Principles of Observation Medicine

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HISTORICAL BACKGROUND OF OBSERVATION SERVICES

Observation has always been a fundamental aspect of how a physician cares for a patient. The early healers of Babylonia and Egypt documented observations of how diseases seemed to progress as early as 1700 BC; however, it was in 410 BC that the father of medicine, Hippocrates, developed a more critical approach to medicine based on observation and experience. This new approach, recorded as the Hippocratic corpus, became the foundation of how medicine is still practiced today.48 Hippocrates

TERMINOLOGY

As a result of this evolution, various terms have arisen. The first term is Emergency Department Observation Unit (EDOU). This is a dedicated area within and under the direction of the ED where patients are managed to determine the need for admission. The crucial concept here is that management is for the sole purpose of determining the need for inpatient admission. This is not to be confused with the Observation Status Bed or 23-hour admit. These terms arose as a result of the original HCFA

DIAGNOSTIC EVALUATION

Diagnostic conditions appropriate for observation have three characteristics. First, they represent a balance between the probability of a condition and that conditions' potential risk. Second, they are conditions for which a physicians' initial clinical diagnostic performance is poor. Third, initial diagnostic testing is often not conclusive.

In terms of disease risk and probability, if a condition were associated with a relatively high mortality rate, then observation would be limited to

SHORT-TERM TREATMENT

There are many emergent conditions that often are not successfully treated in the ED but can be successfully treated with an additional 10 to 15 hours in an EDOU. The traditional admit or discharge model does not match the temporal behavior of patients who need treatment for a period in the range of 6 to 24 hours. As a rule, conditions are observed only after aggressive initial ED treatment has failed. Of these patients, a subset having a 70% to 80% probability of discharge after treatment in

PSYCHOSOCIAL MANAGEMENT

Over the last 30 years, the number of inpatient psychiatric beds in the United States have plummeted from 722,000 in 1960 to less than 170,000 in 1990.6 This has been associated with a shift in psychiatric management to the outpatient setting. Over 5% of ED patients have a psychosocial problem as the reason for their presentation. Many of these patients' needs are not addressed within a 3- to 4-hour ED evaluation that will consist of 20 to 24 minutes with the physician. Psychiatric patients

SUMMARY

The defining characteristic of emergency medicine is “time,” or the acuity of disease presentation. Observation, like resuscitation, involves the management of time-sensitive conditions. In the ED there is a continuum of time-sensitive conditions. This continuum extends from resuscitation on one end to observation on the other. When performed well, observation services have been shown to improve diagnostic accuracy, improve treatment outcomes, decrease costs, and improve patient satisfaction.

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  • Cited by (39)

    • The Establishment and Management of an Observation Unit

      2017, Emergency Medicine Clinics of North America
    • History, Principles, and Policies of Observation Medicine

      2017, Emergency Medicine Clinics of North America
      Citation Excerpt :

      These 6-hour to 24-hour patients have care that falls between the ED and inpatient settings and is best provided in a dedicated observation unit, otherwise known as a type 1 setting (Table 1). The principles of observation medicine describe how to best manage these 6-hour to 24-hour patients based on clinical research and national policies27,34,35 (Box 1). To understand observation services, it is important to understand past and present Medicare observation policy.

    • Failure of emergency department observation unit treatment for skin and soft tissue infections

      2015, Journal of Emergency Medicine
      Citation Excerpt :

      Our results provide data that are potentially useful in identifying children with SSTI best served in the OU, as well as those suited for direct ward admission from the ED. Observation medicine is used to determine if illnesses will progress or resolve prior to final disposition, to minimize inpatient hospitalization, and reduce costs by treating conditions that resolve rapidly (3,5,22). In addition, it is recommended that OUs be used for patients with a clear diagnosis, specific management plan, and that require little intensity of service (3).

    • Effect on efficiency and cost-effectiveness when an observation unit is managed as a closed unit vs an open unit

      2013, American Journal of Emergency Medicine
      Citation Excerpt :

      Although the handoff process was not compared and measured in this study, because the hand-off during periods 2 and 3 is between two like-minded physicians familiar with the care plans and protocols, it follows that there is less opportunity for communication and care transition errors [32]. One of the 7 principles of managing an observation unit described by Ross and Graff is appropriate staffing [33]. In this study, emergency physicians managed and staffed the OU in the closed model.

    View all citing articles on Scopus

    Address reprint requests to Michael A. Ross, MD, FACEP, Department of Emergency Medicine, William Beaumont Hospital, 3601 W. Thirteen Mile Road, Royal Oak, MI 48073–6769

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