Original ContributionsMaximizing use of the emergency department observation unit: A novel hybrid design*
Introduction
Emergency department observation units have been shown to offer economic and patient care benefits to patients and third-party payers. These include lower overall costs of care relative to inpatient admission, shorter patient length of stay, fewer missed myocardial infarctions, and improved patient satisfaction.1, 2, 3, 4, 5, 6 However, studies have reported difficulties encountered when justifying an ED observation unit (EDOU) to a hospital. The difficulties described in these studies occurred as a result of variable or inadequate patient volumes needed to support nursing staff positions.7, 8
Sinclair and Green7 reported that EDOU nursing positions could not be justified by displacing nursing positions from inpatient units where patients would have otherwise been managed. However, their data source was a low-volume, low-severity ED with a 16% admission rate. Their analysis was made by using estimates of physicians practicing in an ED without an EDOU as to which ED patients might have qualified for an EDOU. Their estimated population accounted for only 0.4% of the ED census and did not include such high-volume conditions as chest pain or most types of asthma. Similarly, Bond and Wiegand8 reported that a pediatric EDOU could not be justified because of the highly variable nature of the pediatric ED census, in part because of seasonal variations. Again, physician estimates rather than actual EDOU patient data were used.
There are several problems faced by hospitals considering a dedicated EDOU. After the initial investment of construction costs, the greatest ongoing cost is maintaining nursing and ancillary support staff salaries. Dedicated units are often staffed with a patient/nurse ratio of between 4:1 and 6:1.9, 10 As with any unit, an adequate census of patients is required to provide adequate revenue to support these staff positions. For higher-volume units, this is not a problem. However, the EDOU census may not be adequate to support dedicated staff in smaller hospitals, units choosing to restrict services to a limited group of patients (eg, those with chest pain), or units experiencing an initially low census because of a slow transition to this alternative approach. Another potential problem is that if the unit is a closed unit (separated from other nursing care areas by 4 walls), it is often required that at least 2 nurses be on duty at all times. This ensures that the unit is not left unattended should 1 nurse take a break or be called to a sick patient.
To maximize census and to better use nursing resources and space, many observation units combine patients who are “holds” with observation patients. In Brillman et al,11 “observation” patients are defined as those requiring further management specifically “to determine the need for inpatient admission.” This concurs with the definition of observation services stated by the Health Care Finance Administration.12 On the other hand, hold patients are defined as those awaiting a prearranged action, such as admission to the hospital, transfer to the operating room, transfer to another facility, or discharge home.11 Hold patients often represent an overload of hospital resources or the failure of a hospital system to work effectively. For example, holding of patients occurs when resources are lacking, such as inpatient beds or available operating room suites. Although hold patients may consume considerable ED resources, there is no additional revenue available to an ED for managing these hold patients pending an admission, transfer, or an emergency procedure. For the ED, managing hold patients is not a true value-added service. Rather, it enables dysfunctional characteristics of a health care system.
A separate group of outpatients are those receiving a scheduled elective procedure or treatment. These patient visits are traditionally unrelated to the ED and in this article are identified as scheduled procedure visits or patients. These patients have hospital service needs that are similar to those of observation patients: they need a treatment room, appropriate equipment, and nursing services for several hours. Their uses of these resources are reimbursed under procedure codes specific to each procedure and unrelated to emergency or observation reimbursement codes. The concept of combining these scheduled procedure patients with an EDOU population and the effect of this model on observation unit occupancy has not been previously studied or reported.
We hypothesized that sharing a closed observation unit with scheduled procedure patients would provide a higher hourly unit census and patient/nurse ratio. Our secondary hypothesis was that scheduled procedure patient length of stay would not be increased when patients were cared for in this hybrid unit setting relative to their alternative inpatient location and that ED observation patient length of stay and discharge rate would not be increased when they shared the unit with scheduled procedure patients.
Section snippets
Materials and methods
This was an institutional review board–exempted, descriptive, retrospective study that uses a “before-and-after” study design. It took place at a major Midwestern teaching hospital, which is an American College of Surgeons–designated Level I trauma center, with an ED volume of 84,439 and a 28% admittance rate in 1997.
Before October 1995, the study unit was a 15-bed closed unit, which was adjacent to the ED and was restricted to scheduled procedure patients only. Its hours of operation were
Results
In 1994, before the transition to a hybrid unit, there were 5,406 scheduled procedure patients. In 1995, the 15-bed unit spent 9 months as a pure scheduled procedure unit and then 3 months as a hybrid EDOU–scheduled procedure unit seeing 4,895 scheduled procedure patients and 484 EDOU patients. Over its first 8 months of operation, the 8-bed EDOU monthly census steadily increased from 135 to an average of 252 patients per month, where it stabilized in mid-1996. The average monthly EDOU census
Discussion
This study demonstrated 2 results by using actual EDOU patient data. First, combining services showed a complementary diurnal occupancy pattern that improved both hourly census and nurse resource use. Second, scheduled procedure patients were managed more rapidly in this unit setting than in alternative inpatient locations, without showing an adverse effect on the length of stay or discharge rate of EDOU patients.
The EDOU census took a period of 8 months to stabilize to roughly 1.1 to 1.3
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Address for reprints: Michael A. Ross, MD, 3601 W Thirteen Mile Road, Royal Oak, MI 48073-6769;,248-551-2015, fax 248-551-2017;, E-mail [email protected].