The Role of Emergency Department Observation Units Sultana

The Role of Emergency Department Observation Units Sultana Qureshi, PGY-2 Resident Grand Rounds December 14, 2006

Principles (ACEP Guidelines)6 § The ultimate goal is to improve the quality of medical care to patients through extended evaluation and treatment while reducing inappropriate admissions and health care costs. § There should be a focused goal of the period of observation. § The intensity of service needs should be limited and consistent with the staffing pattern of the unit § The patient's severity/complexity of illness should be limited. § The patient should have a clinical condition that is appropriate for observation

4 models of OUs § The scatter bed model § The in-house defined unit model § The linked emergency department model (current) § Defined Unit § Technically the ideal model, with unit attached to ED § Under clinical and administrational management of ED

Evolution § Yealy. 19891 – First published on usefulness of OUs in EDs § Over past 15 years, interest and implementation have significantly increased due to changes in healthcare (i. e. ED overcrowding) § Observation Medicine official component of EM in U. S. § 1997 – “Core Content for emergency medicine” (AEM)2 § 2001 – “The model of the clinical practice of emergency medicine” (AEM)3 § 2001 - Observation Medicine Scope of Training Task Force of ACEP, SAEM, RRC, EMRA, CORD, ABEM 4 § 2003 – “A national survey of observation units in the United States” 5

Advantages 7 § Allow additional time for patients requiring extensive ED care before discharge § Enlarge the emergency physician's scope of practice § Unique educational experience for medical students and residents § Reduce hospitalization and health care costs for some patients § Allowing a more comfortable area for patient care § More efficient flow of treatment plan

Advantages 7 § Reduce the ED workload and improve patient flow § 60 -90% of patients can be expected to be discharged home after their period of observation 8 -16 § Reduce physicians' liability risks by allowing more time to make difficult disposition decisions and, thus, allow more certainty of diagnosis (better risk management) § An avenue for clinical pathways § A marketing tool and improved public relations

Daly et al. Short stay units and observation medicine: a systematic review. MJA 2003; 178 (11): 559 -563 Potential benefit Level of evidence Level of Evidence Increased Clinical outcome Improved Medical admissions — No change I 4, 5 Worsened — Length of stay Increased — No change II-214 Decreased I 8 — No change I, 4 II-112 Reduced I, 7 II-16 Cost effectiveness More costly than routine care — Cost neutral — Less costly than routine care I 5 Efficiency of emergency department Patient quality of life Improved I 5 II-19 No change — Decreased — Patient satisfaction Higher satisfaction I 5, 16

Disadvantages 7 § Many advantages become disadvantages if OU not operated properly § Decision making may be prolonged if no clearly defined admission criteria, policies and procedures § May become a "dumping area" § An inadequately staffed facility will overload the emergency staff § A carelessly organized and equipped unit will be unacceptable to the patient because of commotion and lack of privacy § Lack of continuity of care secondary to sign-over

Clinical Indications: ACEP § Evaluation: Critical Diagnostic Syndromes § Abdominal Pain § Chest pain (low probability of myocardial infarction) § Flank pain, rule-out renal colic § GI bleed with initial evaluation § Chest trauma, normal initial evaluation and chest X-ray § Abdominal trauma, normal initial evaluation and lavage § Drug overdose, clinically stable § Syncope, negative initial evaluation § Vaginal bleeding, threatened abortion § Treatment: Emergency Conditions § § § § § Allergic reactions Asthma Acute exacerbation of chronic CHF Dehydration Hyperglycemia, mild to moderate Hypertensive urgencies Selected infections (e. g. , pyelonephritis) Seizure disorder requiring anticonvulsant loading Sickle cell pain crisis Transfusion of blood

Table 1. Common Diagnostic Syndromes in the Observation Unit, 1996 to 1998 Admission to OU N (%) Discharge Home within 23 hours Chest pain 1, 629 (22) 1450 (89) 83– 93 Asthma* 1, 409 (19) 1169 (83) 83– 84 Cellulitis 625 (8) 531 (85) 83– 87 Diabetic emergencies 518 (7) 466 (90) 87– 94 Substance abuse‡ 425 (6) 370 (87) 82– 87 Pneumonia 350 (5) 266 (76) 74– 78 Abdominal pain 242 (3) 201 (83) 80– 88 Pyelonephrits 216 (3) 156 (72) 69– 74 Enteritis/dehydration 140 (2) 113 (81) 77– 84 Congestive heart failure 124 (2) 98 (79) 62– 83 Sickle cell crisis 123 (2) 82 (67) 59– 76 Seizures 84 (1) 70 (83) 74– 89 Other 1, 622 (22) 1362 (84) 77– 88 Total 7, 507 (100) 6334 (85) 84– 87 Martinez et al. Am J EM. 2002; 110(4):

Chest Pain Observation Units

§ Mid 90 s – numerous studies showing effectiveness of managing “low risk” cardiac chest pain in CPU 17 -23

A Clinical Trial of a Chest-Pain Observation Unit for Patients with Unstable Angina (CHEER) Faroukh et al. NEJM. 1998; 339: 1882 -1888 § Prospectively, randomized intermediate risk patients to CPU vs hospital-admission § N=424 § Primary outcomes: § § § nonfatal myocardial infarction death acute congestive heart failure Stroke out-of-hospital cardiac arrest § Cost comparison

Criticism

Validation of a Brief Observation Period for Patients with Cocaine-Associated Chest Pain Weber et al. NEJM. 2003; 348: 510 -517 § Conclusion: Patients with cocaine-associated chest pain who do not have evidence of ischemia or cardiovascular complications over a 9 -to-12 -hour period in a chest-pain observation unit have a very low risk of death or myocardial infarction during the 30 days after discharge.

A comparison of emergency department versus inhospital chest pain observation units Jagminas et al. Am J EM. 2005; 23(2): § Retrospective Observational Study § Concluded EDOU more cost effective than IHOU

Chest Pain Unit § Current Cochrane Review of chest pain unit literature. § Berwanger, O; Polanczyk, CA; Rosito, GA. “Chest pain observation units for patients with symptoms suggestive of acute cardiac ischaemia. ” Cochrane Database of Systematic Reviews. 4, 2006. § Objectives § Comparing chest pain observation units with routine emergency care in terms of morbidity and mortality § Also comparing rates of hospital stay, readmission, and cost benefits

In Summary, § Most studied and validated clinical condition for OU § So, why don’t we have one… § Ideally, would need to build one adjacent to ED § Would require extended hours for cardiology services (i. e. treadmill/chemical stress tests) to risk stratify and discharge

OU Management of Heart Failure

§ Diercks et al. Am J EM. May 2006 – identification of factors to predict OU appropriate cohort (SBP< 160, Tn. T neg) § Peacock et al. Ann EM. Jan 2006 – revised management protocol for HF in OU

Peacock et al. Observation unit management of heart failure. Emerg Med Clin NA. 2001; 19(1)

Trauma Observation

Management of traumatically injured patients in the emergency department observation unit Welch R. Emerg Med Clin NA. 2001; 19(2)

Is it cost-effective? § Yes – by decreasing admission rate (most studies assume that for every admission to the OU an admission is saved) § Most studies assume that for admit to OU, an inpatient admission is saved § Most above prospective studies are diagnosis specific § Undetermined yet – need study on physician impression of suitability for OU vs actual patient disposition

An evaluation of emergency physician selection of observation unit patients Crenshaw et al. AM J EM. 2006; 24(3)

An evaluation of emergency physician selection of observation unit patients Crenshaw et al. AM J EM. 2006; 24(3) § “Selection of patients for observation was suboptimal; emergency physicians routinely identified patients as OU candidates who were not ultimately admitted, and they missed many admitted patients who might have been appropriate OU candidates. ”

Conclusions and areas for discussion… § Do OUs improve patient care, outcomes? § Are OUs cost-effective? § Should CHR plan for OU in future? § What is more cost-effective – having more ED acute beds vs building OU?

Clinical Indications: ACEP § Evaluation: Critical Diagnostic Syndromes § Abdominal Pain § Chest pain (low probability of myocardial infarction) § Flank pain, rule-out renal colic § GI bleed with initial evaluation § Chest trauma, normal initial evaluation and chest X-ray § Abdominal trauma, normal initial evaluation and lavage § Drug overdose, clinically stable § Syncope, negative initial evaluation § Vaginal bleeding, threatened abortion § Treatment: Emergency Conditions § § § § § Allergic reactions Asthma Acute exacerbation of chronic CHF Dehydration Hyperglycemia, mild to moderate Hypertensive urgencies Selected infections (e. g. , pyelonephritis) Seizure disorder requiring anticonvulsant loading Sickle cell pain crisis Transfusion of blood