Focus on Observation

No observation unit? Here are tips for starting one

Two beds for every 7,000 ED visits is rule of thumb

When deciding to open an observation unit, careful planning and a methodical approach can help you avoid pitfalls. Placing an observation unit in a separate section of the hospital is cost-effective only in large facilities with substantial volumes. The advantage of this is that the staff there can be specialized and know the guidelines. They can screen patients and get them into appropriate levels of care, whether that means being discharged to home or being admitted to acute care.

Here is some advice:

· Identify a benchmark hospital.

Don't reinvent the wheel, advises Michael Ross, MD, FACEP, chairman of the section on observation medicine of the Dallas-based American College of Emergency Physicians (ACEP). Review the medical literature and see how observation medicine is practiced at other institutions.

· Decide which conditions will be monitored.

Start small. Determine the most common complaints presenting in your emergency department (ED) that can be managed in the observation setting. "It's probably best to begin with three or four conditions," says Ross. "In our patient population, they were chest pain, dehydration, asthma, and renal colic."

· Develop standard protocols or guidelines for treatment.

For every condition you observe, there should be a written guideline. The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, requires all units to have written protocols for conditions that are treated in the units, but it doesn't say what those protocols should be, says Louis G. Graff, MD, FACEP, assistant director of the emergency department at New Britain (CT) Hospital.

Ross recommends forming a consensus group of ED staff and representatives from other hospital departments to review the medical literature, regional practice patterns, and the practice patterns in the speciality - cardiology, for example, if the condition is chest pain - to draft a guideline covering the most reasonable way to manage the condition.

ACEP has guidelines for observation units from a number of large hospitals, including conditions monitored and performance data.

· Determine the size of the unit.

A number of individual factors will determine the size of your observation unit, says Ross, but a good rule of thumb is two beds for every 7,000 visits an ED receives per year. "Some people say 5,000, some say 10,000, but I think 7,000 is a reasonable estimate."

· Evaluate staffing needs.

Staffing needs will vary greatly depending on the number and complexity of conditions monitored in the unit. Some chest pain units may staff with a ratio of one nurse to every eight patients. But if there is a greater variety of conditions treated, the ratio may drop to one nurse for every four or five patients.

· Allow for an initial lag in the unit's use.

You can't avoid a learning curve and the time it consumes. It may take up to a year for physicians to begin routinely transferring patients to the unit and transferring them properly, says Ross. Physicians may need continuing education on the conditions that can be monitored in the observation unit, and may also need to be reminded of its availability. Managers should prepare to have flexible staffing until unit occupancy reaches 50%, Ross says.

[Editor's note: ACEP's policy statement on observation units is being revised. The standing document is still available, free of charge, through ACEP's FaxBack system. Call (800) 406-2237 and request document #4066. ACEP's Section of Short-Term Observation Services can be reached at P.O. Box 619911, Dallas, TX 75261-9911.]