Determining need for inpatient care

In very practical terms, placing a patient in Observation means that a patient is being assessed, undergoing testing or short-term treatment, and being reassessed before a decision to admit to Inpatient or discharge. It is by far, the safer option for patients who do not present with needs that absolutely requires inpatient hospital care.

Despite the latest infographic from the Center for Medicare Advocacy, the cost and comparative effectiveness of clinical decision units (CDU) have been demonstated in a number of studies over the years.  Yet, there are still hospitals that use acute care beds for outpatients which create confusion for patients and families alike.

CDUs work best when they are separate areas that allow for the observation of patients in order to determine whether or not admission is necessary.  They have been shown to lower costs relative to inpatient admissions, alleviate crowding in EDs and add elements of continuity to patient care. Observation units reduce the number of patients waiting for inpatient beds, thereby reducing ED boarding and reductions in boarding in turn leads to a reduction in diversion hours. 

Geographically, the CDU should be connected to the ED and although best clinically managed by ED physicians and nurses, it should have a distinct CDU medical and nursing team. Protocols should be developed targeting diagnoses that are frequently placed in observation or cases that had long LOS in the ED such as those who need multiple imaging studies, prolonged clinical monitoring or for whom the diagnosis is known but severity of illness is still in question.

Anywhere between 2% - 5% of acute care beds is a popular guide to determine how large a CDU is needed. When CDU beds are not in use, they can be used for either new ED patient evaluations or as holding beds for ED patients waiting for the completion of their workup or for inpatient beds. The multi-use capabilities allows for significant flexibility during times of increased ED demand while still allowing the CDU to accomplish its primary mission of gathering infomation to determine whether a patient needs hospital level inpatient care. Once in the CDU patients remains under the care of an ED physician until evaluation is completed.  If inpatient admission is indicated, a rotating admitting hospitalist is consulted.  

When embarking on the creation of an ED CDU, capture baseline data to analyze the operational impact of the observation unit. Include metrics such as monthly ED volume, observation volume, admission volume, patient satisfaction, ED LOS for inpatient admissions,  ED LOS for patients placed in observation, patients admitted as inpatients and discharged within 24 hours, and hours of LOS till a decision to discharge or admit is made.   

It is not unusual for an organization to convert a regular medical unit to a CDU and often recruit the hospitalist team to manage observation patients. There are many reports of unforeseen challenges in these kind of arrangements.  Most notably, ED nurses and physicians are oriented to manage patients from hour to hour while hospitalists and unit nurses are day-to-day oriented. As a result, LOS may be compromised. In addition, there is the inclination to move patients to observation as a quick fix tactic to decompress the ED.  Often referred to as the 'dumping' syndrome, it results in tension between the ED and hospitalist medical teams and should be avoided.   

Acute care represents the highest risk for iatrogenic events.  Observation is the safer alternative and requires attentive staff and efficient delivery of care.