OBSERVATION Ward

OBSERVATION Ward

Emergency department (ED) patients frequently require services beyond their initial ED care to determine the need for inpatient admission. Observation Ward ( OR ) , also known as Clinical Decision Unit ( CDU ) or Clinical Observation Unit ( COU ) are increasingly becoming an important component of the modern ED. 

Observation is by definition the use of appropriate monitoring, diagnostic testing, therapy, and assessment of patient symptoms, signs, laboratory tests, and response to therapy for the purpose of determining whether a patient will require further treatment as an inpatient or can be discharged form the hospital setting.

To promote quality of care and patient safety for ED observation patients, the American College of Emergency Physicians (ACEP) supports the following principles:

1. Observation of appropriate ED patients in a dedicated ED observation area, instead of a general inpatient bed or an acute care ED bed, is a "best practice" that requires a commitment of staff and hospital resources.
2. An emergency physician and emergency nurse should direct ED observation areas with clearly defined administrative responsibilities for the unit.
3. Written policies and procedures for the ED observation area should be approved by appropriate ED and hospital medical staff representatives.
4. ED observation areas should have adequate space, staffing, equipment, and supplies appropriate for the conditions being managed.
5. Mechanisms should be in place to expedite the discharge or the transfer of patients to an inpatient bed, when appropriate.
6. ED observation area policies and procedures should address the following : 

• Patient criteria for admission into the unit, discharge from the unit, and admission to an inpatient bed;
• A clear statement of which physician bears clinical responsibility for each patient in the area;
• A clear delineation of emergency physician and nursing staff roles and responsibilities throughout the day – including how care will be transferred between providers;
• Circumstances that require notification of the physician who is responsible for the patient;
• Maximum allowable length of stay in the unit and means to address outliers; and
• A description of how utilization and relevant quality measures will be monitored and reported. 

Patient Satisfaction Goals

• To reduce hospitalization and health care costs for patients.
• To provide a more comfortable area for medical care while the patient is in an observation setting.
• To deliver outstanding patient care with high levels of patient satisfaction. 
• The Observation Ward repeatedly elicits letters from patients reiterating high levels of satisfaction

The Philosophy of Observation Ward Care

1. To provide an area to care for any patient who has not been admitted but whose condition necessitates a lengthy observation, not to exceed 24 hours.
2. To provide an area for observation for testing when a patient does not meet screening criteria for an acute care setting.
3. Deliver excellence in clinical care by correctly diagnosing heart attack (Myocardial Infarction or MI) or patients and more rapidly diagnosing acute coronary syndromes so that therapy may be implemented expediently. undefined
4. Allow additional time to make difficult disposition decisions and, thus, allow more certainty of diagnosis. To create new research opportunities and increase overall knowledge in implementation of care in the ED.

Benefits to patients

• Observation services are an extension of ED evaluation and stabilization services beyond the traditional two- to three-hour limit. A benefit of this continued patient management is better definition of the patient's problem with reduction in both costs and inappropriate dispositions.
• 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
• Help minimize patient delays in seeking medical care and delays in the ED itself.
• Cost saving compared with an in-hospital evaluation to rule-out life threatening disease such as acute MI.
• Deliver excellence in clinical care by appropriately identifying MI patients and more rapidly diagnosing acute coronary syndromes so that therapy may be implemented expediently.

The Good

1. Reduced admissions. 

On average, the admission rates from ED to inpatient services are 13.3%.5 In contrast, in hospitals that have a robust Observation Ward in place, the admission rates are much lower. As an example, Cook County Hospital in Chicago in the mid-1990s saw a decline in the admission rates from the emergency room following implementation of a Observation Ward, along with an increase in bed capacity due to the efficient, protocol-driven approach that goes along with successful ED observation units. With well-structured and managed observation units, such a reduction in hospitalization rates has been shown, is reproducible, and is achievable.

2. Improved case-mix multiplier. 

Inpatient reimbursements from the Centers for Medicare and Medicaid Services (CMS) and private insurers frequently are tied to the acuity of care a hospital provides. Critical to making that determination is the case mix that a given hospital sees. Usually, the more complex patients a hospital admits, the higher the reimbursements are. With a successful Observation Ward, a hospital can expect a case-mix multiplier representing patients with greater complexity and higher acuity.

3. Proper admission

What a successful Observation Ward essentially does is lead to the admission of patients with greater comorbidities—those who are sicker than the average patient. In doing so, Observation Ward also facilitate safe discharges of the patients who do not necessarily need to be admitted. As an average, the cohort of patients who are admitted as inpatients then consists of patients who are sick enough and absolutely need to be admitted.

4. Resource utilization. 

When a patient is admitted from the ED to an inpatient floor, a lot of resources are utilized. These include expenses related to transportation, housekeeping, nursing, and ancillary services. Each of these additional resources comes with an expense. The more resources that are put in motion, the greater the expense a hospital incurs. With effective Observation Ward, it is generally expected that suitable patients will get the care in a specific geographic area by the same set of providers. Observation Ward tend to reduce unnecessary hospitalizations, redundancy of manpower utilization, and duplication of documentation—therefore reducing the expenses incurred by the hospital.

5. Infection control. 

The Observation Ward operate based on minimizing the stay of the patients who can be safely discharged after a brief observation period. Decreased duration of stay also means decreased movement and unique provider contact/exposure—thus decreasing the chances for acquiring health-care-related infections. Besides, most Observation Ward are restricted to a certain geographic area within the hospital, which helps to restrict patients to a limited area. This again may be helpful in better overall infection-control practices. More research is necessary to establish this association of the infection-control advantages of Observation Ward. The hypothesis, however, does appear very promising.

6. Prompt and standardized care. 

Most Observation Ward use an evidence-based, standardized approach toward the patients seen in the ED. Several professional bodies have endorsed the use of protocol-driven care for the conditions seen in the Observation Ward. Most professional organizations that have a key role in Observation Ward advocate this approach, and include the ACEP, AHA, and SHM. When a Observation Ward has established itself, it likely is to use specific, expedited, protocol-driven approaches. This allows for care to be focused and standardized. This also is an opportunity to avoid redundant imaging and lab testing.

7. Patient safety. 

In its landmark publication “To Err is Human: Building a Safer Health System,” the Institute of Medicine identified communication error as one of the factors that lead to mistakes inpatient care. Observation Ward often tend to provide bulk of care at a given geographical area; this minimizes the transfer of patients from one place to another, thereby decreasing communication errors.

By providing more time to make decisions, Observation Ward afford a greater diagnostic certainty. In the long run, this also helps a hospital minimize costly lawsuits.

An efficient Observation Ward means that the patients who are admitted are, in fact, sicker. Logically, these patients will have a higher chance of being readmitted. Because the “not so sick” patients were successfully intervened and discharged from Observation Ward, the patients that did get admitted must be pretty sick and must have higher comorbidities.

The Bad

Not everything about Observation Ward is great. There are certain areas that dull the luster of an observation unit.

1. Overzealous approaches. 

Observation Ward are designed to allow more time to make clinical decisions when the triaging is in a gray area: whether to admit or not. Also, Observation Ward provide clinicians with more time to follow the response to the care the patients receive in an emergent fashion. It needs to be emphasized that Observation Ward are designed neither to replace hospitalization, nor to act as urgent care. As a corollary, there is a chance clinicians may be overzealous in discharging patients from Observation Ward close to the 24-hour mark—even though it might not be clear whether the patient needs to be admitted or discharged. Overzealous discharging of Observation Ward patients can damage the premise of these units: to determine the need for admission and ensure patient safety. Having strict inclusion and exclusion criteria and good management can prevent these problems.

2. Staffing. 

Introduction of a Observation Ward can strain an already short-staffed ED. No different from any other novel approach, Observation Ward staffers need to be afforded a learning curve. This requires training personnel and establishing a robust team to staff Observation Ward. It can be a strenuous process, at least in the beginning. Strong leadership and support of hospital, physician, and nursing leadership all play a role in the successful implementation and ongoing utilization of Observation Ward.

3. Logistics. 

Coordination of people, facilities, and supplies that go into instituting a Observation Ward might be a challenge. Also, there may be times where patient ownership may not be very clear. Logistical concerns can include:

• Who owns the patient?
• How much of a role does a consulting service have?
• Who oversees the follow-up plans?

Although a popular Observation Ward setup is to have a dedicated observation unit adjacent to the ED, it is not a standard.

4. Reimbursement. 

Unfortunately, there is some degree of negative incentive built into reimbursements for Observation Ward operations. To understand why this is a bad thing for a hospital, let’s examine how hospitals are paid for services provided in a Observation Ward.

Frequently, Observation Ward patients are treated as “outpatients.” The operating formula is based on the Hospital Outpatient Prospective Payment System (OPPS), which is based on Ambulatory Payment Classification. Reimbursement differences in these two approaches can be quite sizable. Depending on what condition is being treated, the hospital reimbursement can be as little as half to a quarter of the payment for inpatient treatment. 

Essentially, the patient would have received very similar care, diagnostic work-up, antibiotics, imaging, lab work, and equally qualified clinicians as caretakers in both the settings. The payments need to account for the care in the Observation Ward, which is usually more acute than in the ambulatory setting and potentially more efficient than an inpatient setting. The payments, therefore, should be sensitive to these factors.

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