAU) and EDs with an observation unit, respectively. The primary outcome measure was the time from hospital arrival-to-decision for surgery.

MATERIALS AND METHODS

A comparative retrospective study with a cross-sectional design and a before-and-after design was carried out during January 2011 to December 2012 at a SAU and an ED at a university hospital (U-SAU and U-ED) and at an ED at a regional hospital (R-ED). Data included time of arrival, decision for surgery, surgery and discharge, and number of blood tests.

RESULTS

In total, 250 patients were included. Time to decision for surgery was 4.50, 4.95, and 4.63 h (P=0.58) in the U-SAU, R-ED, and U-ED, respectively. Time from decision for surgery to start of surgery was 4.60, 3.29, and 4.12 h in the U-SAU, R-ED, and U-ED, respectively. The difference was significant between the U-SAU and R-ED (P=0.05) and between R-ED and U-ED (P=0.03). Time from surgery to discharge from the hospital was 17.88, 19.28, and 15.13 h in the U-SAU, R-ED, and U-ED, respectively. The difference was significant between the EDs (P=0.02). Significantly more blood tests were performed in the EDs than in the U-SAU.

CONCLUSION

The introduction of EDs with observation units did not influence time to decision for surgery, but more blood tests were performed.

European Society of Cardiology - Acute Cardiovascular Care Association position paper on safe discharge of acute heart failure patients from the emergency department

Heart failure is a global public health challenge frequently presenting to the emergency department. After initial stabilization and management, one of the most important decisions is to determine which patients can be safely discharged and which require hospitalization. This is a complex decision that depends on numerous subjective factors, including both the severity of the patient's underlying condition and an estimate of the acuity of the presentation. An emergency department observation period may help select the correct option. Ideally, during an observation period, risk stratification should be carried out using parameters specifically designed for use in the emergency department. Unfortunately, there is little objective literature to guide this disposition decision. An objective and reliable definition of low-risk characteristics to identify early discharge candidates is needed. Benchmarking outcomes in patients discharged from the emergency department without hospitalization could aid this process. Biomarker determinations, although undoubtedly useful in establishing diagnosis and predicting longer-term prognosis, require prospective validation for emergency department disposition guidance. The challenge of identifying emergency department acute heart failure discharge candidates will only be overcome by future multidisciplinary research defining the current knowledge gaps and identifying potential solutions.

Identifying patients with mild traumatic intracranial hemorrhage at low risk of decompensation who are safe for ED observation

BACKGROUND

Patients with traumatic intracranial hemorrhage and mild traumatic brain injury (mTIH) receive broadly variable care which often includes transfer to a trauma center, neurosurgery consultation and ICU admission. However, there may be a low risk cohort of patients who can be managed without utilizing such significant resources.

OBJECTIVE

Describe mTIH patients who are at low risk of clinical or radiographic decompensation and can be safely managed in an ED observation unit (EDOU).

METHODS

Retrospective evaluation of patients age≥16, GCS≥13 with ICH on CT. Primary outcomes included clinical/neurologic deterioration, CT worsening or need for neurosurgery.

RESULTS

1185 consecutive patients were studied. 814 were admitted and 371 observed patients (OP) were monitored in the EDOU or discharged from the ED after a period of observation. None of the OP deteriorated clinically. 299 OP (81%) had a single lesion on CT; 72 had mixed lesions. 120 patients had isolated subarachnoid hemorrhage (iSAH) and they did uniformly well. Of the 119 OP who had subdural hematoma (SDH), 6 had worsening CT scans and 3 underwent burr hole drainage procedures as inpatients due to persistent SDH without new deficit. Of the 39 OP who had cerebral contusions, 3 had worsening CT scans and one required NSG admission. No patient returned to the ED with a complication. Follow-up was obtained on 81% of OP. 2 patients with SDH required burr hole procedure >2weeks after discharge.

CONCLUSIONS

Patients with mTIH, particularly those with iSAH, have very low rates of clinical or radiographic deterioration and may be safe for monitoring in an emergency department observation unit.

A Model Longitudinal Observation Medicine Curriculum for an Emergency Medicine Residency

The role of observation services for emergency department patients has increased in recent years. Driven by changing health care practices and evolving payer policies, many hospitals in the United States currently have or are developing an observation unit (OU) and emergency physicians are most often expected to manage patients in this setting. Yet, few residency programs dedicate a portion of their clinical curriculum to observation medicine. This knowledge set should be integrated into the core training curriculum of emergency physicians. Presented here is a model observation medicine longitudinal training curriculum, which can be integrated into an emergency medicine (EM) residency. It was developed by a consensus of content experts representing the observation medicine interest group and observation medicine section, respectively, from EM's two major specialty societies: the Society for Academic Emergency Medicine (SAEM) and the American College of Emergency Physicians (ACEP). The curriculum consists of didactic, clinical, and self-directed elements. It is longitudinal, with learning objectives for each year of training, focusing initially on the basic principles of observation medicine and appropriate observation patient selection; moving to the management of various observation appropriate conditions; and then incorporating further concepts of OU management, billing, and administration. This curriculum is flexible and designed to be used in both academic and community EM training programs within the United States. Additionally, scholarly opportunities, such as elective rotations and fellowship training, are explored.

Prospective evaluation of outcomes among geriatric chest pain patients in an ED observation unit

OBJECTIVE

Because of concerns of high admission rates and adverse events in geriatric patients, hospitals may exclude this group from emergency department observation unit (EDOU) chest pain protocols. We sought to evaluate characteristics and outcomes of geriatric chest pain patients treated in an EDOU.

METHODS

We performed a prospective, observational study of chest pain patients admitted to our EDOU over a 36-month period. We recorded baseline demographics and risk factors as well as outcomes related to the EDOU stay. We performed 30-day follow-up using telephone contact and review of the electronic medical record.

RESULTS

Over the 36-month study period, 1276 chest pain patients agreed to participate in the study. Two hundred seventy-six patients (21.6%) were 65 years and older. Geriatric patients in the EDOU were more likely to report a history of coronary artery disease than nongeriatric patients (27.1% vs 11.6%, P<.001). There were no clinically significant adverse events nor deaths among geriatric patients. The proportion of geriatric patients who experienced myocardial infarction, stent, or coronary artery bypass graft during the EDOU stay or follow-up period was 4.7% vs 2.7% for nongeriatric patients (P=.09). Inpatient admission rates were significantly higher for geriatric patients (15.6% vs 9.7%, P=.006). Similarly, geriatric patients had higher rates of cardiac catheterization than did nongeriatric patients (13.4% vs 7.9%, P=.005).

CONCLUSION

Geriatric patients with chest pain may represent a higher-risk group for evaluation in the EDOU. In our experience, however, these patients were safely evaluated in the EDOU setting and their inpatient admission rate fell within generally accepted guidelines.

Structure and Function of Observation Units in Children's Hospitals: A Mixed-Methods Study

OBJECTIVE

Observation unit (OU) use has been promoted recently to decrease resource utilization and costs for select patients, but little is known about the operations of pediatric OUs. This study aimed to characterize the infrastructure and function of OUs within freestanding children's hospitals and to compare characteristics between hospitals with and without OUs.

METHODS

All 43 freestanding children's hospitals that submit data to the Pediatric Health Information System were contacted in 2013 to identify OUs that admitted unscheduled patients from their emergency department (ED) in 2011. Semistructured interviews were conducted with representatives at hospitals with these OUs. Characteristics of hospitals with and without OUs were compared.

RESULTS

Fourteen (33%) of 43 hospitals had an OU during 2011. Hospitals with OUs had more beds and more annual ED visits compared to those without OUs. Most OUs (65%) were located in the ED and had <12 beds (65%). Staffing models and patient populations differed between OUs. Nearly 60% were hybrid OUs, providing scheduled services. OUs lacked uniform outcome measures. Themes included: admissions were intuition based, certain patients were not well suited for OUs, OUs had rapid-turnover cultures, and the designation of observation status was arbitrary. Challenges included patient discontent with copayments and payer-driven utilization reviews.

CONCLUSIONS

OUs were located in higher volume hospitals and varied by location, size, and staffing. Most functioned as hybrid OUs. OUs based admissions on intuition, had staffing cultures centered on rapid turnover of patient care, lacked consistent outcome measures, and faced challenges regarding utilization review and patient copayments.

National cost savings from observation unit management of syncope

OBJECTIVES

Syncope is a frequent emergency department (ED) presenting complaint and results in a disproportionate rate of hospitalization with variable management strategies. The objective was to estimate the annual national cost savings, reduction in inpatient hospitalizations, and reduction in hospital bed hours from implementation of protocolized care in an observation unit.

METHODS

We created a Monte Carlo simulation by building a model that reflects current clinical practice in the United States and uses inputs gathered from the most recent available peer-reviewed literature and national survey data. ED visit volume was adjusted to reflect observation unit availability and the portion of observation visits requiring subsequent inpatient care. A recent multicenter randomized controlled study informed the cost savings and length of stay reduction per observation unit visit model inputs. The study population included patients aged 50 years and older with syncope deemed at intermediate risk for serious 30-day cardiovascular outcomes.

RESULTS

The mean (±SD) annual cost savings was estimated to be $108 million (±$89 million) from avoiding 235,000 (±13,900) inpatient admissions, resulting in 4,297,000 (±1,242,000) fewer hospital bed hours.

CONCLUSIONS

The potential national cost savings for managing selected patients with syncope in a dedicated observation unit is substantial. Syncope is one of many conditions suitable for care in an observation unit as an alternative to an inpatient setting. As pressure to decrease hospital length of stay and bill short-stay hospitalizations as observation increases, syncope illustrates the value of observation unit care.

Variability in the initial costs of care and one-year outcomes of observation services

Introduction

The use of observation units (OUs) following emergency departments (ED) visits as a model of care has increased exponentially in the last decade. About one-third of U.S. hospitals now have OUs within their facilities. While their use is associated with lower costs and comparable level of care compared to inpatient units, there is a wide variation in OUs characteristics and operational procedures. The objective of this research was to explore the variability in the initial costs of care of placing patients with non-specific chest pain in observation units (OUs) and the one-year outcomes.

Methods

The author retrospectively investigated medical insurance claims of 22,962 privately insured patients (2009–2011) admitted to 41 OUs. Outcomes included the one-year chest pain/cardiovascular related costs and primary and secondary outcomes. Primary outcomes included myocardial infarction, congestive heart failure, stroke or cardiac arrest, while secondary outcomes included revascularization procedures, ED revisits for angina pectoris or chest pain and hospitalization due to cardiovascular diseases. The author aggregated the adjusted costs and prevalence rates of outcomes for patients over OUs, and computed the weighted coefficients of variation (WCV) to compare variations across OUs.

Results

There was minimal variability in the initial costs of care (WCV=2.2%), while the author noticed greater variability in the outcomes. Greater variability were associated with the adjusted cardiovascular-related costs of medical services (WCV=17.6%) followed by the adjusted prevalence odds ratio of patients experiencing primary outcomes (WCV=16.3%) and secondary outcomes (WCV=10%).

Conclusion

Higher variability in the outcomes suggests the need for more standardization of the observation services for chest pain patients.

Protocol-driven emergency department observation units offer savings, shorter stays, and reduced admissions

Many patients who seek emergency department (ED) treatment are not well enough for immediate discharge but are not clearly sick enough to warrant full inpatient admission. These patients are increasingly treated as outpatients using observation services. Hospitals employ four basic approaches to observation services, which can be categorized by the presence or absence of a dedicated observation unit and of defined protocols. To understand which approach might have the greatest impact, we compared 2010 data from three sources: a case study of observation units in Atlanta, Georgia; statewide discharge data for Georgia; and national survey and discharge data. Compared to patients receiving observation services elsewhere in the hospital, patients cared for in "type 1" observation units-dedicated units with defined protocols-have a 23-38 percent shorter length-of-stay, a 17-44 percent lower probability of subsequent inpatient admission, and $950 million in potential national cost savings each year. Furthermore, we estimate that 11.7 percent of short-stay inpatients nationwide could be treated in a type 1 unit, with possible savings of $5.5-$8.5 billion annually. Policy makers should have hospitals report the setting in which observation services are provided and consider payment incentives for care in a type 1 unit.