Emergency department observation beds improve patient care: Society for academic emergency medicine debate

doi:10.1016/S0196-0644(05)82937-3

Annals of Emergency Medicine

Volume 21, Issue 8, August 1992, Pages 967-975

https://doi.org/10.1016/S0196-0644(05)82937-3 Get rights and content

Summary

Pro Side: Dr Graff What we are dealing with is not a physical unit but in reality a concept. We are not emergency room doctors — we are emergency physician specialists. We deal with emergency medicine in all its aspects; we don't deal with a room. Whether you have an observation unit or an observation policy, what is important is the concept of how to deal with a certain type of patient. The overcrowding issue may actually help us. Rather than us putting our head into a hole saying we can't deal with this type of patient — ie, we don't deal with continuing care — we should provide ongoing care for a certain type of patient, a patient who is appropriate for an observation unit. We shouldn't deal with a patient who is appropriate for admission to the hospital, who has 20 or 30 medicines, and who needs intensive services. We are going to manage patients who have a limited intensity of service that we define as manageable for our nurses, a level of service similar to that on the medicine floors. This saves the bed upstairs for patients who are “train wrecks” with very high service needs that would consume our staff's energies.

At the same time, we are offering to society a way of dealing with the health care crisis. The latest Health Care Financing Administration statistics show that more than 12.4% of our nation's gross national product is for health care. This is up from 11.6% of the gross national product from last year despite cost-containment studies and efforts. Our specialty should have input into solutions being developed for these problems. With observation units we are part of the safety net for the population, managing many common emergencies that otherwise would have needed hospital admission. We are part of the solution trying to deal with health care policy.

References (58)

YealyD
A survey of observation units in the United States
Am J Emerg Med
(1989)
LynnSG et al.
Critical decision making: Managing the emergency department in an overcrowded hospital
Ann Emerg Med
(1991)
LeikinJB
The uprooting of observation units from emergency departments: Opportunity lost for emergency medicine?
Am J Emerg Med
(1988)
CallahamM et al.
Epidemiology of tricyclic antidepressant ingestion: Implications for management
Ann Emerg Med
(1985)
KizerKW
Toxic inhalation
Emerg Med Clin North Am
(1984)
HeimbachDM et al.
Inhalation injuries
Ann Emerg Med
(1988)
CohenMA et al.
Inhalation of products of combustion
Ann Emerg Med
(1983)
KinsellaJ
Increased airways reactivity after smoke inhalation
Lancet
(1991)
LeeTH et al.
Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room
Am J Cardiol
(1987)
HedgesJR et al.
Use of cardiac enzymes identifies patients with acute myocardial infarction otherwise unrecognized in the emergency department
Ann Emerg Med
(1987)

RusnakRA et al.

Litigation against the emergency physician: Common features in cases of missed myocardial infarction

Ann Emerg Med

(1989)

GiblerWB et al.

Early detection of AMI in patients presenting with chest pain and nondiagnostic ECGs: Serial CK-MB sampling in the ED

Ann Emerg Med

(1990)

GraffLG et al.

Probability of appendicitis before and after observation

Ann Emerg Med

(1991)

AlvaradoA

A practical score for the early diagnosis of acute appendicitis

Ann Emerg Med

(1986)

KromeRL

Observation care units

Ann Emerg Med

(1989)

American College of Emergency Physicians

Management of observation units

Ann Emerg Med

(1988)

WardG et al.

Treatment of pyelonephritis in an observation unit

Ann Emerg Med

(1991)

ZwickeDL et al.

Use of the emergency department observation unit in the treatment of acute asthma

Ann Emerg Med

(1982)

ConradL et al.

The role of an emergency department observation unit in the management of trauma patients

J Emerg Mad

(1985)

AmmonsMA et al.

Role of the observation unit in the management of thoracic trauma

J Emerg Med

(1986)

American College of Emergency Physicians Practice Management Committee

Management of observation units

Ann Emerg Med

(1988)

KellermanA et al.

Hospital and emergency department overcrowding: Results of a national survey

Ann Emerg Med

(1990)

ColtHG et al.

Adverse drug reactions

JAm Geriatric Soc

(1989)

HaddadLM et al.

Clinical Management of Poisoning and Drug Overdose

(1990)

Cited by (25)

Takotsubo syndrome and chest pain units
2013, American Journal of Emergency Medicine
Algorithm for probable acute coronary syndrome using high-sensitivity troponin T assay vs fourth-generation troponin T assay
2013, American Journal of Emergency Medicine
Citation Excerpt :
Characterization of chest pain is sometimes difficult, and strategies should focus on preventing inappropriate discharge of patients with acute coronary syndromes or avoiding unnecessary admissions to the coronary care unit (30%-70% of cases) [1-8]. Over the last decades, different protocols have been developed for evaluating patients with chest pain suggestive of acute coronary syndrome; most of them include observation of patients for a few hours and serial measurement of biomarkers of myocardial injury [9-29]. High-sensitivity troponin has proved to be useful for the evaluation of this type of patients, mainly due to its high negative predictive value and to the rapid positive result in cases of myocardial injury [30].
Chest pain represents between 5% and 10% of annual visits to emergency departments (EDs) and near 25% of hospitalizations. Characterization of chest pain is sometimes difficult, and strategies should focus on preventing inappropriate discharge of patients with acute coronary syndrome. The goal of our study is to compare negative predictive value of the algorithm in the chest pain unit using the fourth-generation troponin T assay (4GTT) vs high-sensitivity troponin T assay (HSTT).
We included 600 patients with probable acute coronary syndrome, who were discharged from the chest pain unit without an acute coronary syndrome: 300 patients in the 4GTT group and 300 patients in the HSTT group. Clinical and laboratory variables were analyzed. All the patients were followed up at 30 days, and the cardiovascular events were recorded.
Major cardiac events occurred in only 3 (1.2%) in the HSTT group vs 5 (1.7%) in the 4GTT group (P, nonsignificant). The negative predictive value was 99% in both groups. Emergency department length of stay was 4.3 ± 2.6 hours in HSTT group vs 10 ± 3.4 hours in the 4GTT group (P = .01).
The algorithm in the chest pain unit using HSTT showed to have the same negative predictive value as the algorithm with the 4GTT but with a shorter stay in the ED.
A Critical Pathway for Patients With Acute Chest Pain and Low Risk for Short-Term Adverse Cardiac Events: Role of Outpatient Stress Testing
2006, Annals of Emergency Medicine
We evaluate the safety and feasibility of a critical care pathway protocol in which patients with acute chest pain who are low risk for coronary artery disease and short-term adverse cardiac outcomes receive outpatient stress testing within 72 hours of an emergency department (ED) visit.
We performed an observational study of an ED-based chest pain critical pathway in an urban, community hospital in 979 consecutive patients. Patients enrolled in the protocol were observed in the ED before receiving 72-hour outpatient stress testing. The pathway was primarily analyzed for rates of death or myocardial infarction in the 6 months after ED discharge and outpatient stress testing. Secondary outcome measures included need for coronary intervention at initial stress testing and within 6 months after discharge, subsequent ED visits for chest pain, and subsequent hospitalization.
Of 871 stress-tested patients aged 40 years or older, who had low risk for coronary artery disease and short-term adverse cardiac events, and had 6-month follow-up, 18 (2%) required coronary intervention, 1 (0.1%) had a myocardial infarction within 1 month, 2 (0.2%) had a myocardial infarction within 6 months, 6 (0.7%) had normal stress test results after discharge but required cardiac catheterization within 6 months, and 5 (0.6%) returned to the ED within 6 months for ongoing chest pain. Hospital admission rates decreased significantly from 31.2% to 26.1% after initiation of the protocol (P<.001).
For patients with chest pain and low risk for short-term cardiac events, outpatient stress testing is feasible, safe, and associated with decreased hospital admission rates. With an evidence-based protocol, physicians efficiently identify patients at low risk for clinically significant coronary artery disease and short-term adverse cardiac outcomes.
An evaluation of emergency physician selection of observation unit patients
2006, American Journal of Emergency Medicine
Appropriate patient selection is critical for maximal observation unit (OU) effectiveness. We hypothesized emergency physicians underuse the OU for admitted patients and overuse the OU for patients who would otherwise be discharged.
Treating emergency physicians were asked about patient suitability for admission to an OU at a busy, urban, academic emergency department (ED) as part of a prospective cohort study of ED patients who were admitted or had an ED length of stay exceeding 4 hours. The OU was closed for renovation during the 2-month study, so physician opinion could be compared with patient course in the absence of observation services. Two blinded emergency physicians reviewed charts using structured forms and explicit definitions to determine actual patient course. Hospitalized patients were considered potential OU candidates according to a priori criteria: (1) hospital length of stay less than 48 hours, (2) no procedure or diagnosis requiring hospitalization, and (3) no death.
Of 1747 enrolled patients, 131 were excluded with incomplete data. Median age was 45 years. Patients were 40% white and 48% men. Emergency physicians identified 363 (23%) patients as observation candidates. Of these, 182 (50%) were actually discharged directly. The remaining 181 (50%) were hospitalized; 101 (56%) were observation candidates based on chart review. Of 799 admitted patients not selected for observation, 232 (29%) were suitable for observation by chart review.
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. Both over- and underuse should be addressed to maximize the effectiveness of OUs.
Implication of emergency departments in the regulation of public hospitalizations
2003, Revue de Medecine Interne
Propos. – Le service d’urgences devient le mode d’accès privilégié aux soins hospitaliers. Depuis ces dernières années, les difficultés d’hospitalisation, surtout celles des sujets âgés, à partir des services d’urgences n’ont cessé de croître.
Actualités et points forts. – Les urgences constituent une source de recrutement importante pour les services hospitaliers, 4 patients sur 10 entrent à l’hôpital par le service d’urgences. Les difficultés d’hospitalisation à partir du service d’urgences sont surtout importantes pour les patients âgés. Il existe actuellement 2 filières de prise en charge, l’hospitalisation programmée et l’hospitalisation non programmée. La création d’unités d’hospitalisation de très courte durée spécifique aux services d’urgences a permis de répondre à certaines de ces difficultés. Mais ces unités sont limitées par le nombre réduit de lits et une durée de séjour inférieure à 36 heures. Certains hôpitaux ont développé des unités de court séjour d’urgence polyvalentes pour accueillir des patients admis au service d’urgence ne justifiant pas d’une prise en charge spécialisée.
Perspectives et projets. – Ce constat doit conduire à mieux réguler les hospitalisations en intégrant les services d’urgences à des réseaux de soins prenant en charge les différentes filières. Une filière d’aval adaptée à l’hospitalisation des urgences pourrait être organisée. Elle serait constituée du service d’urgence, de l’unité d’hospitalisation de très courte durée et de l’unité d’hospitalisation de court séjour d’urgence en interface avec les services de médecine interne, de médecine polyvalente, de gériatrie et de spécialités au sein d’un réseau ville–hôpital.
Purpose. – Emergency departments become a useful way to access to hospital care. Since these last years difficulties of hospitalization, mainly of the elderly, after visit to the emergency department, are on the increase.
Current knowledge and key points. – Emergency departments are an important mode of recruitment for hospital units, 4 patients to 10 are hospitalized from emergency departments. The difficulties of hospitalization starting at the emergency department are more important for the elderly. Actually, there are 2 type of hospital care, planed and non planed care. The development of observation units specific to the emergency departments allowed to resolve some of these difficulties. But they are limited by their small number of beds and the duration of hospitalization below to 36 h. Some hospitals developed polyvalent emergency short stay unit to hospitalize patients who visited emergency department without necessity to give them a specialized care.
Future prospects and projects. – This situation must allow us to purpose a better regulation of hospitalizations which includes emergency departments in a network system including the different hospital ways of taking care. A downstream way of care adapted to the emergency hospitalizations would be developed. This could include the emergency department, the observation unit and the emergency short stay unit in interface with internal medicine and general medicine units, geriatric unit and specialized units, all of them will be included in a town-hospital care network.
Principles of observation medicine
2001, Emergency Medicine Clinics of North America
Citation Excerpt :
In 1988 the American College of Emergency Physicians' (ACEP) practice management committee issued a policy statement on ED OUs and the first guidelines on their management.3,19 One year later the Society for Academic Emergency Medicine (SAEM) formed an observation medicine committee that developed an annotated bibliography on the topic and a curriculum.28,46 In 1991 ACEP formed a section of membership for observation services to serve as an organization for physicians providing those services.

View all citing articles on Scopus

: This article does not represent the views of the Department of Human Services, Commission of Public Health, or the Government of the District of Columbia and is for debate purposes only.

View full text

ConceptEmergency department observation beds improve patient care: Society for academic emergency medicine debate

Summary

Am J Emerg Med

Ann Emerg Med

Am J Emerg Med

Ann Emerg Med

Emerg Med Clin North Am

Ann Emerg Med

Ann Emerg Med

Lancet

Am J Cardiol

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

J Emerg Mad

J Emerg Med

Management of observation units

Ann Emerg Med

Hospital and emergency department overcrowding: Results of a national survey

Ann Emerg Med

Adverse drug reactions

JAm Geriatric Soc

Clinical Management of Poisoning and Drug Overdose

Concept
Emergency department observation beds improve patient care: Society for academic emergency medicine debate