Critical Path Network
Observation unit moves patients quickly through continuum
Patient satisfaction is high, length of stay is short
A 16-bed observation unit has increased bed capacity and improved patient flow at Ingham Regional Medical Center in Lansing, MI.
Before the unit opened at the end of January, the average length of stay for observation patients was 42 hours. After five months, the average observation length of stay dropped to 24 hours and 44 minutes, according to Sherry Lothschutz, RN, case manager for the observation unit.
An observation unit creates a win-win situation for the hospital and the patients, Dennis J. Perry, MD, MPH, medical director and director of case management and utilization review, points out.
Patients receive the care they need and are discharged home in a timely manner. Hospitals provide high-quality care efficiently and free up inpatient beds for patients who need an acute care stay, he says.
"Patient satisfaction is high on observation units. The majority of people who come to the hospital don't want to stay. They really appreciate it when we focus on getting them expedient care so that their problem is taken care of and they can go home," Perry says.
When observation patients are placed on the floor among patients admitted in inpatient status, the staff on the unit don't always realize that they need to be in and out in a short time and observation patients may end up having two- or three-day stays, he says.
Since reimbursement for observation patients is low, hospitals need to treat these patients efficiently to make sure they get the care they need and are discharged in a timely manner, he adds.
"We are looking closely at cost per patient vs. reimbursement. Even when the hospital gets paid for an observation stay, the reimbursement isn't very high and if the patient ends up having a two- to three-day stay, it costs the hospital money," Perry says.
The nurses on the observation unit know that their patients should be there only 24 hours and see that they get the tests and procedures they need as quickly as possible, he says.
For instance, the nurses in the observation unit don't wait for the laboratory results on their patients to be entered into the system; they mark down a time when the results should be expected, then call the laboratory to get the results. When the results are in, they call the doctor and ask him or her to review the results and write discharge orders if appropriate.
Before the unit opened, the case management team looked at the possibility of flagging observation patients or using different colored charts so that they would stand out when they were on other floors, but decided that an observation unit would be the most efficient way to provide care for patients who don't meet inpatient criteria, Perry reports.
The hospital tried assigning one case manager to review all the new admissions in the hospital for admission status but the system was cumbersome, he says.
"Just having an observation unit where we know the patients' status helps us move them more quickly," Perry says.
The hospital wants to move toward turning the observation unit into a clinical decision unit, he explains.
The 16-bed unit was created from part of the same-day surgery unit's space during the hospital's recent renovation and expansion project.
Two of the beds in the unit are dedicated to patients who are being transferred from other hospitals. They stay on the observation unit until a bed that meets their needs is available.
The unit also is used for "outpatients in a bed," patients who are hospitalized for a blood transfusion or other procedure, and those who need to stay longer than usual due to complications after same-day surgery.
The goal is to have patients in and out of the unit within 24 hours from admission to discharge, Lothschutz says.
Before the unit opened, the case management team compiled a list of targeted diagnoses that would likely be appropriate for the observation unit and educated the ED and bed board staff about them.
Among the diagnoses on the list are chest pain, abdominal pain, weakness, falls, dehydration, chronic obstructive pulmonary disease, or asthma exacerbation.
Most of the patients in the observation unit come through the ED. Direct admissions from physician offices may be admitted to the observation unit if they don't meet inpatient criteria.
As observation case manager, Lothschutz regularly assesses the charts of all patients in the unit to determine if they should remain in observation or be transferred to inpatient status.
She also works in the ED to determine if new admissions qualify for an inpatient bed or should be placed in the observation unit.
"I work closely with the bed board staff. They are the gatekeepers and the ones who place patients in a bed," Lothschutz says.
The weekend case management staff review patients admitted over the weekend if they have questionable diagnoses.
If a patient being admitted has a questionable diagnosis, the bed board staff contact Lothschutz to review the chart if she is in the hospital. If the patient's diagnosis doesn't meet inpatient criteria, Lothschutz calls the admitting physician and gets an order for observation.
When Lothschutz is not able to go to the ED, the nurse in the bed board department calls the physician for more information, and then reports to Lothschutz.
"We can always change admission status once someone gets to the observation unit, and I can determine if the patient needs to be moved to a full admission," she says.
The unit-based inpatient case managers make new admissions top priority every morning, Perry says.
The goal is to have patients with "soft" diagnoses admitted overnight reviewed before 9 a.m. to determine if they meet inpatient criteria, notes Lothschutz. "These patients have diagnoses like weakness or abdominal pain as an admitting diagnosis. The chart of someone with a heart attack or renal failure is not going to be reviewed immediately," she says.
Shifting inpatient to observation
When the unit case manager determines that a newly admitted patient doesn't meet inpatient criteria, the case manager calls the admitting physician and gets the patient status changed to observation. If the patient is likely to be in the hospital for several hours, the case manager alerts the bed board staff, who move the patient to the observation unit.
"If patients are likely to be discharged within a few hours, when the test results are back, we keep them where they are even though their status has been changed from a full admission to observation. As long as a case manager is involved, we can make a speedy discharge happen on the floor," Perry says.
A big board in the ED lists patients who are going to be admitted and those with admission orders. When she reviews cases in the ED, Lothschutz targets those charts to look for admission criteria.
"If I truly feel this is an observation patient, I can change the status on my own. If I have questions or am not sure, I consult with Dr. Perry," she says.
Lothschutz spends most of her time on the observation unit.
"The reality is I have 13-16 new patients to turn around every day. It's a whole new floor every morning," she says.
Lothschutz often takes care of discharge issues to make sure the patient is discharged from observation in a timely manner.
For instance, a patient from New Mexico with chronic obstructive pulmonary disease was placed in the observation unit when he visited the ED after his portable nebulizer broke and he ran out of oxygen and suffered an exacerbation of his condition. His equipment company didn't provide services in Michigan.
Lothschutz was able to get his equipment company to contract with a local oxygen company to fill his tanks and get him a nebulizer that plugged into the wall.
"I got everything processed and in the works so he could be in and out on the same day," she recalls.
If a patient comes from an adult foster care provider or a nursing home or is going to need home therapy, she makes sure everything is in place so the patient can be safely discharged from the observation unit.
Lothschutz works closely with the staff from the hospital's psychiatric unit and with social workers to facilitate consults for patients in the observation unit.
(For more information, contact Sherry Lothschutz at [email protected].)
A 16-bed observation unit has increased bed capacity and improved patient flow at Ingham Regional Medical Center in Lansing, MI.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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