Critical Path Network
Cutting the cost of observation: Create a hybrid unit’
If you want to keep your observation unit open, you’ll need to look at new strategies, explains Patricia Hall, RN, MSN, CEN, service leader for emergency services at Howard Young Health Care in Woodruff, WI. "The advent of APCs [ambulatory payment classifications] has made it difficult for observation units to be financially sound," she adds.
Although there is not currently a separate APC for observation, the Baltimore-based Centers for Medicare and Medicaid Services (CMS), formerly the Health Care Financing Administration, is expected to add a separate APC this year (For more details, go to the Society of Chest Pain Centers and Providers web site: www.scpcp.org, and click on "HCFA discussion on observation services.") Taking these steps can help cut your unit’s costs:
• Create a "hybrid" unit. The observation unit at William Beaumont Hospital in Royal Oak, MI, began as a hybrid "observation/scheduled-procedure" unit, says Michael A. Ross, MD, FACEP, director of the emergency observation unit and chest pain center. There was a problem with low census in the afternoon, he explains. "We would drop down to one or two patients, which is prohibitive from a nursing staffing standpoint." The eight-bed unit was separate from the emergency department (ED), so it wasn’t possible to decrease the nursing staff to a single nurse, adds Ross.
The solution was to allocate a set number of beds for observation patients and for scheduled-procedure patients. "Combining these two services enabled us to always have enough patients and maximize the use of that space," says Ross. As the observation service grew to 21 beds, the ED was able to maintain an adequate census of observation patients. "We found we no longer needed to be a hybrid unit. Over time, we weaned out the scheduled-procedure patients. We identified an inpatient location that could accommodate those patients and displaced them to that setting."
• Address staffing issues. Initially, the observation unit at William Beaumont had an all-nursing staff doing primary care with a case ratio of one nurse per four patients, says Pat Zientek, RN, the emergency center’s administrative nurse manager. But the current ratio is one nurse per five patients. "Increasing the ratio was important to decrease costs," she notes. "Two less-costly technicians were introduced per shift who were cross-trained for the unit secretary duties." The hybrid model allows you to staff with an average hourly patient/nurse ratio of 3.7 compared with the ratio of 2.5 for a regular observation unit, says Ross. "This reduces the cost by 0.13 nurse full-time equivalent per patient."1
• Avoid prolonged observation. Patients who "succeed" in observation will be discharged long before 24 hours, says Ross. "The concept of a 24-hour observation unit is antiquated," he argues. "Most patients define themselves by 18 hours. If they cannot go home by then, they have a very high probability of needing hospitalization." The ED observation unit requires that a disposition be made in 18 hours, unless the physician documents a clear and compelling reason to continue observing the patient, says Ross. (To see Physicians Order Sheet — EC Observation Unit, Observation Unit Chest Pain Tracking Sheet, and Patient Observation Record, click here.)
• Only observe appropriate patients. At Howard Young Health Care, the ED has become more selective with the patients placed on observation status, notes Hall. "If their condition appears to be more complicated with potential comorbidities, we are opting for admission. This seems to be exactly contrary to how we used to think. But honestly, they traditionally have ended up staying more than 23 hours anyway."
At William Beaumont’s ED, only specific conditions can be sent to the unit, based on specific inclusion/exclusion criteria. "The physician or nurse covering the unit is empowered to refuse a patient based on failure to meet these criteria," says Ross. (See "Which patients to observe," in this issue.) The ED uses written guidelines for 32 conditions, along with general principles on which patients are appropriate for observation, says Ross. "You must be managing only one specific acute problem, and it must be a problem of limited severity of illness that has a 70% to 80% probability of being discharged within 18 hours." The guidelines are converted into orders specific for 80% of the conditions sent to the unit. "This helps to maintain consistency," he says.
• Offer stress testing in close proximity. Previously, 25% of the patient volume was transported to the eighth floor for stress testing, which necessitated a 15-minute trip each way of "nonproductive time," says Zientek. "To decrease the time off the unit, we have installed a stress lab directly adjacent to the unit, with a one- or two-minute trip each way."
The satellite stress-testing lab reduced the length of stay of chest pain patients by a couple of hours, says Ross. "This allows the hospital to do stress testing on weekends for chest pain patients and get inpatients out sooner."
[For more information, contact:
• Michael A. Ross, MD, FACEP, Department of Emergency Medicine, William Beaumont Hospital, 3601 W. Thirteen Mile Road, Royal Oak, MI 48073-6769. Telephone: (248) 551-3080. Fax: (248) 551-2017. E-mail: [email protected].]
Reference
1. Ross MA, Naylor S, Compton S, et al. Maximizing use of the emergency department observation unit: A novel hybrid design. Ann Emerg Med 2001; 37:267-274.
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