Physician assistants (PAs) have helped one hospital improve care in its observation unit without increasing costs, partly by providing more contact with patients than physicians can. The hospital also has optimized its observation unit model.

Northwest Hospital, part of LifeBridge Health in Randallstown, MD, can employ nearly two PAs for the cost of a physician, so patients can be seen more frequently. They make up one of several strategies the hospital uses to make the observation unit as efficient as possible.

The PAs aim to “touch” patients in the unit every two to four hours, collect information quickly, and get more timely consults, says Richard Rohrs, PA-C, DFAAPA, SFHM, assistant vice president for provider operations at the hospital. He was the third PA to work at the hospital in 1977, soon after the PA concept emerged.

PAs have been used in the 1,200-bed LifeBridge system primarily in a hospitalist capacity, Rohrs explains. PAs also work in the ED, surgery, and in subspecialties. The LifeBridge system currently uses about 400 PAs, most of whom are employed by the hospitals.

LifeBridge uses a model that has PAs working closely with nurse practitioners, and they are particularly valuable in the ED and observation unit, Rohrs says.

The more frequent patient contact from PAs helps to keep patients moving along, he says. The average length of stay (LOS) is under 13 hours, and the conversion rate is lower than average. Research has shown no statistical difference in mortality, readmissions, LOS, or consultant use when there was a higher ratio of PAs to physicians on the team, Rohrs notes.

“Emergency room and observation throughput is a big issue for all hospitals. About 90% of our patient admissions come through the emergency department, so as our emergency and observation services go, so goes our hospital in terms of things like patient experience and throughput,” he says.

The PAs’ effects on the observation unit are closely monitored with several metrics, says Tracie Vock, PA-C, director of APPs for Observation Medicine with US Acute Care Solutions, the PA staffing company that provides PAs for the hospital’s observation unit. Length of stay is a top metric, with the health system looking for an LOS of less than 20 hours, as well as conversion rates for moving patients from observation to inpatient status, where the goal is to be under 15%.

The 30-day readmission rate target is less than 5%, which is less than half of the national average of 12%, Vock notes.

Observation services, and the patient experience in them, have received more attention recently, Rohrs notes. The use of the PAs at Northwest Hospital helps the observation unit be as efficient as possible while still providing the highest level of care to patients, he says.

“There is a lot of pressure on hospitals to do this right. Patients aren’t always happy to be in observation because, as an outpatient, there’s a higher charge, so we want to have the patients that go into observation to be the right ones,” Rohrs says. “We don’t want patients who will end up being admitted anyway to go to observation first, because that just delays the process and makes the patient unhappy for no reason.”

Hospitals also are incentivized to keep patients in observation for as little time as possible, just as they try to not keep patients admitted any longer than necessary, he notes. The PAs have protocols in place to help ensure the right patients are sent to the observation unit, as well as additional protocols to ensure patients don’t stay longer than necessary, all backed up by 24-hour access to physician support.

Northwest Hospital has a dedicated observation unit, which is becoming more common than in the past, Rohrs notes. When observation first emerged it was more of a patient status than a location, he says, and that is still true in some facilities. That can stand in the way of efficiency and patient satisfaction, he notes.

“You might have an inpatient unit with five observation patients on it, and your nurses had to switch from acting like an inpatient nurse to an outpatient nurse all the time. That’s a hard thing to do,” Rohrs says. “The first thing we did was to cohort the patient in a single unit, but we still had an issue because it was part of an inpatient unit, not in the emergency room. That led to patients feeling like they were inpatients, not emergency room patients, so patients and families were thinking in terms of staying for days, not hours.”

That expectation by patients and families can affect the LOS, so Northwest Hospital made other changes, like altering the signage to say “outpatient observation” instead of simply “observation.”

“Sometimes it’s the message we deliver to the patient that can have a measurable effect, so we use scripting that this is a short-term stay unit and we’re doing our best to get them out as quickly as possible without shortchanging their treatment,” Rohrs says.

The hospital also maintains high turnaround metrics for testing in the observation unit, treating them like tests from the ED rather than from an inpatient unit where the patient will still be around tomorrow if the lab needs to delay the results.

“A lot of this is about getting everyone in the same frame of mind about what observation is and isn’t,” Rohrs says. “That includes the patient, family, the clinicians, and the rest of your hospital services.”

SOURCES

• Richard Rohrs, PA-C, DFAAPA, SFHM, Assistant Vice President for Provider Operations, Northwest Hospital, LifeBridge Health, Randallstown, MD. Email: rrohrs@lifebridgehealth.org.
• Tracie Vock, PA-C, Director of APPs for Observation Medicine, US Acute Care Solutions, Canton, OH. Email: tvock@usacs.com.