Observation Unit Operational Guideline


An overview of the goals and purpose of the unit. It is best to review the hospitals’ yearly goal and overall mission statement when drafting this. The two should be complimentary.


  • Unit location and operation
  • Administrative structure — Hospital, nursing, and physician leadership should be defined
  • "Gatekeeping" and accountability for patients in the unit
  • Guidelines adherence


Indications for observation

  • Focused goal of patient care — Diagnostic evaluation, short-term treatment, psychosocial, and post procedural.
  • Limited intensity of service
  • Limited severity of illness
  • Clinical condition appropriate for observation — It is useful to append the unit guideline with a list of all conditions that seem reasonable for observation as a frame of reference for physicians and nursing.

Contraindications to observation

  • High severity of illness
  • High intensity of service
  • Patients requiring admission, unless "holds" are included in unit, or patients without a focused goal of care.
  • Length of stay — exclusion based upon projected minimum and maximum length of stay in the unit
  • Limitation parameters to consider:
  • Pediatric limitations (i.e., minimal age cut off)
  • Obstetric limitations (i.e., obstetrical conditions or gestational age)


This should detail the following:

  • Emergency Department care — What the minimal required interventions or duration of management should be.
  • Private physician notification process
  • Observation orders and documents initiated in the Emergency Department
  • Generation of an Observation Unit chart
  • Nursing report
  • Transport to the Observation Unit
  • Observation Unit care — Nursing and physician intake management, ongoing care/documentation
  • Final disposition process

STAFFING - 24 hour a day staffing pattern


  • Sending Emergency Department physician (if different than Observation Unit physician) responsibilities
  • Observation Unit Emergency Department physician — detail the following:
    • Who is responsible during all shifts.
    • How is care transferred from physician to physician ( i.e. at shift change, or when a patient is transferred to the unit)
    • What is the role and responsibilities of consultants and private attendings. How is communication with them documented.
  • Physician Assistants — Responsibilities, and reporting to the Emergency Department physician


  • Nurse to patient ratio used (i.e., 4:1, 6:1, monitored vs. nonmonitored)
  • Job requirement (i.e., training or experience required)
  • Basic duties
  • Responsibilities for other areas covered, if any

Ancillary support used — such as dedicated technicians, clerks, respiratory therapists, and pharmacy support.


  • General
  • Physician — detail if dictated or written
  • Intake assessment — two options
    • 1. An addendum dictation
    • 2. A history, physical, course in the Emergency Department differential diagnosis, and plan
  • Progress notes — dictated or written, how often, etc.
  • Final documentation — course in the unit and disposition
  • Consultants — dictated vs. written notes, communication with Emergency Department physician
  • Nursing, respiratory, ancillary staff


"Hold" Patient Management

  • Eligibility
  • Physician/nursing responsibility
  • Tracking holds


Quality Assurance

  • General — relation to existing Emergency Department quality assurance monitors, reporting, and continuous quality improvement goals
  • Specific quality assurance/continuous quality improvement monitors to be conducted

Utilization Review

  • General goals of utilization review monitors and reporting mechanism
  • Specific monitors — Volume, admissions, timeliness of care

Source: William Beaumont Hospital, Royal Oak, MI.