Aggarwal, P, Wali, J, et al. (1995). "Utility of an observation ward in the emergency department of a tertiary care hospital in India." European Journal of Emergency Medicine 2(1): 1-5.

This retrospective study was conducted to evaluate whether an observation unit (OU) attached to the emergency department (ED) of a tertiary care hospital in India is safe, is effective in minimizing hospitalization of acutely ill patients and is acceptable to the patients. Of 115,916 patients who attended the ED, 11,130 (9.6%) were observed in the OU. The average period of observation was 7.74 h. Of the patients observed, 21.3% required hospitalization, while 78.5% were discharged after treatment. Twenty-four patients left the hospital against medical advice, and three patients died in the OU. It is concluded that an OU in the ED is safe in treating acutely ill patients, is effective in reducing substantially the number of patients requiring admission to the hospital, and is acceptable to the patients.

American College of Emergency Physicians (1988). "Management of observation units." Annals of Emergency Medicine 17: 1348-52.

As concern mounts over health care costs, observation and holding units are becoming common in hospitals. Emergency physicians may be asked to play a role in the implementation and management of these units. To assist members, the ACEP Practice Management Committee has developed this document.
Observation and holding units fall into three broad categories: emergency department observation/treatment unit - designated area within and under the direction of the ED for patients who require further treatment or observation; holding unit - designated area in the outpatient setting that may or may not be under the control of the ED in which a patient is held pending prearranged actions, such as admission or transfer; and "23-hour" beds - beds located in the inpatient area of the hospital in which a patient may be observed or treated for up to 24 hours before a decision regarding disposition is needed. These are often used for Medicare (US) patients who do not meet Medicare DRG admission criteria.

American College of Emergency Physicians (1995). "Emergency department observation units." Annals of Emergency Medicine 25(6): 863-4.

Emergency department patients frequently require services beyond initial ED management. These separately identifiable and reimbursable services may include extended observation of suspected medical conditions, prolonged therapy for identified medical conditions, and other forms of ongoing evaluation and management. In some hospitals, these services may be provided in a designated ED observation unit or area.

Ammons, M, Moore, E, et al. (1986). "Role of the observation unit in the management of thoracic trauma." Journal of Emergency Medicine 4: 279-82.

Use of the observation unit in the management of 150 consecutive patients sustaining blunt or penetrating thoracic trauma, and initially presenting with stable vital signs, normal physical examination findings, and normal chest x-ray studies, was reviewed. All patients requiring admission declared themselves within six hours, with the exception of one asymptomatic patient whose repeat x-ray study was slightly delayed. Of the 150 patients, 129 (86%) were spared hospital admission, and no increased morbidity or mortality could be associated with our policy of selective hospital admission.

Anonymous (1997). "Observation units key to the future." ED Management 9(4): 1.

Forward-thinking ED managers and hospital administrators are increasingly using observation units to monitor certain types of patients instead of admitting them. Some experts suggest these units may even be the key to the survival of the ED.

Anonymous (1998). "No observation unit? Here are tips on starting one." Hospital Peer Review 23: 76-8.

Editorial offers advice on opening a short stay observation unit, such as:
* identify a benchmark hospital
* decide which conditions will be monitored
* develop standard protocols or guidelines for treatment
* determine the size of the unit
* evaluate staffing needs
* allow for an initial lag in the unit's use

Barbado Ajo, M, Jimeno Carruez, A, et al. (1999). "Short-stay units depending on internal medicine." Anales de Medicina Interna 16(10): 504-10.

Background: Wetry to establish the utility that a Short Stay Unit depending on Internal Medicine has for a third level hospital. This unit manages the patients under the "appropriate stay" concept.
Methods: Several clinical and epidemic variables and sanitary indicators were studied in 867 patients. Cost was measured as the origin by average stays, explorations and readmission. Effectiveness was considered as the percentage of discharges that stay in the hospital for three days or less.
Results: The average age of the patients was 65.05 years. 55% were males. 82.24% had any previous disease. The most common diagnosis (ICD-9) were respiratory diseases, nervous system diseases and digestive diseases. The average stay of the patients was 57 hours, 2,259 explorations were ordered, it supposes an average of 0.328 urgent explorations and 2,276 UCE explorations. 310 explorations were no received when the patient was sent home. 36.56% of the patients required no explorations. 62.4% of the patients were sent home. Explorations not received had a bad influence in the average stay and in the discharges. Readmissions were 9.36%.
Conclusions: We got hay 62.4% of the patients had a stay of 2,375 days in the hospital, With a reasonably low cost in readmissions and explorations. However it wasn't possible to establish which patient coming to the Emergency Service is appropriate for this Short Stay Unit.

Biddulph, J (1984). "A paediatric observation ward." Papua New Guinea Medical Journal 27(3-4): 163-5.

The paediatric ward and paediatric outpatients at Port Moresby General Hospital have become increasingly crowded during the past few years. 15% of paediatric admissions stayed less than 24 hours, which meant that much work was done unnecessarily on these patients who would be better regarded as outpatients. A paediatric observation ward was opened in September 1982 to help overcome these problems. An analysis of the 2132 admissions to the observation ward during 1983 showed that 89% of the children were later sent home without requiring hospital admission.

Bobzien, W (1979). "The observation holding area: A prospective study." JACEP 8: 508-12.

Although emergency department observation-holding units have been shown to be effective in limiting hospitalizations and improving the accuracy of disposition, the possibility of adverse outcome following discharge from such units has not been addressed. To establish the safety of the unit, a five-month prospective study of all patients admitted to this area was carried out and included long-term follow-up. There were 442 patients admitted. Of these, 78% were discharged improved. Complications in the unit were minimal and there were no deaths. Long-term follow-up revealed four deaths (1%) and four patients (1%) who had complicated hospitalizations. Diagnosis, age, patient condition, and time of admission to the unit were predictive of the need for inpatient hospitalization. We conclude that the observation-holding unit, with appropriate supervision, represents a safe alternative disposition for selected emergency patients.

Bond, G and Wiegand, C (1997). "Estimated use of a pediatric emergency department observation unit." Annals of Emergency Medicine 29(6): 739-42.

Study objective: To estimate the use of a pediatric ED observation unit, including the number of anticipated admissions per 10,000 pediatric ED visits per year and the distribution of those admissions by age group, by month, and by time of day.
Methods: Hospital and ED computer records on all ED patients younger than 18 years who were seen during a 2-year period were abstracted for diagnostic, demographic, and time-flow data. We retrospectively reviewed the charts of patients admitted to the hospital and discharged within 24 hours to determine whether discharge in less than 24 hours could have been anticipated and whether the patient could have been cared for in a pediatric ED observation unit. To refine the estimate, we also reviewed the ICD-9 discharge diagnoses of patients who were not admitted to the hospital but spent more than 6 hours in the pediatric ED.
Results: Of 29,667 pediatric ED visits in a 2-year period, 2,940 (10%) resulted in admission. Of 626 patients discharged in less than 24 hours, only 410 met the anticipation and pediatric ED observation unit level of care criteria. Patients younger than 4 years represented 43% of potential observation unit patients; those aged 16 and 17 years represented 15%. Potential use of an observation unit varied throughout the year. Admission occurred between 3 and 11:59 PM in 60% of the patients. Only 20% of the 176 patients who were not admitted to the hospital but spent more than 6 hours in the pediatric ED were estimated to be candidates for a pediatric ED observation unit.
Conclusion: On the basis of these data, approximately 150 patients per 10,000 each year who visit the University of Virginia pediatric ED would be likely to use an observation unit. Staffing and facility use would be seasonally uneven and would be required during the busiest part of the day. Furthermore, even in a pediatric ED large enough to admit 365 pediatric ED observation unit patients each year, random daily variation in demand means that a single bed would be inadequate 25% of the time and empty 37% of the time. Optimal use of even a single-bed pediatric ED observation unit would not occur until pediatric ED census exceeded 30,000 to 40,000 visits annually.

Brett, A, Rothschild, N, et al. (1987). "Predicting the clinical course in intentional drug overdose. Implications for use of the intensive care unit." Archives of Internal Medicine 147(1): 133-7.

Many patients admitted for observation to the intensive care unit after a drug overdose do not ultimately require intensive care interventions. We retrospectively analyzed data on 209 overdose cases to determine whether clinical assessment in the emergency room could identify patients at risk for complications. Patients were classified as low risk when none of the following high-risk criteria were present in the emergency room: need for intubation; seizures; unresponsiveness to verbal stimuli; arterial carbon dioxide pressure (tension) greater than or equal to 45 mm Hg; any rhythm except sinus; second- or third-degree atrioventricular block; QRS greater than or equal to 0.12 s; or systolic pressure less than 80 mm Hg. Of 151 low-risk patients, none developed a high-risk condition after admission, and none required an intensive care intervention. The use of these predictive criteria in our patient population would have eliminated over half the intensive care days without compromising quality of care.

Brillman, J and Tandberg, D (1994). "Observation unit impact on emergency department admissions for asthma." American Journal of Emergency Medicine 12: 11-4.

The hypothesis that the use of an observation unit (OU) in the emergency department (ED) results in monetary savings by lowering the hospital admission rate for asthma was studied in a retrospective comparative cohort at an urban university county hospital. All acute asthmatic patients seen in the ED during a 22-month period were included. Preobservation patients were seen before the OU opened (n = 834); postobservation patients were treated afterward (n = 390). Postobservation patients in the experimental group meeting standard criteria were admitted to the OU. Fisher's exact test and the binomial distribution were used to analyze proportions of patients admitted. Median charges were compared with the Mann-Whitney test. The difference between groups in hospital admission rate was only 2.7% and was not significant (P = .25). However, 5.3% less patients were admitted directly to the hospital (P = .01), and 6.7% less patients were discharged directly from the ED (P = .005). The OU produced no demonstrable cost savings. The use of an OU for asthmatic patients results in lower initial discharge rates from the ED and does not reduce eventual hospital admission appreciably.

Brillman, J, Mathers-Dunbar, L, et al. (1995). "Management of observation units." Annals of Emergency Medicine 25(6): 823-30.

Traditionally, patients who require services beyond the first hours in the emergency department have been admitted to the acute care hospital. As concern mounts over health care costs, more patients' cases are being managed on an outpatient basis. Observation and holding units are becoming common in hospitals because they are an alternative to admission or discharge. Emergency physicians are often asked to play a role in the implementation and management of these units. To assist members who provide observation service, the ACEP Practice Management Committee developed "Guidelines on Management of Observation Units", first published in 1988.

Brown, S, Raine, C, et al. (1994). "Management of minor head injuries in the accident and emergency department: The effect of an observation ward." Journal of Accident and Emergency Medicine 11(3): 144-8.

The management of 483 patients presenting with minor head injury to the accident and emergency (A&E) departments of two Scottish hospitals was studied prospectively. Such patients comprised 5.7 and 3.9% of the total attendances to each department. Of the 277 patients assessed in the former department, 83 (30%) fulfilled at least one of the currently accepted criteria for recommending admission to hospital and 49 (17.7%) patients were actually admitted. Patients in whom head injury was not the principal reason for admission were excluded from the study. In the same time period the second department dealt with 206 patients with minor head injury, 49 (24%) of whom had criteria for admission. However, significantly fewer, 10 (4.9%) patients, were actually admitted. The major relevant factor when comparing the two departments was the existence in the former of an observation ward. These results support the view that easy access to hospital beds is a major determinant of management in patients presenting with minor head injury to the A&E department and may be more influential than clinical findings.

Browne, G and Penna, A (1996). "Short stay facilities: The future of efficient paediatric emergency services." Archives of Disease in Childhood 74(4): 309-13.

Many children admitted to hospital can stay for 24 hours or less. Short stay facilities offer such children rapid stabilisation and early discharge with considerable financial saving. A 12 month study was completed in which data were collected from the children's emergency annex (CEA) at Westmead Hospital in Sydney's western suburbs. This university based teaching hospital provides care for a large paediatric population as well as three other district hospitals with limited children's bed capacity. From April 1994 to April 1995, 1300 children were admitted and entered into a database of general and hospital-specific information. Critical incident monitoring was undertaken and follow up with review within 24-72 hours for all children. The CEA increased hospital efficiency significantly by reducing bed days, with a saving of over $500 000 to the department. The average length of stay was 17.5 hours, and 58% of users were children of 2 years and under. Only 3% remained beyond 24 hours, and another 4% were admitted to inpatient beds for continued management of the primarily diagnosed condition. No critical incident was reported during this 12 month period. Short stay facilities are efficient and cost-effective for children with acute illness who can be rapidly stabilised with early discharge without critical incident. Children 12 months and under are particularly suited to this type of facility. Short stay facilities should be used to augment efficiency within children's emergency services which have high turnover and limited bed capacity.

Burgess, C (1998). "Are short stay admissions to an acute general medical unit appropriate? Wellington Hospital experience." New Zealand Medical Journal 111(1072): 314-5.

Aim: This audit was performed to ascertain whether the admission of patients to the General Medical Unit (Wellington Hospital) for one day or less was appropriate.
Methods: Between 1 July 1996 and 30 June 1997, 494 patients were admitted to General Medicine for one day or less. The medical records for a random sample of 245 patients were reviewed. A modification of the Oxford Bed Study Instrument was used to assess the appropriateness of admission.
Results: Twenty admissions (8.2%) were deemed inappropriate, six patients could have been referred to medical outpatients, four were known epileptics who presented following a seizure, and none of the others merited admission on severity criteria. Ten patients were triaged after 10.00 pm, when discharge becomes more difficult. Forty-two patients required an investigation which delayed discharge.
Conclusion: With the present community and investigation facilities available, there is no evidence that the majority of 24-hour admissions to acute General Medicine are inappropriate.

Campbell, D, Greenberg, P, et al. (2000). "Emergency department observation wards." Medical Journal of Australia 173(8): 397-8.

Until recently, observation wards (OWs) were a relatively unrecognised component of emergency medicine and were used in a limited way for specific conditions like minor head injuries. The recent formalisation of observation medicine in emergency departments and the expansion of conditions treated broadens the choice of venues for managing patients who require brief admissions. Such developments challenge the role of the traditional inpatient ward and may ultimately have an impact rivalling the introduction of same day admissions for elective procedures.

Conrad, L, Marchovichick, V, et al. (1985). "The role of an emergency department observation unit in the management of trauma patients." Journal of Emergency Medicine 2: 325-33.

During a 12-month period, 20,838 patients with acute traumatic injuries were seen in the Emergency Department (ED) of Denver General Hospital. Of these patients, 520 (2.5%) were admitted to the ED Observation Unit, a seven-bed acute care unit situated within the ED and sufficient data were available on 485 (93%) for inclusion into the study. Fifty-three (15.4%) of these observation unit patients required subsequent admission, 389 (80%) were discharged, and 16 (4%) left against medical advice. There were no observation unit deaths. These groups of patients were analyzed and compared with regard to severity of injury, length of stay, and discharge diagnosis. The observation unit is useful in the evaluation of blunt chest or abdominal trauma when work-up, including chest x-ray studies and peritoneal lavage, is initially negative and when drug or alcohol ingestion obscures the initial evaluation in the ED. An observation unit within the ED is cost-efficient and has proven very useful in the management of trauma victims.

Dallos, V and Mouzas, G (1981). "An evaluation of the functions of short stay observation ward in the accident and emergency department." British Medical Journal 282: 37-40.

In this provisionary paper, the authors attempt to evaluate the functions of short-stay observation wards at Whipps Cross Hospital and Chase Farm Hospital and the importance of these wards to the accident and emergency departments in which they are situated, as well as to the hospitals concerned and the communities they serve.

Diamond, N, Schofferman, J, et al. (1976). "Evaluation of an emergency department observation ward." JACEP 5(1): 29-31.

To evaluate the usefulness of an observation or holding area in the operation of an emergency department, the 166 cases held in the observation area of the Harbor General Hospital Emergency Department during September, 1974, were reviewed. Among the 166 patients, who made up 2% of the 10,452 patients seen in the ED that month, drug overdose and alcohol withdrawal were the primary disorders admitted, 42 and 34 respectively. Neurological disorders were next with 29 cases. Fluids administered intravenously, analgesics and sedatives were the most common therapeutic modalities used. Psychiatric was the type of consultation required most often. Seventy-seven of the 166 patients went home; 61 were admitted to the hospital and none died. Fifteen were transferred to nursing homes, 8 to detoxification centers and 5 to a mental hospital. The advantages and disadvantages of an observation ward are listed and discussed.

Duggan, J and Graham, R (1989). "Audit of the activity of a same day ward." Australian Clinical Review 9(3-4): 115-8.

Objective: To assess the utilization of a 16-bed same day ward with particular reference to preadmission, discharge and after-care planning, and complication and delayed discharge rates.
Method: Three audits, each of 200 consecutive patients, were carried out during 1987 with a questionnaire suitable for desk-top data processing.
Results: The same day ward was capable of being used by a wide variety of disciplines, with one in five patients aged more than 70 years. Significant falls in complication and delayed discharge rates occurred, with increasing use of discharge notes and follow up arrangements by medical staff. Preadmission visits by a community nurse may facilitate the appropriate use of the ward by elderly patients.

Ellerstein, N and Sullivan, T (1980). "Observation unit in children's hospital; adjunct to delivery and teaching of ambulatory pediatric care." New York State Journal of Medicine 80(11): 1684-6.

To provide a possible solution to the dilemma of outpatient versus inpatient management, several authors have recommended the use of a short-stay observation unit. Such a unit was included in a construction project revamping the emergency and outpatient departments at the Children's Hospital of Buffalo in 1972.

Farrell, R (1982). "Use of an observation ward in a community hospital." Annals of Emergency Medicine 11(7): 353-7.

A six-bed observation ward has been an integral part of our community hospital emergency department for 10 years. During a recent 4-month period, 574 patients were admitted with 65 different clinical presentations. Length of stay, treatment, complications, and disposition were evaluated. An estimated 1.7 hospital admissions per day were avoided at an annual cost savings of $240,000. Guidelines have been developed which avoid most potential pitfalls in the use of an observation ward. Significant flexibility is gained and improved patient care is possible with the addition of an observation ward to the emergency department.

Finefrock, S (1994). "Stretching the health dollar: The emergency department observation unit." New England Journal of Medicine 20(6): 487-90.

This article describes the development and operation of the observation units at the Riverside Methodist Hospital.

Gaspoz, J, Lee, T, et al. (1994). "Cost-effectiveness of a new short-stay unit to 'rule out' acute myocardial infarction in low risk patients." Journal of the American College of Cardiology 24(5): 1249-59.

Objectives: This study attempted to determine the safety and costs of a new short-stay unit for low risk patients who may be admitted to a hospital to rule out myocardial infarction or ischemia.
Background: One strategy to reduce the costs of ruling out acute myocardial infarction in low risk patients is to develop alternatives to coronary care units.
Methods: The short-term and 6-month clinical outcomes and costs for 592 patients admitted to a short-stay coronary observation unit at Brigham and Women's Hospital with a low (< or = 10%) probability of acute myocardial infarction were compared with those for 924 consecutive comparison patients who were eligible for the same unit but were admitted to other hospital settings or discharged home. Actual costs were calculated using detailed cost-accounting methods that incorporated nursing intensity weights.
Results: The rate of major complications, recurrent myocardial infarction or cardiac death during 6 months after the initial presentation of the 592 patients admitted to the coronary observation unit was similar to that of the 924 comparison patients before and after adjustment for clinical factors influencing triage and initial diagnoses (adjusted relative risk 0.86, 95% confidence interval 0.49 to 1.53). Their median total costs (25th, 75th percentile) at 6 months ($1,927; 1,455, 3,650) were significantly lower than for comparison patients admitted to the wards $4,712; 1,868, 11,187), to stepdown or intermediate care units ($4,031; 2,069, 9,169) or to the coronary care unit ($9,201; 3,171, 20,011) but were higher than for comparison patients discharged home from the emergency department ($403; 403,927) before and after the same adjustments (all adjusted p < 0.0001).
Conclusions: These data suggest that the coronary observation unit may be a safe and cost-saving alternative to current triage strategies for patients with a low risk of acute myocardial infarction admitted from the emergency department. Its replication in other hospitals should be tested.

Goodacre, S (1998). "Role of the short stay observation ward in accident and emergency departments in the United Kingdom." Emergency Medicine Journal 15(1): 26-30.

Objective: To define the role of the accident and emergency (A&E) short stay ward by a survey of departments in the United Kingdom and review of published reports.
Methods: A postal questionnaire with telephone follow up to all major A&E departments with short stay beds.
Results: 95 departments were found to have short stay beds. These units received between 19000 and 121000 new patients per year (mean 51000, median 50500) and had access to between two and 20 beds (mean 7.5, median 6). The level of provision varied from one bed per 2440 new attendances to one bed per 27250 new attendances (mean 8380, median 6625). Where data on admission rates were available the departments admitted between 0.1% and 13.3% of their new attendances (mean 2.62%, median 1.9%). Cover was typically provided by an A&E senior house officer with frequent senior ward rounds. While the casemix usually included minor head injuries and alcohol intoxicated patients, there was considerable variation in the cases admitted.
Conclusions: Short stay provision is highly variable in the United Kingdom. While there are many reports of well run short stay units, consistent evidence of clinical value and cost-effectiveness compared to other methods of care is lacking. Further comparative studies are required to define the role of the A&E short stay ward.

Gouin, S, Macarthur, C, et al. (1997). "Effect of a pediatric observation unit on the rate of hospitalization for asthma." Annals of Emergency Medicine 29(2): 218-22.

Study Objective: To determine the asthma admission rate and the rate of repeat visits to the emergency department for asthma within 72 hours before and after the introduction of an observation unit (OU). When necessary, admission to the ward from the OU is usually made within 12 hours.
Methods: We conducted a before-and-after study with retrospective data collection in an urban tertiary care pediatric ED. Our subjects were patients aged 1 to 18 years who presented to the ED with asthma. The pre-OU group comprised patients seen between July 1, 1991, and June 30, 1992, before the opening of the OU. The post-OU group consisted of children seen between July 1, 1993, and June 30, 1994, after the opening of the OU.
Results: The pre- and post-OU groups had 1,979 and 2,248 asthma visits, respectively. The admission rate decreased from 31% in the pre-OU group to 24% in the post-OU group (P < .01). The frequency of inpatient admissions of less than 24 hours decreased from 17% in the pre-OU group to 10% in the post-OU group (P < or = 01). The rate of repeat ED visits within 72 hours was 3% in the pre-OU group and 5% in the post-OU group (P = .01).
Conclusion: The use of an OU in the ED was associated with a reduction in the hospitalization rate for children with acute asthma exacerbation. However, we also noted an increased rate of repeat visits to the ED after the introduction of the OU.

Graff, L, Radford, M, et al. (1991). "Probability of appendicitis before and after observation." Annals of Emergency Medicine 20: 503-7.

Study Objective: To examine patients with abdominal pain for changes in probability of appendicitis during observation.
Study Design: Retrospective cohort study.
Setting: University-affiliated community hospital.
Methods: 252 patients with abdominal pain who were examined underwent short-term (10.4 hours) observation (95% confidence interval [CI], 8.7, 12.1) before the decision to operate during a one-year period. Alvarado's scoring system and a probability-of-diagnosis nomogram were used to assign scores and estimate probability of appendicitis.
Measurements and Results: In the study group, mean score of patients with appendicitis increased after observation from 6.8 (95% CI, 6.2, 7.4) to 7.8 (95% CI, 7.3, 8.3), corresponding to a change in probability of appendicitis from 50% to 65%. Mean score of patients without appendicitis decreased from 3.8 (95% CI, 3.5, 4.1) to 1.6 (95% CI, 1.58, 1.62), corresponding to a change in probability from 35% to 22%. The difference between mean scores for patients with and without appendicitis increased from 2.6 (95% CI, 2.0, 3.2) to 6.2 (95% CI, 6.15, 6.25) during observation. The study group initially had intermediate probability of appendicitis (score, 4.35; 95% CI, 4.04, 4.66) compared with high probability for patients who went directly to surgery after their initial evaluation (63 patients; score, 7.59; 95% CI, 7.05, 8.73) and low probability for patients with abdominal pain who were sent home after their initial evaluation without observation or surgery (2,097 patients; score, 1.87; 95% CI, 1.48, 2.26).
Conclusion: In this group of patients with intermediate initial probability of appendicitis, observation improved the ability to distinguish patients with from those without appendicitis.

Graff, L (1992). "Utilisation Review: Emergency medicine implications." Emergency Medicine Clinics of North America 10: 583-96.

The medical profession has made utilization review a priority in its efforts to limit health care expenditures. In emergency medicine this has ranged from initiatives to limit inappropriate emergency department visits to guidelines to limit emergency department testing and criteria to limit hospital admissions. The emergency department observation unit is an area in which the emergency physicians follow these practice guidelines without compromising patient care. The emergency department utilization review/quality assurance committee is a management tool by which emergency physicians monitor and implement these strategies for cost-effective patient care.

Graff, L, Zun, L, et al. (1992). "Emergency department observation beds improve patient care: Society for Academic Emergency Medicine Debate." Annals of Emergency Medicine 21(8): 967-75.

The following question was addressed to the speakers: Is it in the patient's best interest to be treated in an ED observation unit?

Graff, L, Dunbar, L, et al. (1992). "Observation medicine curriculum." Annals of Emergency Medicine 21(8): 963-6.

Observation services are offered frequently in emergency departments. Observation units are present in 27% of EDs in the United States. 50% of EDs in Australia, and most EDs in the United Kingdom and Canada. In the past decade, many EDs have offered observation services as the use of inpatient services has been restricted and the use of outpatient services has increased. These services are extensions of basic ED services and place additional requirements on the ED staff. They are governed by extended care principles rather than by episodic care principles. They required personnel and expertise different from those involved in other types of emergency services. The purpose of this curriculum is to teach the areas of additional knowledge needed by emergency physicians to provide observational services.

Graff, L, Gibler, W, et al. (1992). "Observation medicine: An annotated bibliography." American Journal of Emergency Medicine 10(1): 84-91.

Observation units have become a significant component of emergency medicine practice. Presently one third of United States emergency departments, one half of Australian emergency departments, and most English and Canadian emergency departments have observation units. A large proportion of patients who have traditionally been treated in the hospital as short-term admissions are now being managed in emergency department-attached observation units. As the emphasis of health care shifts to the outpatient setting, there is an increasing interest in extended care services in the emergency department.
The Society for Academic Emergency Medicine (SAEM) formed its observation medicine committee in 1989 to promote education and research related to observation medicine. An initial objective of the committee was to identify existent knowledge necessary or useful to emergency physicians who provide observation services. In this first part of the bibliography, articles are reviewed which focus on the use of observation beds for diagnostic evaluation of patients with critical diagnostic syndromes. The second part of the bibliography will review articles which examine the use of observation beds for short-term therapy of emergent conditions, for meeting psychosocial needs, and for the provision of services to pediatric and geriatric patients. The third part of the bibliography will review articles useful in the management of observation units: policies, guidelines, and standards; admission decisions; financial effects; and general reviews of the operation of different observation units.

Graff, L, Prete, M, et al. (2000). "Implementing emergency department observation units within a multihospital network." Joint Commission Journal on Quality Improvement 26(7): 421-7.

Background: The proportion of emergency department (ED) chest pain patients who undergo an extended "rule out MI (myocardial infarction)" evaluation beyond the ED determines both the quality and cost of patient care. The higher an organization's rate of such evaluations, the lower the average miss rate for MI. Five of the 13 hospitals in the Voluntary Hospital Association Northeast multihospital network implemented ED observation units by June 1997 for outpatient rule out MI evaluations.
Results: Compared with historical and case controls, the five hospitals with ED observation units had a higher observation rate (16% versus 0% [p < .001] and 2% [p < .001]) and a higher rule out MI evaluation rate (61% versus 46% [p < .01] and 45% [p < .01]), without a significantly higher admission rate (47% versus 46% and 45%). For the three hospitals with observation units that collected charge data during 1997 on a consecutive series of chest pain patients who had negative rule out MI evaluations, charges for patient services were lower for patients evaluated in the ED observation unit ($2,214.80 +/- $80.40) than in the hospital ($5,464.30 +/- $393.60).
Conclusions: ED observation units represent a cost-effective restructuring of the diagnostic approach to patients with acute chest pain. In an improvement of quality of patient care, a larger proportion of ED chest pain patients receive an extended evaluation than is possible with hospital admission as the only ED disposition option.

Hadden, D, Dearden, C, et al. (1996). "Short stay observation patients: General wards are inappropriate." Journal of Accident and Emergency Medicine 13(3): 163-5.

Objective: To assess the efficiency of a short stay observation ward attached to the accident and emergency (A&E) department of a main teaching hospital.
Methods: The study was done on 107 patients admitted to the A&E observation ward and 107 similar patients admitted to general wards after closure of the observation ward. Patients of 13 years and over who required short term admission to hospital for observation or investigation were included.
Results: Patients admitted to the A&E observation ward were seen sooner by a senior doctor, had fewer investigations, and had a shorter stay in hospital than similar patients admitted to the general wards.
Conclusions: The A&E observation ward was more efficient than the general acute wards at dealing with short stay patients.

Harrop, S and Morgan, W (1985). "Emergency care of the elderly in the short-stay ward of the accident and emergency department." Archives of Emergency Medicine 2(3): 141-7.

Review of a consecutive series of the elderly patients who presented unheralded to the Accident and Emergency Department of the Royal Gwent Hospital showed that a relative minority (11%) were difficult to manage because they had no obvious acute medical condition or injury which qualified them for admission by the firms to whom they were first referred. The difficulty was compounded by the shortage of geriatric beds. Judicious use of short-stay ward beds in the accident and emergency department relieved pressure on beds elsewhere and allowed a short space of time in which preparation could be made for the patient's further care in the community. Elderly patients were removed quickly from the stretcher area of the accident and emergency department to the quieter surroundings of the short-stay ward, where their immediate nursing requirements could be readily met. It was not then necessary for them to be on a trolley for hours while junior doctors haggled on the telephone or nurses were too busy to administer food, drink and bedpans.

Hennemen, P (1989). "The use of an emergency department observation unit in the management of abdominal trauma." Annals of Emergency Medicine 18: 647-50.

Diagnostic peritoneal lavage (DPL) is a valuable triage tool in the evaluation of patients with abdominal trauma. Observation after a negative lavage is necessary to detect injuries not well discerned by DPL performed in the early postinjury period. We evaluated the use of 12 hours of monitoring in an emergency department observation unit in the management of 230 patients with abdominal trauma and a negative initial DPL. One hundred five of the patients had blunt and 125 had penetrating trauma. One hundred eighty-seven patients (81%) were discharged home from the observation unit without any reported significant complications. Thirty-eight patients (17%) required admission to our hospital; four of the 38 underwent necessary laparotomy. In the 230 patients evaluated, no deaths or complications could be assigned to the use of 12 hours of observation in the unit. The use of an observation unit in our study resulted in the potential savings of $51,329. Our study supports the concept that selected patients with significant abdominal trauma and a negative DPL can be managed safely and cost effectively in an ED observation unit.

Hodgkinson, D, Jellet, L, et al. (1991). "A review of the management of oral drug overdose in the Accident and Emergency Department of the Royal Brisbane Hospital." Archives of Emergency Medicine 8(1): 8-16.

Two-hundred and eighty-nine patients who made a total of 323 presentations to the Royal Brisbane Hospital Accident and Emergency Department with a known or suspected oral drug overdose were reviewed. The majority of patients (76%) could be managed in a 24 h Accident and Emergency observation unit. Activated charcoal given orally or via a nasogastric tube was the recommended method of preventing further absorption of an ingested drug. The use of syrup of ipecac was not encouraged and orogastric lavage was used in only specific situations. The morbidity and mortality of these patients when compared with other studies, was not adversely affected by this protocol which dramatically reduced the indications for the use of orogastric lavage and syrup of ipecac.

Israel, R, Lowenstein, S, et al. (1991). "Management of acute pyelonephritis in an emergency department observation unit." Annals of Emergency Medicine 20(3): 253-7.

Study Objectives: To determine whether moderately to severely ill patients with acute pyelonephritis can be treated successfully on an outpatient basis, and whether any aspect of history, physical examination, or initial laboratory data predicts failure of outpatient therapy and the need for hospitalization.
Design: Retrospective chart review of all patients with a diagnosis of acute pyelonephritis seen during a three-year period.
Setting: Emergency department observation unit of an urban teaching hospital serving residents of the city and county of Denver.
Type of Participants: Women between the ages of 15 and 50 with symptoms, physical examination, and initial laboratory data consistent with a diagnosis of pyelonephritis.
Interventions: Patients received IV antibiotics, rehydration, analgesics, and antiemetics in an observation unit for up to 12 hours, when they were either admitted to the hospital or discharged home on oral antibiotics.
Measurements and Main Results: Sixty-three of 87 patients (72%) with acute pyelonephritis were managed successfully as outpatients, nine (22%) were hospitalized directly from the observation unit because they were considered to be too ill to go home, and five (6%) returned with persistent symptoms after ED therapy and were hospitalized. No clinical or laboratory variable predicted success or failure of ED observation unit therapy at the time of initial presentation.
Conclusion: In selected patients, the observation unit may be used to initiate therapy for acute pyelonephritis. Those with an adequate clinical response to initial treatment may be discharged on oral antibiotic therapy with appropriate follow-up.

Jelinek, G and Galvin, G (1989). "Observation wards in Australian hospitals." Medical Journal of Australia 151: 80-3.

Observation wards have not been discussed in the Australian literature. In the United Kingdom, the few published reports suggest that they are an essential part of the function of emergency departments. This paper presents the results of a survey of 44 major Australian hospitals regarding their use of observation wards. Half the hospitals that were surveyed had such wards but variations existed in the way that they functioned. Nearly half the remaining hospitals wanted to establish an observation ward. Our concept of observation wards is discussed.

Jelinek, G, Mountain, D, et al. (1999). "Re-engineering an Australian emergency department: Can we measure success?" Journal of Quality in Clinical Practice 19(3): 133-8.

In 1996, in response to perceived deficiencies of the Emergency Department, Sir Charles Gairdner Hospital made emergency medicine a key strategic initiative. Major staffing and functional changes occurred as a result, including creation of the first Chair in Emergency Medicine in Australasia. We present a before and after study, using a range of measured variables, including the accepted Australian Council on Healthcare Standards emergency medicine clinical indicators. Clinically, there were great improvements in waiting times, time to thrombolysis in acute myocardial infarction, complaint rate, and misdiagnosed fracture rate. Increased throughput of short stay patients in a re-opened observation ward greatly shortened average length of stay for patients with a range of acute conditions. Data also indicated significant improvements in teaching and research. We conclude that with firm commitment from hospital management, re-engineering an emergency department can be shown to improve the quality-of-care.

Jones, A, O'Driscoll, K, et al. (1995). "Head injuries and the observation ward." Journal of Accident and Emergency Medicine 12(2): 160-1.

Letter to the editor in reference to:
Brown, SR et al (1994) - Ref # 387)

Khan, S (1997). "Benefits of an accident and emergency short stay ward in the staged hospital care of elderly patients." Journal of Accident and Emergency Medicine 14(3): 151-2.

Objective: To study the potential of a short stay ward attached to an accident and emergency (A&E) department to improve care and reduce admissions to hospital by enabling elderly patients to be monitored closely for up to 24 h before being formally admitted to hospital or discharged home. Patients admitted to the short stay ward were those who appeared to need only a brief period of assessment or treatment.
Methods: The medical records of all patients aged 65 years and above admitted to the short stay ward over a nine month period (April to December 1993, inclusive) were reviewed.
Results: 13% of all the patients over 65 attending A&E were admitted to the A&E ward. Of patients over 65 who were admitted to hospital, 20% were first admitted to the A&E ward. There were 502 admissions to the short stay ward of patients aged 65 years and above, who constituted 38% of the total admissions to that ward. Admitting these selected patients to the short stay ward allowed 71% to be discharged home, usually within 24 h, rather than being formally admitted to hospital.
Conclusions: The addition of a short stay ward can shorten the hospital stay for selected elderly patients and reduce the demand for inpatient hospital beds. This ward also improves the quality of care to elderly patients attending the A&E department.

Klein, B and Patterson, M (1991). "Observation unit management of pediatric emergency." Emergency Medicine Clinics of North America 9(3): 669-76.

Observation units for children in an Emergency Department setting can serve to improve the quality of medical care provided as well as reduce overall costs; however, they must be properly organized with careful consideration for the needs of children. Policies must be written specifying who is in charge as well as who can be accepted into these units and for how long. Procedures regarding documentation and sign-out must be formulated. These units must be well staffed and fully equipped, and they should be pleasant places for the children to stay; otherwise, what might begin as assets can quickly become disorganized and potentially dangerous liabilities.

MacLaren, R, Ghoorahoo, H, et al. (1993). "Use of an accident and emergency department observation ward in the management of head injury." British Journal of Surgery 80(2): 215-7.

The management of 405 patients presenting with head injury to an accident and emergency department was assessed. Sixty-nine patients were admitted, although this number should have been 127 according to current guidelines on the management of head injury. Only three attenders were admitted inappropriately according to these guidelines. An accident and emergency observation ward was open on weekdays only; at weekends, patients with head injury were admitted to a general surgical ward. When the observation ward was open, 51 of the 76 patients (67 per cent) presenting with admission criteria were admitted. When closed, only 15 of the 51 patients (29 per cent) with these criteria were admitted. Guidelines were applied effectively to reduce the number of unnecessary admissions, but there was a significant number of patients with minor head injury who were discharged inappropriately. This number was much reduced when an observation ward was available.

Maimaris, C and Kirby, N (1991). "The impact of the observation ward on acute admissions to Guy's Hospital." Health Trends 23(1): 33-5.

This paper describes an evaluation of the short-stay ward at Guy's Hospital Accident and Emergency Department. It includes an audit of the operational policy, the care provided to patients, and the impact of the short-stay ward on hospital admissions. The results indicate that by concentrating patients in a short-stay ward, the quality of care is improved, delays are reduced, and the pressure on inpatient beds is relieved.

Markovich, V (1990). "An observation unit: Essential to the safe and effective practice of emergency medicine." Journal of Emergency Medicine 8(4): 493.

Editorial which accompanies reference in same issue:
Zun, L. Observation units: Boom or bust for emergency medicine. J Emerg Med. 1990; 8: 485-90

Marks, M, Baskin, M, et al. (1997). "Intern learning and education in a short stay unit. A qualitative study." Archives of Paediatric and Adolescent Medicine 151(2): 193-8.

Objective: To study interns' perceptions of their learning during their rotation through a short stay unit (SSU).
Design: Case-based, qualitative research study.
Setting: A tertiary care pediatric hospital (The Children's Hospital, Boston, Mass).
Participants: Ten interns who had worked in the SSU in the 3 months prior to June 1, 1995, and on a general medical team in the previous 12 months.
Intervention: None.
Main Outcome Measures: In July 1995, the interns participated in focused, open-ended interviews lasting about 40 to 60 minutes to document their perceptions of their learning during their SSU rotation. The interviews were recorded on audiotape and transcribed prior to analysis. Data were analyzed to discern and categorize themes from the interns' responses.
Results: All interns responded favorably to their educational and learning experiences during their rotation through the SSU. Two major themes emerged: (1) the interns' learning, which was affected by the role of the attending physician, the organization and structure of the SSU, and the teaching strategies in the SSU; and (2) the interns' collaborative work with the nursing staff in the SSU, which affected patient care but did not facilitate the interns' learning.
Conclusion: Clustering in the SSU of patients whose symptoms suggested straightforward diagnoses enhanced interns' educational experiences.

McDermott, M, Murphy, D, et al. (1997). "A comparison between emergency diagnostic and treatment unit and inpatient care in the management of acute asthma." Archives of Internal Medicine 157(18): 2055-62.

Background: Emergency diagnostic and treatment units (EDTUs) may provide an alternative to hospitalisation for patients with reversible diseases, such as asthma, who fail to adequately respond to emergency department therapy.
Objective: To evaluate the medical and cost-effectiveness, patient satisfaction, and quality of life of patients receiving EDTU care for acute asthma compared with inpatient care.
Methods: A prospective, randomised clinical trial performed at 2 urban public hospitals enrolled patients with acute asthma (age range, 18-55 years) not meeting discharge criteria after 3 hours of emergency department therapy. Patients were treated with inhaled adrenergic agonists and steroids in an EDTU for up to 9 hours after randomisation or with routine therapy in a hospital ward. Patients were followed up for 8 weeks.
Main Outcome Measures: Discharge rate from the EDTU, length of stay, relapse rates, days missed from work or school, days incapacitated during waking hours, symptom-free days and nights, nocturnal awakenings, direct medical costs, patient satisfaction, and patient quality of life.
Results: The study consisted of 222 patients with asthma. Sixty-five patients (59%) treated in an EDTU were discharged home; the remainder were admitted to the hospital. There were no differences during the follow-up period in relapse rates (P=.74) or in any other morbidities between the EDTU and inpatient groups. There were significant differences in the length of stay, patient satisfaction, and quality of life favouring EDTU care. The mean (+/- SD) cost per patient in the EDTU group was $1202.79 +/- $1343.96, compared with $2247.32 +/- $1110.18 for the control group (P<.001).
Conclusions: Treatment of selected patients with asthma in an EDTU results in the safe discharge of most such patients. This study suggests that quality gains and cost-effective measures can be achieved by the use of such units.

Melbourne Health (2001). Short Stay and Observation Units. Melbourne, Melbourne Health: 1-82.

This project was commissioned by the Victorian Department of Human Services to investigate the use of Short Stay Observation Units and to understand the potential for expanding this model of care within Victoria. The project was undertaken by the Clinical Epidemiology and Health Service Evaluation Unit based at Melbourne Health and was overseen by a Steering Committee with broad representation from Victorian hospitals (see Appendix A). The focus of this study complements an evaluation of Chest Pain Evaluation Units (CPEAs), which involved Royal Melbourne Hospital, The Alfred and Monash Medical Centre. For detail relating to CPEAs, readers are referred to the Department of Human Services Review of Chest Pain Evaluation Areas Final Report, September 2000.
The specific objectives of this project were to:
1. conduct a review of the published literature and local evaluation data concerning the establishment and operation of SOU™s and outcomes of care for patients
2. describe the features of SOU™s operating in Victorian public hospitals
3. identify models for SOU™s in the following settings:
§ teaching hospitals - large
§ teaching hospitals - other
§ large regional base and suburban hospitals
4. make recommendations concerning:
§ models of service
§ types of patients best managed in short stay/observation units
§ staffing structure and management of SOU™s
§ relationship of the SOU to demand management strategies for the hospital
§ communication with patient and community-based continuing medical care
5. identify potential performance indicators for SOU™s
6. identify and make recommendations concerning the recording of SOU patients in the VEMD and VAED
The initial project scope was expanded to include differentiating the features of SOUs from those of Medical Assessment and Planning Units (MAPUs), which provide an alternative approach to fast-tracking episodes of care.
Conclusions
From the various sources of information analysed throughout this project, SOUs clearly have potential to improve the management of a small proportion (ie in the order of 5-10%) of emergency department presentations. This equates to approximately 20,000 to 40,000 patients across the 12 major Melbourne metropolitan hospitals per year. Further to this, SOUs have potential to:
§ Improve patient satisfaction,
§ Improve efficiencies in the operation of emergency departments,
§ Improve the utilisation of hospital resources, and
§ Facilitate treatment of increased numbers of patients.
However, despite the potential benefits to be gained from an SOU; of the 5 Victorian hospitals that have implemented these facilities for managing general conditions, 3 were unable to maintain their SOU function as they were ‚blocked™ by patients who had been admitted to these beds awaiting a ward bed. Acute care demand pressures in the metropolitan region have reached an unprecedented level over the last 12 months and peaked at around the time of this survey. Emergency departments have experienced extreme workloads, which have adversely impacted on emergency department efficiency. Despite the fact that SOUs are intended to optimise the efficiency of emergency departments, the function of these units in 3 Victorian sites has been compromised to the extent that they operate as ‚holding™ or ‚multi-day stay™ wards. This approach precludes achieving the potential benefits that these units could deliver in terms of improved patient management and enhanced efficiency. Therefore, future expansion of this approach to patient care requires careful consideration, with the potential benefits weighed against the risks that arise from current demand pressures.
Factors that have been identified as critical to the successful management of an SOU include:
§ Evidence of executive support
§ Nomination of a medical and a nursing champion
§ Evidence of medical and nursing support
§ Capacity to manage 2-5% of emergency presentations
§ A planned 24 hour time limit
§ Admission criteria that preclude use of the SOU beds for patients awaiting an inpatient bed
§ Clearly defined processes for patient management planning
§ Clear discharge criteria
§ Careful selection of candidate conditions
§ Priority access to pathology tests and radiology investigations
§ An appropriate staffing structure that enables frequent medical review of patients
§ A clear and comprehensive strategy for evaluating the performance of the SOU and the impact of the Unit on the hospital.
While there may be a cost benefit in implementation of an observation unit, in our current environment it is probable that the real benefits to be gained will arise from improved utilisation of in-hospital facilities, with bed-days saved from medical admissions becoming available for alternative use. However, the potential to ‚save™ bed days from medical admissions through the use of SOUs, needs to be very carefully managed. SOUs may benefit organizations in two key ways:
§ by providing a small number of additional inpatient beds (ie increasing capacity) and
§ by improving patient flow for a small, but significant proportion of emergency department presentations.
If SOUs are managed in such a way that they become ‚holding units™ for patients awaiting a ward bed, the benefits achieved will be limited to those relating to increased capacity only. More significant benefits can be achieved through initiatives that increase patient flow. SOUs thus have the potential to provide for benefits arising from both increased capacity and increased flow if they are managed to preserve their short stay function.

Morgan, W (1981). "Functions of the observation ward in the accident and emergency department." British Medical Journal 282: 398-9.

Letter to the editor in reference to:
Dallos V et al (1981) - Ref # 26

Neville, L and Rowland, R (1983). "Short stay unit solves emergency overcrowding." Dimensions in Health Service 60: 26-7.

Many hospitals are experiencing bed shortages due to the recent increased demand for inpatient hospital services and relatively little growth in the availability of facilities. As a result, patients are not being admitted when they should be or they are held in the emergency department for a long time prior to admission to a bed. In the latter situation, the consequential blocking of treatment and diagnostic space reduces the efficiency of the emergency department.

Numa, A and Oberklaid, F (1991). "Can short hospital admissions be avoided? A review of admissions of less than 24 hours' duration in a paediatric teaching hospital." Medical Journal of Australia 155(6): 395-8.

Objective: To review the records of children admitted to hospital for less than 24 hours to assess the appropriateness of the admission and subsequent discharge, and the suitability of these patients for admission to a short stay area rather than the hospital wards.
Design: Retrospective study consisting of a one in three sample of all children admitted to the hospital's general medical units over one year. All admissions were listed sequentially, and every third patient was included in the study.
Setting: Royal Children's Hospital, Melbourne; a tertiary paediatric hospital with a major primary care role.
Participants: There were a total of 660 patients eligible for inclusion in the study; 220 were selected, and all records were reviewed.
Results: It was found that although 87.7% of admissions could be justified on medical grounds alone, the children quickly recovered with at least 65% being fit for discharge within 12 hours of admission. In spite of this the mean duration of admission was 17.0 hours. The majority of patients were suffering from easily diagnosed and treated disorders, with 78.9% falling into four diagnostic groups (asthma, ingestions, infections, and convulsions). Criteria for admission to a short stay observation area were satisfied in 65% of patients (at the time of the study no such area existed in the hospital). No patients were discharged inappropriately early.
Conclusions: A significant number of children require brief hospitalisation for relatively minor illness, but unnecessary delays caused by administrative aspects of hospital admission and relatively infrequent inpatient review by medical staff often lengthen the period of admission. Significant cost savings are possible with the use of a short stay facility, and a large number of patients are suitable for this form of care.

O'Brien, S, Hein, E, et al. (1980). "Treatment of acute asthmatic attacks in a holding unit of a paediatric emergency room." Annals of Allergy 45: 159-62.

Four hundred and thirty-four children diagnosed as asthmatics in an emergency room were studied to evaluate the usefulness of treatment in a holding unit to minimize hospitalizations for the treatment of status asthmaticus and to facilitate early institution of effective therapy. Three hundred and twenty-eight children (76%) improved sufficiently following subcutaneous injections of epinephrine to be sent home. Of the remaining 106 patients, 71 were discharged after further therapy. Four of the patients discharged returned within one week requiring further therapy and eventual admission to the hospital. The average cost of hospitalization for 35 patients eventually admitted was more than five times the average cost of care for those treated only in the holding unit, and hospitalization for 24 hours would have more than doubled the cost of care for those discharged from the holding unit.

Oie, B and Fanebust, R (1993). "Emergency admissions to a department of internal medicine. Are departments of internal medicine used optimally, and how would observation units affect the management of the department?" Tidsskr Nor Laegeforen 113(7): 836-8.

279 consecutive emergency admissions to our Department of Internal Medicine were reviewed. Admission was appropriate for 58%. These patients consumed 88% of the "ward-days" during the period studied. Of the remaining patients, 22% could have been treated adequately in an observation unit, 10% need not have been hospitalized, and 10% should have been admitted to a different department. All stays in hospital lasting more than 50 days were due to lack of a place in a nursing home. If no patient had to wait more than 50 days, this would release 23% of the total "ward-day" capacity. The pressure on Departments of Internal Medicine could be reduced substantially by establishing observation units, and reducing the waiting time for a place in a nursing home.

Platt, F (1994). "Reviews and notes: Emergency medicine: Observation medicine;\and\presenting signs and symptoms in the emergency department: Evaluation and treatment." Annals of Internal Medicine 120(7): 624.

FULL TEXT
Observation Medicine
Louis G. Graff; ed. 440 pages. Stoneham, Massachusetts: Andover Medical Publishers; 1993. $55.00.
Presenting Signs and Symptoms in the Emergency Department: Evaluation and Treatment
Glenn C. Hamilton; ed. 815 pages. Baltimore: Williams & Wilkins; 1993. $95.00.

Remember when emergency medicine was a new specialty? When its practitioners were renaming hospital emergency rooms as emergency departments? Now Graff and coauthors have defined a new field of medical practice: "Observation Medicine"
At least 30% of U.S. hospitals have observation units, and, in many that lack around-the-clock physician staffing, the care of such patients falls to the emergency department staff. In fact, that coverage is the medical reason for the existence of observation units and their propinquity to the emergency department. However, a better explanation for the ubiquity of medical observation units is financial. When DRGs came into being, it became economically advantageous for hospitals to label and charge differently their short-stay patients. Groff believes that "the primary impetus for the delineation of observation services is the financial savings available to the health-care payer." But the truth is that a clear and more powerful impetus exists: income available to the health care provider. The DRG system rewards hospitals for briefer stays and earlier discharges, but too early is not good either. If your sick patient goes home in 20 or 30 or even 50 hours, he or she may not have been sick enough to satisfy Medicare's admission criteria. Thus was born the 23-hour observation admission, now extended to 48 or even 72 hours.
From the perspective of the emergency physician, the observable patient is one whose diagnosis is unclear, in whom at least one diagnostic possibility cannot be safely evaluated while the patient is a true outpatient, whose easy diagnosis is not possible, and whose condition hampers the physician's diagnostic performance. We see a hyperbolic relation between the seriousness of the potential diagnosis and the probability of that diagnosis in patients suitable for observation: A patient with a high probability of serious disease is admitted to the hospital; one with a low probability of such disease can be "observed." Observation Medicine does a good job of focusing on the care of and diagnostic approach to just such patients. Even those who do not work in emergency medicine can learn from such a focus on the first 24 hours of a patient's stay in a hospital.
Presenting Signs and Symptoms in the Emergency Department was proudly written by the entire residency program staff and residents of the Emergency Medicine Department at Wright State University. The title page says so in bold print, and a reader immediately feels the sense of ownership that department must have had in developing and writing this text. At 815 pages, it is no overnight read and falls between short, readable emergency medicine books and the larger, more encyclopedic texts.
Both these small texts are multiauthor books and thus of varying quality. Both might have benefited from more stringent editing. I often found myself differing with chapter authors on the appropriate emergency or observational evaluation for a particular presenting problem. However, both books would be additions to an emergency department library and useful for browsing and short-bolus, as-needed education.

Ramaiah, R and Pal, A (1987). "The work load and cost implications of patients with self injury / assault in a short stay ward." British Journal of Accident and Emergency Medicine Sept: 5-6.

This paper describes the characteristics of patients admitted to the short stay ward attached to the A&E department at Ysbyty Glan Clwyd in North Wales during two separate study periods. In addition the paper attempts to identify the costs to the health service of providing care to these patients.

Ross, M, Naylor, S, et al. (2001). "Maximizing use of the emergency department observation unit: a novel hybrid design." Annals of Emergency Medicine 37(3): 267-74.

Study Objective: We sought to determine whether sharing an observation unit with scheduled procedure patients would maintain a more consistent unit census and patient/nurse ratio. A secondary objective was to determine the effect of this model on patient length of stay and discharge rates.
Methods: This retrospective, descriptive study was conducted in a high-volume suburban teaching hospital, using a "before-and-after" study design. A "pure" postprocedure unit became a "hybrid" observation postprocedure unit by displacing specific postprocedure patients to inpatient locations. Subsequently, the displaced patients were returned to the unit. On weekends, the unit operated as a pure observation unit. Hourly unit occupancy and census data were prospectively collected, and hourly patient/nurse ratios were calculated. Patient length of stay and discharge data were collected and compared in different settings.
Results: The 2 services showed a complementary census pattern that allowed the hybrid unit to maintain an average hourly patient/nurse ratio of 3.7 compared with the ratio of 2.5 for a pure observation unit. There was no difference in observation patient length of stay (14.8 hours versus 14.7 hours) or discharge rate (20.4% versus 18.1%) between weekdays and weekends. However, scheduled procedure patients experienced significantly shorter lengths of stay in the hybrid unit setting (4.3 hours) than in alternative inpatient locations (9.4 hours).
Conclusion: The hybrid model showed better hourly census and nurse resource use rates, with no adverse effect on observation patients. However, scheduled procedure patient length of stay was shorter in this setting.

Ross, M, Wilson, A, et al. (2001). "The impact of an ED observation unit bed on inpatient bed availability." Academic Emergency Medicine 8(5): 576.

Objective: ED overcrowding often occurs due to the lack of available inpatient beds. We sought to determine the impact of one ED observation unit (EDOU) bed on inpatient bed availability.
Methods: This is a retrospective cohort study of consecutive patients managed in a high-volume suburban teaching hospital with a protocol-driven 14-bed EDOU. 12 months (1999) were used to obtain length of stay (LOS) and discharge data for all EDOU patients. Use of the EDOU was not compulsory. A convenience sample of admitted non-EDOU patients was used to determine comparison inpatient DRG LOS for comparable DRGs (chest pain-143, back pain-243, asthma-97, syncope-142, cellulitis-278, pyelonephritis-321, and dehydration-297). Assuming all discharged EDOU patients were alternatively managed as inpatients, inpatient bed utilization was calculated using three LOS estimates-no change from the EDOU LOS, the shortest comparison DRG LOS, and the average comparison DRG LOS. Annual hospital bed days were then adjusted to daily beds used. Initial bed-days use was calculated for admitted EDOU patients, and included in bed estimates.
Results: In 1999 the EDOU managed 5,802 patients with an average LOS of 15.2 hr (16.2 if admitted, 14.9 if discharged), and 80% being discharged. The seven comparison DRGs corresponded with conditions representing 58% of the EDOU census. 1,536 patients were in the IP DRG comparison cohort, using 5,062 IP bed-days with an IP LOS range from 2.41 days (chest pain) to 5.42 days (non-operative back pain), and an average of 3.30 days. Admitted EDOU patients used 2.19 beds before IP bed use occurred. Admitting all discharged EDOU patients would have occupied 14 IP beds if there was no increase in LOS, 32.9 beds if the LOS was 2.41 days, and 44.2 beds if the LOS was 3.30 days. For the three scenarios, one EDOU bed kept 1.00, 2.35, and 3.16 IP beds available for other uses.
Conclusions: Accelerated care in an EDOU may be effective in improving inpatient bed availability.

Ross, M, Compton, S, et al. (2001). "An ED observation unit is effective for elders." Academic Emergency Medicine 8(5): 452-3.

Objectives: To the best of the authors' knowledge, there are no U.S. studies evaluating the efficacy of an ED observation unit (EDOU) for elder patients. This study describes the utilization of an EDOU by elder patients, and determines its efficacy in this population.
Methods: This retrospective observational cohort study of consecutive adult patients sent to an EDOU from 1996 to 2000 occurred in a high-volume tertiary care suburban teaching hospital. All patients were initially managed in the ED. This protocol-driven, emergency physician-run EDOU adheres to ACEP operational guidelines. Efficacy is defined as an EDOU length of stay (LOS) under 18 hours, and inpatient admit rates less than 30%. Descriptive statistics were generated and the frequencies of conditions were compared between elder (>65 yo) and younger patients using chi square. Unadjusted odds rations and 95% confidence intervals were constructed for hospital admission by age group.
Results: 15,359 adult patients were observed, representing 4.3% of the ED census. Complete study data were obtained on 97% of these patients. EDOU age distribution was bimodal, with age peaks at 45 and 75, and a median of 53. Of the adult EDOU census, 35.6% were over age 65. For elders, the five most common EDOU conditions were chest pain, dehydration, syncope, COPD, and back pain, accounting for 52% of this group. Average EDOU LOS for elders was longer, but still under 18 hours (15.8 (CI = 15.6, 16.0) vs 14.4 (CI = 14.3, 14.6) hrs). Overall, 26.7% of the elders were admitted, compared to 19.3% of younger patients (p < 0.01). The elders were 52% (CI = 40%, 65%) more likely to be admitted to the hospital than younger patients. Among common conditions, odds ratios for admission were highest for back pain (2.37, CI = 1.70, 3.29), upper GI bleed (1.90, CI = 0.98, 3.68), and pyelonephritis (1.56, CI = 0.89, 2.72).
Conclusions: Elder EDOU patients experience admit rates and lengths of stay that are greater than younger patients, yet still acceptable for this setting.

Ross, M and Zalenski, R (2001). "Observation services - Past, present, and future." American Journal of Medicine 110(4): 324-5.

Discusses the potential benefits and disadvantages of observation beds. Reflects on the article by Martinez et al in the same issue.

Royal Women's Hospital (1997). Pregnancy Day Care Centre. Melbourne, Royal Women's Hospital: 1-19.

Pregnancy day care units have been established in recent years in various overseas maternity centres to enable expeditious evaluation and/or management of clinical conditions such as nonproteinuric hypertension, suspected intrauterine growth retardation, post-term pregnancy and so on, without the need for expensive, time-consuming and socially disruptive (for the patients concerned) overnight ward admissions. The establishment of these units has led to a fall in traditional antenatal ward bed occupancy, a consequent financial saving for the hospitals involved and no increase in adverse perinatal and/or maternal outcomes. Patients prefer this type of short-stay care as it allows women to spend less time in hospital and more time at home with their families. Out hospital's preliminary experience with pregnancy day care would support these conclusions.

Ryan, J, Clemmett, S, et al. (1996). "Managing patients with deliberate self harm admitted to an accident and emergency observation ward." Journal of Accident and Emergency Medicine 13(1): 31-3.

Objective: To review the case records of patients admitted to an accident and emergency (A&E) observation ward following deliberate self harm.
Methods: The hospital notes of 568 patients admitted during one year following episodes of deliberate self harm were reviewed. The study was retrospective.
Results: The majority of these patients had taken an overdose and were between 18 and 35 years of age. Most patients were admitted to the observation ward after midnight or in the evening and were subsequently managed by an A&E based deliberate self harm team. Only 20% of admissions required evaluation by a psychiatrist. Most patients were discharged the next day without further follow up.
Conclusions: The use of a specialised A&E based team and an A&E observation ward is appropriate for the management of many deliberate self harm patients.

Rydman, R, Isola, M, et al. (1998). "Emergency department observation unit versus hospital inpatient care for a chronic asthmatic population." Medical Care 36(4): 599-609.

Objectives: This study was designed to determine if an accelerated treatment protocol administered to acute asthmatics presenting to a Hospital Emergency Department Observation Unit (EDOU) can offset the need for inpatient admissions and reduce total cost per episode of care without sacrificing patient quality of life.
Methods: The authors used a prospective randomized controlled trial comparing postintervention patient quality of life for EDOU care versus standard inpatient care as measured by the standardized Medical Outcomes Study (MOS) SF-36 instrument. Other measures reported include: clinical status as measured by peak flow rates, total cost per treatment arm using microcosting techniques, and relapse-free survival 8 weeks after treatment. Eligible patients (n = 113) were assigned randomly to an EDOU or inpatient care from a consecutive sample of 250 acute asthmatic patients presenting to an urban hospital emergency department who could not resolve their acute asthma exacerbation after 3 hours of emergency department therapy.
Results: Patients assigned to the EDOU had lower mean costs of treatment (EDOU = $1,202 versus Hospital Inpatient = $2,247) and higher quality of life outcomes after intervention in five of eight domains measured by the MOS SF-36: Physical Functioning, Role Functioning-Emotional, Social Functioning, Mental Health, and Vitality. No differences were found in clinical outcomes as measured by peak flow rates or postintervention relapse-free survival. Univariate comparative findings were re-examined and confirmed through multivariable analysis when baseline SF-36 scores and postintervention peak expiratory flow rates clinical status were used as covariates.
Conclusions: The study showed that the EDOU was a lower cost and more effective treatment alternative for a refractory asthmatic population presenting to the Emergency Department. Several baseline MOS SF-36 domains proved useful in predicting or validating posttreatment clinical status, relapse, and total costs of care. Outcome SF-36 domain scores were also useful in identifying patients with the most favorable clinical, cost, and relapse rate outcomes at the study endpoint.

Rydman, R, Roberts, R, et al. (1999). "Patient satisfaction with an emergency department asthma observation unit." Academic Emergency Medicine 6(3): 178-83.

Objective: To compare levels of patient satisfaction between the diagnostic and treatment protocols in an ED-based asthma observation unit (AOU) and those with standard inpatient hospitalization.
Methods: This was a prospective, randomized, controlled trial with a sample of 163 patients presenting to the ED with acute asthma exacerbations over a 30-month period. Eligible patients were those who could not resolve their symptoms after three hours of standard ED therapy. Patients were then randomly assigned to an ED-based AOU (experimental group) or to-customary inpatient care (control group). Patient satisfaction and problems with care processes were assessed by standardized instrumentation at discharge in both groups.
Results: The AOU patients scored higher than those randomized to the inpatient hospitalization protocol on four summary ratings of patient satisfaction measures: received service wanted, recommendation of the service to others, satisfaction with the service, and overall satisfaction. The AOU patients reported fewer total number of problems with care received, and fewer specific problems with communication, emotional support, physical comfort, and special needs, than did the inpatient group. However, the AOU patients reported more problems regarding their knowledge of financial costs and liabilities for their service than did the inpatients.
Conclusion: Patients were more satisfied and had fewer problems with rapid diagnosis and treatment in the AOU than they did with routine inpatient hospitalization. Since AOUs represent a new ambulatory service modality, patients would benefit from greater awareness of the costs and coverage for AOUs as compared with hospital inpatient care. These findings have important implications for the future short- and long-term success and feasibility of ED-based AOUs.

Saunders, C and Gentile, D (1988). "Treatment of mild exacerbations of recurrent alcoholic pancreatitis in an emergency department observation unit." Southern Medical Journal 81: 317-20.

Patients with mild exacerbations of recurrent alcoholic pancreatitis are occasionally treated in the emergency department observation unit with parenteral hydration and analgesia in hopes of avoiding hospitalization. To determine whether such treatment is efficacious and cost-effective, we reviewed 27 consecutive admissions to the emergency department observation unit for exacerbation of previously documented recurrent alcoholic pancreatitis. For comparison, we studied 27 randomly selected, matched patients admitted directly to the hospital. Of the 27 admitted to the observation unit, 14 (52%) improved sufficiently for discharge in less than 24 hours (group A; mean duration of observation, 14.4 hours); the other 13 (48%) required continued hospitalization (group B; average length of stay, 7.5 days). The group admitted directly to the hospital (group C) had a mean stay of 5.8 days (difference not significant). Of a variety of parameters compared, only serum amylase values differed significantly between the three groups. A serum amylase cutoff of 300 U/dl would have correctly identified all patients in group A (sensitivity 100%), though with a relatively low specificity (60%). We conclude that there may be a subset of patients with mild exacerbation of recurrent alcoholic pancreatitis, identifiable by a low serum amylase level, who would benefit from a trial of management in an emergency department observation unit.

Sinclair, D and Green, R (1998). "Emergency department observation unit: Can it be funded through reduced inpatient admission?" Annals of Emergency Medicine 32(6): 670-5.

Study objective: We sought to test the assumption that an emergency department observation unit can be funded through the reallocation of resources made available through the unit's impact in reducing inpatient admissions and facilitating bed closures.
Methods: We conducted our study in a tertiary care center ED with 46,000 visits annually. For a 3-month period, all patients admitted to the hospital through the ED were screened by an emergency physician for suitability for admission to an observation unit. Any patient in the hospital for 3 days or less who did not undergo surgery or other inpatient procedure, and who was admitted through the ED, was considered a candidate for the observation unit.
Results: Of 1,840 admissions, 147 patients met the admission criteria. Only 48 (32.2%) could have been treated in an observation unit, and these patients were not admitted to any single unit in high frequency. The potential savings from inpatient bed closures would only have amounted to 1.68 full-time equivalents-not enough to staff a 4-bed observation unit, which would require 5 full-time equivalents.
Conclusion: Because of the diffuse and inconsistent effect such a unit had on inpatient bed use, funding for an ED observation unit at our institution could not be justified on the basis of the closure of inpatient beds and transfer of resources.

Ward, G, Jorden, R, et al. (1991). "Treatment of pyelonephritis in an observation unit." Annals of Emergency Medicine 20(3): 258-61.

Study Objective: To determine the feasibility of managing patients with acute pyelonephritis as outpatients after initial treatment with IV antibiotics in an emergency department observation unit.
Design: Prospective and uncontrolled.
Setting: ED observation unit.
Type of Participants: Nonpregnant female patients 14 years old or older without immunocompromise or serious underlying disease and no evidence of septic shock.
Interventions: All patients received two IV doses of trimethoprim/sulfamethoxazole at a 12-hour dosing interval and promethazine and acetaminophen as needed for nausea and fever, respectively. Baseline laboratory data, urinalysis, and urine and blood cultures were obtained.
Measurements and Main Results: Patients were observed for signs of septic shock, nausea, vomiting, and the ability to tolerate an oral intake. At the end of the observation period, 43 of 44 patients were discharged on oral trimethoprim/sulfamethoxazole. One additional patient who was doing well clinically was recalled and admitted because of a positive blood culture.
Conclusion: Patients with acute pyelonephritis, despite significant fever or nausea and vomiting, can be treated effectively as outpatients after a brief period of observation and IV antibiotics.

Waters, J and Hall, J (1988). "Staff satisfaction in short stay wards." Australian Health Review 11(4): 302-10.

Two Short Stay Wards (SSW) have been opened in a large teaching hospital in Sydney's outer Western suburbs, as a means of overcoming budget constraints and a shortage of nurses prepared to work conventional rosters. This paper reports a survey of the attitudes of medical and nursing staff using these two SSWs. Overall, medical personnel were found to hold positive attitudes to the SSWs and reported higher patient turnover as a result of their opening. Identified barriers to usage of the wards included scheduling of operating suite time, and lack of flexibility in the booking, admission and movement of SSW patients. Nurses who work in the SSWs have chosen to work under these special nursing conditions. They were found to be particularly satisfied with their work hours, rapport with patients and other staff, the high patient turnover and varied case mix. Sources of dissatisfaction included Friday night duty and deployment, and the administrative procedures practised by medical staff, including difficulties in contacting them.

Willert, C, Davis, A, et al. (1985). "Short-term holding room treatment of asthmatic children." Journal of Pediatrics 106(5): 707-11.

We undertook a randomized trial to compare holding room treatment vs hospitalization of patients with childhood status asthmaticus. Two thirds of 51 patients were discharged from a holding room within 24 hours (mean 11.8 +/- 4.61 hours); the others required hospitalization. One third of 52 hospitalized patients received less than or equal to 1 day of intravenously administered therapy, and two thirds received less than 2 days of therapy (mean 45.6 +/- 12 hours). There were no statistically significant differences in recurrence rates between the two groups in the 28 days following status asthmaticus. For patients receiving less than or equal to 1 day of therapy, the holding room cost was $526 +/- $226 vs $1439 +/- $339 for hospitalized patients (P less than 0.001). Thus, holding room therapy for childhood status asthmaticus is both medically and economically effective.

Williams, A, Jelinek, G, et al. (2000). "The effect on hospital admission profiles of establishing an emergency department observation ward." Medical Journal of Australia 173(8): 411-4.

Objective: To determine the effect of establishing an emergency department observation ward (OW) on admission numbers, average length of stay (ALOS) for the entire hospital and overall bed days for conditions commonly treated in the OW.
Setting: Sir Charles Gairdner Hospital (SCGH), Perth, a tertiary referral teaching hospital.
Design: Retrospective analysis of routinely collected hospital data for the 10 most common diagnosis-related group (DRG) categories of patients discharged from the OW for the financial years 1995-96 to 1998-99. Comparison of these data with those for adult patients at the other Perth teaching hospitals over the same period.
Main outcome measures: For patients in the 10 most common DRGs: numbers of admissions to the OW compared with other inpatient wards; total number of patients admitted to the hospital compared with total bed days; ALOS at SCGH compared with other Perth teaching hospitals.
Results: Increased admissions to the OW were paralleled by a decrease in admissions for the same DRG codes to other inpatient wards. ALOS remained approximately the same from 1995-96 to 1998-99 for patients in the OW (one day) and other inpatient wards (4.38 to 4.20 days). However, overall ALOS for patients in these DRGs fell by over a third (from 3.97 to 2.59 days) over this time. The total number of patients in these DRGs treated by the hospital increased by 19% over the four years, but the total number of bed days fell by 23%. By contrast, the ALOS for patients in the same DRGs treated at the other Perth teaching hospitals rose 8% (from 2.12 to 2.28 days).
Conclusion: Establishment of a formal emergency department OW results in the more efficient management of certain groups of patients, with a decrease in overall hospital bed days and length of stay.

Yealy, D, DeHart, D, et al. (1989). "A survey of observation units in the United States." American Journal of Emergency Medicine 7: 576-80.

Observation units have been proposed as a tool in lowering over-all health care costs and increasing the quality of care in outpatient facilities. Emergency department (ED) use of these units has been evaluated at single facilities but never at a national level. A survey of 250 facilities across the United States was performed to gather information about the observation unit phenomenon. Of the 250 hospitals in the survey group, 27% had operational observation or holding units and another 16% planned units within 1 year. A statistically significant increase in the use of these units was noted in nonteaching facilities when compared with their teaching counterparts. A trend toward higher use of observation units in suburban/urban settings was noted when compared with rural locations, although the difference was not statistically significant. Of the units in existence, 93% were located within the ED, staffed by emergency physicians, and administrated by the ED director. Most are staffed by ED nurses and ancillary help. No hospital had both an ED unit and a non-ED unit, and many units functioned as both holding and observation areas. The units are perceived to be beneficial in patient care and in lowering health care casts, although objective documentation to validate these beliefs is lacking. Further prospective research is needed to evaluate these units scientifically before broad recommendations can be made.

Yeung, K (1999). "Evaluation of the value of an observation ward in an emergency department." European Journal of Emergency Medicine 6(1): 49-53.

A prospective study was undertaken to describe the pattern of utilization of an observation ward in an emergency department (ED). During a 1-month study period, the following data were collected for all patients admitted to the observation ward: (1) patient demographics, (2) purpose of observation, (3) interventions at the observation ward, (4) disposal destinations, (5) disposal diagnosis, (6) outcome categories, and (7) duration of stay. A total of 12188 patients attended our ED and 1042 (8.51%) patients were admitted into the observation ward. An average of 34 patients was admitted into the observation ward each day. The age of the patients ranged from neonates to 94 years (mean age of 45.7 years, +/-25.7 SD). Sex distribution was almost equal. The diagnostic evaluation group was the largest (58%) followed by short-term therapy (38%) and psychosocial problems (3.5%). Of the 554 patients with a disposal diagnosis, 350 (59%) had their diagnosis clarified after the observation period. The percentage of patients admitted to the hospital was 23%. There were 42 chest pain and 46 trauma patients. The impact of an observation ward on the service in ED was discussed.

Zimmermann, P (1996). "Holding areas/observation units: Deja vu all over again." Journal of Emergency Nursing 22(4): 307-10.

Recent reductions in the number of inpatient beds, fluctuating hospital census, financial reimbursement changes, and ED crowding have brought a resurgence of "holding" areas in the emergency department. The popularized concept of chest pain management has developed into new focuses of waiting for inpatient beds (with or without cardiac monitoring), continuing the treatment of stable medical conditions of patients intended for discharge, or observing patients until a disposition decision can be made.
Successful programs typically have the following: (1) a physically separate area, (2) strict policies governing the use of the area, (3) requirements that any patients in unstable or deteriorating condition be managed in the main emergency department, (4) rotation of ED staff through assignments to the area, and (5) measures to enhance patient comfort.

Zoltowski, C, Rose, L, et al. (1998). "Justifying an observation unit." Journal of Emergency Nursing 24(5): 436-8.

FULL TEXT
What data do I use to justify setting up an observation unit?
Answer No. 1 About 5.5 million patients come to the emergency department each year with a primary complaint of chest pain. Approximately 10% to 15% are experiencing an infarct, and another 15% have ischemia. Most of the remaining 70% of patients with atypical chest pain (eg, no EKG changes and normal cardiac enzyme levels) are admitted for an average of 3 days at a cost of approximately $2700 to $6000. Part of the reason these patients are admitted is the very real liability issue; 20% of all emergency physician malpractice dollars paid are for the missed diagnosis of acute myocardial infarction (AMI).
The American Heart Association recommends the following guidelines for treatment of an AMI: community education, prehospital EKG, accurate computer-interpreted 12-lead algorithm, continuous ST segment monitoring, cardiac biomarker blood tests, serial EKG comparisons, and a stress test EKG before discharge. One suggestion for increasing community awareness is to offer a free EKG at a health fair and store it at the hospital (in addition to providing the individual with his or her own copy) for possible future comparison.
I am now involved in advocating the use of chest pain observation centers to do these rule-out procedures for patients with a low to moderate risk. With these units the inadvertent release of a patient with an AMI-a result commonly termed the "zero-defect model"-is avoided. Cardiac monitoring, serial cardiac biomarker testing, and a stress test are performed before the patient is discharged. Chest pain centers can rule out an AMI in 12 hours or less with a 99.9% accuracy rate at 20% to 50% the cost of in-hospital evaluation.
The 6 essential components for this type of observation unit include outreach to the community, prehospital hospital availability of trained personnel and equipment, observation units capable of monitoring, unit design, staffing, and management. [1] Time studies have shown that these observation patients require twice the amount of emergency physician services required by traditional ED patients. [2] The American College of Emergency Physicians has published guidelines on the management of ED observation beds. [3]*
Use of the chest pain centers for rule-outs for only 1000 patients with chest pain a year can result in a return on the initial set-up investment in as little as a month. In addition, staff find the involvement emotionally rewarding. Combined with the community teaching component, a difference can be made as the focus is toward prevention rather than toward only treating illness. [1]
Christine Zoltowski, RN, BS, CEN, Clinical Sales Specialist. The Education Alliance, Marquette Medical Systems, Milwaukee, Wis

Answer No. 2 A review of the number of ED admissions who end up staying only 24 hours in the hospital points out that some patients with certain diagnoses would do well in an emergency diagnostic treatment unit. Patients with diseases that are reversible (for example, asthma and congestive heart failure) can be treated intensively and released in 12 to 18 hours, avoiding a hospital admission. Dr Michael F. McDermott at Cook County Hospital showed that more than half of the patients with asthma admitted to the hospital could be treated in the emergency diagnostic treatment unit at about half the cost with equivalent clinical outcomes and greater patient satisfaction. You need to evaluate the population you are taking care of when you attempt to justify an observation unit.
Lindy Rose, RN, BS, Director of Emergency Department, Harris Methodist Hospital, Fort Worth, Tex

Answer No. 3 I am president of a health care consulting firm specializing in emergency service. The old rule of thumb of 2000 to 3000 patients for treatment area beds is not appropriate for observation unit beds. The standard used will depend on the way that observation patients are defined by a particular emergency department.
If this unit is intended to handle the real short-term patients such as those with a migraine headache or gastric disturbance who would otherwise be sent home with the family, then you probably need 600 to 800 patients per bed per year. However, if this unit will be handling more acute patients such as someone with a rule-out acute myocardial infarction, then you probably want to use 300 to 350 patients per bed per year. The other possibility is that this unit will be used not only by the emergency department but by private medical staff for their own 23-hour observation patients. In that case, the recommended statistic would be about 300 patients per bed per year.
Defining the type of unit is essential for success. You should also include the issue of medical staff oversight for these patients in your definition of the unit and staffing.
Susan M. Reese, RN, MBA, InfoScript, Inc, Palm Harbor, Fla, (813) 789-3263, infoscript@email.msn.com
*For a copy or more information, call ACEP at (800) 798-1822.
References
1. Graff L, Joseph T, Andelman R, Bahr R, DeHart D, Espinosa J, et al. American College of Emergency Physicians information paper: chest pain units in emergency departments-a report from the short-term observation services sections. Am J Cardiol 1995;76:1036-9.
2. Graff LG, Wolf S, Dinwoodie R, Buono D, Mucci D. Emergency physician workload: a time study. Ann Emerg Med 1993;22:1156-63.
3. Brillman J, Mathers-Dunbar L, Graff L, Joseph T, Leikin JB, Schultz C, et al, for the Short Term Observation Services Section of the American College of Emergency Physicians. Management of observations units. Ann Emerg Med 1995;25:823-30.

Zun, L (1990). "Observation units: Boom or bust for emergency medicine." Journal of Emergency Medicine 8: 485-90.

Observation units (OBS) are becoming a common addition to the emergency department. The diagnostic and socioeconomic categories of patients admitted to the OBS unit resemble those seen in the emergency department. There are many advantages and disadvantages in establishing such a unit. Although OBS units provide improved patient care, current difficulties in reimbursement may delay their widespread acceptance.

Zwicke, D, Donohue, J, et al. (1982). "Use of the emergency department observation unit in the treatment of acute asthma." Annals of Emergency Medicine 11: 77-83.

Because asthmatics have the highest utilization rate (11%) kin our emergency department (ED) observation unit (OU), we conducted a study correlating predictors of the need for OU therapy to initial disposition (ID) and final disposition (FD) using chart audit of treated asthmatics. Twenty-four clinical variables. (historical, physiological, laboratory, therapy response) were examined utilizing chi-square and Student's t tests. Forty-six asthmatics were treated during a four-month period in 1980. The ID breakdown was as follows: 1) home, 17; 2) OU, 23; and 3) admit, 6. Twenty-seven (59%) of the patients received treatment in the OU at some point in their attack (initial or rebound); 18 (39%) were definitively treated in the ED, and nine (20%) were admitted. The mean OU stay was 19 hours at a cost that was 34% of that incurred for a hospital admission. The FD differed from the ID in 14 of 46 (30%): 1) home, 12; 2) holding, observation, and short-term therapy, 18; and 3) admit, 16. Clinical variables correlating significantly with definitive therapy based on ID and FD were historical; symptoms greater than 24 hours, prior OU admissions, and prior hospitalizations. We conclude that the OU is appropriate, safe, and less expensive than admission; is not used for procrastination in decision making and decreases the hospitalization rate. Historical data correlated significantly with both ID and FD, while clinical variables were of little predictive value.