'Hybrid' obs unit offsets 60% volume growth

LOS remains steady despite explosive demand

If someone told you that an ED had experienced a 60% increase in volume between 2000 and 2008, you wouldn't be surprised to learn that the average length of stay (LOS) for their patients also had increased dramatically. You would be surprised to learn that patient flow hadn't suffered at all, but that's exactly what has happened in the ED at Wake Forest University Baptist Medical Center in Winston-Salem, NC.

Annual volume has increased from 58,000 to 92,000, while LOS had held firm at 3.29 hours. What's more, Press Ganey patient satisfaction scores are in the 99th percentile. What's behind this success story? It's what the ED managers call a "hybrid" observation unit.

"The unit serves two patient populations," explains Bret Nicks, MD, assistant medical director, who oversees the unit. One, he notes, is the standard obs patient, when the staff members believe they have correctly identified the underlying disease process, will be able to treat the patient, and will likely send them home in eight to 14 hours (23 at the maximum).

"The second, that makes it a hybrid, is patients identified in the ED that are stable medically but will require an extended time period for evaluation or work-up," says Nicks. "The underlying diagnosis may remain uncertain." A classic scenario, he offers, would be a middle-aged patient with a primary complaint of abdominal pain.

The unit, which has been functional since 2005, was developed from the start as a hybrid, "knowing what our needs were going to be," says Nicks. It works like this: The patient comes through triage, is identified as requiring acute care management, and is transferred to a bed in the ED proper. He or she is examined by a physician.

"If they are identified as requiring labs, maybe a CT scan, diagnostic imaging, therapeutics like IV fluids, or antibiotics, and if their vital signs are stable, and if the patient does not have an emergent surgical presentation, then they can be sent to the obs unit as a 'holding' patient," says Nicks. "Then the doctor will call a midlevel provider [nurse practitioners or physician assistant] to discuss the patient and a possible differential diagnosis, as well as the current medical plan and anticipated disposition." At that point, he says, they are moved to the obs unit, where the midlevel providers "take the torch, continue care, exams, and any other imaging."

This concept is taking hold in several EDs, notes James B. Bryant, MSN, CEN, CAN-BC, director of emergency and transport services. "In looking at what my colleagues across the country are doing, they all have to move toward this approach," Bryant says. "Patients in the ED have longer lengths of stay as we employ more modalities: CT, lab tests, additional consults." At the same time, he notes, when there are fewer beds available on the inpatient units, proper care still needs to begin on those patients.

"It's very uncomfortable to lie on a stretcher for a long time, without amenities like a TV and phone," says Bryant. "This unit allows patients to move to a more pleasing environment and receive better care while we are able to keep flow in the ED going."

A quick look at last year's statistics shows how the unit has offset growing volume. "For 2007, we put just under 9,000 patient through obs, 7,500 of whom were 'hybrid' patients," notes Nicks. "Total volume last year was just over 90,000, and that 9,000 patients accounted for the growth in our ED volume that year — so we maintained our level of care without increasing LOS, stays in the ED, or the waiting room." (A unit such as this one requires more space and more staff. See story.)