Tips for Starting an ED Observation
• Identify a benchmark hospital. Don’t go out and try to reinvent the wheel, advises Michael Ross, MD, FACEP, chairman of the American College of Emergency Physicians’ section on observation medicine. Review the medical literature and see how observation medicine is practiced at other institutions. The section has a packet of guidelines for observation units from a number of large hospitals that includes the guidelines for the conditions monitored and the performance data, says Ross.
• Decide what conditions to monitor. Determine the conditions that are the most common complaints presenting in the ED and can be managed in the observation setting. "It’s probably best to take three or four conditions that are going to be your most common," says Ross. "In our patient population, it is chest pain, dehydration, asthma, and renal colic."
• Develop standard protocols or guidelines for treatment. For every condition they observe, there is a written guideline, says Ross. The unit started with treating three conditions; then, as they developed more guidelines, they added more.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires all units to have written protocols for conditions that are treated in the units, though it doesn’t say what those protocols should be, says Louis Graff, MD, FACEP, assistant director of the emergency department at New Britain Hospital in New Britain, CT.
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, if the condition is chest pain) to develop draft a guideline covering the most reasonable way to manage the condition.
• Determine the size of the unit. A number of individual factors will determine the size of the observation unit, says Ross. But a good rule of thumb is two beds for every 7000 visits an ED receives per year. "Some people say 5000, some people say 10,000, but I think 7000 is a reasonable estimate."
• Evaluate staffing needs. Staffing needs will vary greatly depending on the number and complexity of conditions monitored in the unit, Ross notes. 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, he says.
There also has to be management staff in place that can handle issues dealing with giving prolonged care as opposed to just the typical ED episodic service, says Graff.
"You have to deal with things like standing orders, protocols, and amenities like feeding them or giving them routine medication," he says.
• Allow for an initial lag in use of the unit. "There is a learning curve that you are not going to be able to avoid," says Ross. It may take up to a year for physicians to begin routinely transferring patients to the unit and transferring them properly, says Ross. They may need continual education on the conditions that can be monitored in the observation unit and may also need to be reminded about its availability.
Managers should prepare to have flexible staffing until unit occupancy reaches 50%, Ross says.
Additional Sources: Here are some more sources of information about observation units and chest pain centers.
Graff L. Observation Medicine. Boston: Andover Medical Publishers; 1993.
Graff L, Joseph T, Andelman R, et al. American College of Emergency Physicians Information Paper: Chest Pain Units in Emergency DepartmentsA Report from the Short-Term Observation Services Section. Am J Cardiol 1995;76:1036-1039.
National Heart Attack Alert Program Coordinating Committee, 60 Minutes to Treatment Working Group. Emergency department: Rapid identification and treatment of patients with acute myocardial infarction. Ann Emerg Med 1994;23:311-329.
For information about membership in the American College of Emergency Physicians’ Section of Short-Term Observation Services, address correspondence to the Short-Term Observation Services Section, ACEP, P.O. Box 619911, Dallas, TX 75261-9911.
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