ED observation unit targets 24-hour stays
Quick discharges are the norm
An emergency department observation unit targeting patients whose stays are likely to be 24 hours or less has been so successful that Massachusetts General Hospital has opened a second unit.
The hospital opened the first emergency department observation unit, a 13-bed unit on the 12th floor of the hospital, in 2006 as payers began denying short inpatient stays and the emergency department was under pressure to move patients out after state of Massachusetts regulations no longer allowed hospitals to go on diversion, says Barbara McLaughlin, RN, BSN, MSM, CCM, case manager on the emergency department observation unit. The second unit, with 18 beds on the hospital’s main floor, is called the Short Stay Unit and opened in 2012. Both units use the same criteria for admitting patients and rotate taking patients who qualify.
"We worked with the emergency department to develop a strategy to move patients to a dedicated unit that could provide a quicker discharge than the regular medical-surgical units," McLaughlin says.
The emergency department and case management staff compiled a list of diagnoses and complaints that are appropriate for transfer to the observation unit, including syncope, chest pain, vertigo, abdominal pain, and others that typically result in less than a 24-hour stay. The unit is staffed by a dedicated team of nurses, case managers, nurse practitioners, and a dedicated physical therapist who comes on duty early in the morning to evaluate patients.
The hospital set up the 12th floor observation unit on an existing unit that originally had only community bathrooms. "In the beginning, patients had to be ambulatory and not require supervision. We realized this wasn’t realistic and installed commodes in some rooms and made sure patients in the other rooms could walk to the bathroom," she says.
Case managers staff the unit from 7:30 a.m. to 6 p.m., seven days a week. The emergency department case managers cover the unit on other hours. "Most of the patients who come in after 6 p.m. are going to need a stress test or other procedures the next morning. If a patient is going to be going to a post-acute facility or go home after the case managers no longer are on the unit, we make sure the ambulance and other patient services are set up before we leave," she says.
When the unit first opened, there was one nurse practitioner who worked all day. "We soon realized that with the morning turnover, most of the patients were discharged by 1 p.m. and a whole new group of patients were coming in," she says. Now one nurse practitioner comes in at 7 a.m. and another begins work at 1 p.m. A third handles new admissions from 7 p.m. to 7 a.m.
When the emergency department staff determine that a patient is appropriate for the unit, an emergency department physician writes the order for the transfer and acts as the attending physician. The nurse practitioner and nurse, along with the case manager and the interdisciplinary team, make an assessment and determine what the patient will need for discharge. Nurse practitioners are responsible for the care on the unit. The case managers review the chart for high-risk patients and set priorities depending on the patient’s age, insurance coverage, living situation, ambulatory status, cognitive issues, and barriers to discharge.
"We watch the clock and try to limit the stay to 24 hours. We are focused on moving patients out as soon as it is safe and appropriate. We have rounds every morning when we talk about barriers to discharge and what we can do to get the patients out as soon as possible," McLaughlin says. Tests and procedures for patients on the observation units get priority.
When patients are expected to need post-acute services, McLaughlin lines them up as soon as she finds out. She prepares patients to line up transportation so they will be ready to go when the discharge order is written.
The hospital is participating in a Medicare Demonstration Project to waive the 72-hour required stay for a skilled nursing admission, which makes it possible for the case managers to divert some patients to a skilled nursing facility right from the observation unit. For instance, if a patient had a fall with no broken bones but could benefit from physical therapy but can’t be discharged to home, he or she can go directly to a skilled nursing facility.
When a physician decides that patients in the observation unit need to be admitted, the observation unit case managers already have collected information on the patients and started the plan of care. "Even if we can’t get them out, we’ve started the ball rolling for the inpatient case managers," she says.
The emergency department and observation unit nurses and case managers are cross-trained to work in either location if needed. Before the observation unit had dedicated staff, the nurses from the emergency department took turns covering it. "They learned the routine and the kind of patients we take and now can make a suggestion to the physician if they think a patient would qualify for the observation unit," she says.
Communication between the emergency department staff and the observation units is key to the success of the unit, McLaughlin says. "We are in constant contact about patient needs and bed availability. In addition, the case managers from the two observation units and the emergency department meet monthly to discuss cases and ways to improve the process," she says.