Observation units provide additional time to stabilize, treat, and develop rapport with an ED patient with a potentially serious condition. “This often can lead to increased patient satisfaction and, thus, reduced medicolegal risk,” observes Everett Stephens, MD, FAAEM, assistant clinical professor in the department of emergency medicine at the University of Louisville.
On the other hand, if observation units are used as a way to avoid admission (because of few available inpatient beds, financial reasons, or another reason), EDs may be exposed to additional legal risks.
“Many of our ED patients are complex — not just medically, but socially as well,” Stephens notes. “Some are facing social, geographic, or economic barriers to care that would be difficult to solve in an ED observation unit.”
A common example is a fluid-overloaded congestive heart failure patient. In addition to diuresis, the patient may need assistance in filling prescriptions due to mobility issues. Ensuring access to hypertensives and diuretics after discharge can significantly reduce the chance of a return visit. Other patients may face transportation difficulties in filling prescriptions or arriving at a follow-up medical appointment. “In many cases, social services steps in to assist with these challenges,” Stephens says.
Some ED outpatient units have access to an outpatient pharmacy, allowing access to a limited supply of antihypertensives and/or diuretics. Prior arrangements also can be made with a health service that, even after hours, can arrange a follow-up home visit to check on the patient. “Some argue that care in an ED observation unit is more compressed due to time constraints, prompting EPs to be more aggressive in treatment in order to have a successful outcome, such as being discharged home from the ED observation unit,” Stephens offers.
This can happen to patients with congestive heart failure who are fluid overloaded and require diuresis. After receiving a diuretic, the patient is monitored for urine output and improvement in the observation unit. “The temptation to be more aggressive in diuretic dosing could result in overaggressive diuresis and possible electrolyte disturbance,” Stephens warns. “Such a scenario could result in admission, an undesired event in this scenario.”
Another avenue of risk comes from the accumulation of detail generated in a lengthy patient visit and workup during the hours the patient is in observation status. For example, an ED provider could become overly focused on urine output. Once that patient is discharged, the provider might overlook an abnormal finding, such as a pulmonary nodule on chest X-ray that requires follow-up. That could lead to a malpractice claim of failure to diagnose.
“The challenge of tracking those findings and following clinical progress of the ED observation patient, all while managing the continued flow of the main ED, can permit oversights to occur,” Stephens says.
According to Stephens, successful observation units start with a well-defined patient cohort. “Carefully defining patients who would benefit from short, intensive care in an ED observation unit significantly increases the success of such a unit,” Stephens says.
The observation unit might be dedicated to respiratory illnesses, such as asthma, or cardiac processes, such as low-risk chest pain. “Drafting a functional set of criteria for admission to the unit helps the provider simplify the question that must be asked for every patient: Can I diurese/improve/rule out this patient in the time frame I have?’” Stephens asks.
Attempting to use the observation unit for complex patients with multifactorial disease processes makes it more difficult to successfully treat and discharge the patient in the narrow time frame. “It also places the EP in a position of managing multiple processes,” Stephens says.
Once the goal of an observation unit admit is defined, using templates for care can reduce risk. Such templates can involve scheduled labs, ECGs, imaging, diet, or education that is specifically targeted to reduce the risk of an ED observation unit. “Other medical disciplines can be involved to answer specific questions during the observation unit stay,” Stephens adds.
For example, social services can arrange a follow-up appointment with the patient’s primary care provider, provide education on diet for congestive heart failure patients, or explain asthma triggers for vulnerable patients.
“Following a predetermined care template can reduce risk,” Stephens says. “It can be very useful in standardizing care in patients admitted to the ED observation unit.”
Patient feedback is another important way to reduce risk in observation units. Recently, quite a few patients complained their pain or nausea was not treated effectively overnight at Mercy St. Vincent Medical Center in Toledo, OH. All the patients had been admitted from the ED observation unit. “At our institution, the ED writes the admitting orders for observation patients until the extended treatment unit team takes over in the morning,” explains David Ledrick, MD, director of observation medicine in the department of emergency medicine.
The ED created an order entry template in the electronic medical record specifically for this situation. For EPs, it is a reminder to address pain medications, diet, antiemetics, a sleep aid, venous thromboembolism prophylaxis, and to request appropriate consults. “It turned the admission process for the ED into a seven-click problem,” Ledrick says.
Observation units provide additional time to stabilize, treat, and develop rapport with an ED patient with a potentially serious condition. On the other hand, if observation units are used as a way to avoid admission, EDs may be exposed to additional legal risks.
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