Observation Medicine: Get Off to the Right Start
Observation units. Rapid treatment centers. Clinical decision units. They go by many names, and they are turning up in more and more EDs across the country, proving their worth in reducing the incidence of missed diagnoses, boosting patient satisfaction, and attracting managed care dollars.
The American College of Emergency Physicians’ section on observation medicine is the fastest growing section at the college and has seen steady and strong growth since its inception eight years ago, says Michael Ross, MD, FACEP, the section chairman and the director of the ED observation unit at William Beaumont Hospital in Royal Oak, MI.
"I think it’s a combination of, number one, people recognize that there is a large group of patients that they can no longer just automatically admit," says Ross, when asked about the section’s popularity. "Secondly, I think anybody can understand that, by embracing this practice pattern, there is a group of people you can rapidly and efficiently diagnose and avoid a hospital admission on, and, by doing so, you have a product that’s been shown to be much more cost-effective than the traditional approach. Third, an emergency physician’s clinical performance is improved in terms of diagnostic accuracy, treatment outcomes, and patient satisfaction with an ED observation unit."
Observations units come in many different shapes and sizes and have been around in one form or another for many years, says Louis Graff, MD, FACEP, assistant director of emergency medicine at New Britain Hospital in New Britain, CT, which has had an observation unit since 1967. Graff is also the author of the textbook Observational Medicine.
There are two broad categories of conditions that describe what observation units are used to treat, Graff says. The units, located in or adjacent to the ED, can be used in the critical evaluation of a diagnostic syndromeruling out a heart attack in a patient with chest pain, or eliminating appendicitis as the cause of a patient’s abdominal painor treat a chronic condition, such as an asthma exacerbation, dehydration, or congestive heart failure.
"A large percentage of patients present to the ED with a chief complaint that may indicate some serious disease, but after complete evaluation you can show that they don’t really have a serious disease," says Graff. "But, after the initial two or three hours in the ED, it isn’t that clear. If that’s all you’ve got, you’re probably going to put them in the hospital."
Similarly, someone with an asthma exacerbation treated in the ED may be better, but not well enough to be discharged home, says Ross. They can be managed in a bed in a unit for several hours, but still be discharged in less time than if they had been admitted.
The observation unit offers the physicians a "third pathway," by which they may avoid an unnecessary admission while at the same time ensuring that someone with a hidden, life-threatening condition is not sent home, says Graff.
Cost-effective treatment of chest pain/rule out MI
An good example of the benefits of the observation approach vs. the traditional method is chest pain, the number one chief complaint presenting to the ED.
The missed diagnosis of acute myocardial infarction (AMI) is the number one malpractice problem for emergency medicine, says Graff. It consumes an estimated 39% of the malpractice dollar spent, even though 60% of people presenting to the department with chest pain are admitted to the hospital.
Conversely, Graff notes, half of those admitted turn out to have no serious medical condition.
The problem is such that many EDs have set up chest pain units, observation units solely devoted to diagnosing the cause of chest pain and ruling out AMI, says Ross.
Using the observation approach, the units simply accelerate what happens in a 23-hour hospital admission, he says.
"You’re giving the same treatment under more closely monitored conditions," he says. "The physician who is accountable for the patient is always in the department, whereas the attending is in his office and can only come in for rounds once a day."
That means that there is usually only one time every 24 hours that a patient can be discharged or a change in treatment ordered in a traditional inpatient admission.
"It’s a system set up for serious disease, not rapid treatment," agrees Graff.
In the observation unit, the physician and nurses check on the patient every few hours.
The ROMIO study, published in the Journal of the American College of Cardiology, prospectively randomized chest pain patients to a either a hospital admit or observation in an ED’s chest pain unit, says Ross.
The patients’ average length of stay (LOS) was 12 hours in the observation unit vs. 24 hours in the hospital, says Ross. The cost was about $893 for the ED and $1349 for the hospital, he says.
Because the investigators were concerned that the observation patients were simply not undergoing as much study as was needed, they reevaluated the costs at 30 days, and the ED still came out on top, he says. "The unit was $898, and the inpatient [cost] was $1522."
Other recent studies have delineated new rapid diagnostic methods that allow for an even more rapid rule-out of AMI, says Michael Tomko, an emergency medical consultant with American Medical Consulting in Columbus, OH.
Use of continuous rhythm and ST-segment monitoring, along with serial cardiac biomarkers over an 8- to 12-hour period, allows physicians to rapidly rule out the presence of an AMI, even in patients presenting with atypical symptoms, says Tomko. Patients can then undergo stress-testing in the observation unit to determine the presence of underlying cardiac disease, all in less time than the standard hospital admission for evaluation of chest pain.
"It turns out to be that short-term observation is just an extension of an emergency physician’s role," says Tomko.
Marketing the unit to managed care
A multicenter study put together by ACEP’s observation section compiled information from eight medical centers that contributed their observation unit data, says Ross.
One of the most significant findings was that, if an ED had a chest pain observation unit as an option, the rate at which MIs were missed was about 0.3%, whereas in the traditional setting, the miss rates are closer to 4-5%, says Ross. "So, you get a tenfold decrease in the miss rate and about a 50% decrease in costs.
"If you are a third-party payer and somebody comes to you with this and says, Hey, the cost of the evaluation for the people who don’t have an MI is half as much, and that’s most of the people, and we miss fewer MIs,’ I think they will think that this is the way to go."
It is important, however, to plan your observation unit first, deciding what conditions you will observe, the staffing you will need, how it will be run, and what the cost will be before approaching payers, Ross emphasizes. (See related story on planning an observation unit.)
"Then, I’d say meet with the third-party payers, explain to them what you are planning on doing, see what requirements they have and come to some kind of decision," he says.
Though most payers he has negotiated with have been very receptive, some will not buy into the idea of observation medicine. "You have to decide what to do about that."
"Generally, they will often pay the facility, but they may vary on how they pay the professional. So you will have to meet with them on that."
Cost concerns
Though it appears that payers will benefit from having patients treated in observation units, the financial benefit to the hospital is less clear.
"For the hospital, it all depends," notes Graff. "You are having lower costs, but you are also getting lower reimbursements."
Given that costs vary, whether or not the unit is profitable for the hospital depends in large part on the deal with the insurance company, he says. "If the payer is reimbursing you for what you charge and you charge for a more expensive setting, then you are going to get more revenue."
For Medicaid, the hospital has DRGs, and other insurance companies may have different arrangements, Graff says. But, with more payers striking agreements ranging from true capitation, discounted FFS, or something in between, it may make more sense to go for an observation unit.
How broad the unit is and what conditions will be monitored will also impact the cost to the hospital, says Ross. "If you include pediatric patients, you are going to need nurses with pediatric training. If you are going to accept psychiatric patients, you are going to need a unit that allows actual visual monitoring of patients in case tries to hurt himself."
Some shared staffing between the ED and observation unit may be possible, depending on the peak busy hours of both departments.
At William Beaumont, the census in the ED is relatively low between 6-10 a.m., and that is when the census in the unit is the highest, Ross says. "With that consideration, there are some cross-staffing issues to consider."
Ross also acknowledges that some hospitals may be reluctant to let go of admissions.
"If your occupancy is low, then that’s a bigger problem," he states. "You have to ask yourself why it is low. Is it because your hospital isn’t competitive with local players? Are you more expensive? Third-party payers and managed care don’t want to use you. If that’s the case, this is part of the solution. But, it does often mean not admitting people who don’t need to be admitted."
Other advantages
When William Beaumont started its observation unit, the hospital had a problem with overcrowding. Patients were often kept waiting in the ED 8-10 hours, Ross says.
"By opening the unit and moving these patients who tied up the beds, we were able to leave those beds open for acute care patients," Ross says. "We saw a precipitous drop in the number of hours we diverted ambulances. Shortly after we opened, for the first time we had a month where we had zero ambulance diversion." The ED now does not divert ambulances at all.
A subsequent study performed by the department found that for every hour they diverted ambulances, one or two hospital admissions were lost.
At large academic centers, observation units are also becoming known for their contribution to clinical outcomes research, because they allow personnel to study the best approach to different conditions within a controlled environment, Ross says.
"Operationally, it’s a win-win for the ED," he says.
Reference
Gomez MA, et al. An emergency department-based protocol for rapidly ruling out myocardial ischemia reduces hospital time and expense (ROMIO). J Am Coll Cardiol 1996:28:25-28.
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