Which patients to observe
Indications for observation
— Focused goal of patient care. The physician’s notes should document the reason for observation. Generally, there should be only one specific problem that requires acute management. When multiple problems require management, the likelihood of admission is much higher. The three broad categories of observation are:
• diagnostic evaluation of a critical syndrome, such as chest pain, abdominal pain, etc.;
• short-term treatment of emergency condition, such as dehydration, asthma, renal colic, etc.;
• management of psychosocial needs, such as psychiatric, social worker, or continuing-care evaluation and management of selected problems.
— Limited intensity of service. This is judged clinically by the emergency center (EC) physician. Patients not meeting this criterion should be managed in the EC or admitted to the hospital (i.e., patients who require one-on-one nursing care).
— Limited severity of illness. This also is judged clinically by the EC physician (i.e., patients who are in extreme conditions or clinically unstable). Following low severity of illness/intensity of service (SI/IS) criteria enables the observation unit to be run effectively.
— Clinical condition appropriate for observation. In general, the observed condition should have a high (70% to 80%) probability of discharge within 18 hours. It should also be a condition for which initial discharge from the EC is not likely (i.e., an otherwise admitted condition). In addition to the list of "Observation Unit Clinical Conditions" included in this packet, the physician covering the unit may elect to observe other conditions if they meet the above criteria. This group will be monitored.
Contraindications to observation
— High severity of illness. Patients requiring more nursing care than can be offered in the unit. For example, patients with unstable vital signs, or unstable cardiac, pulmonary, or neurological condition. These patients should be managed in the initial EC treatment area until deemed to be stable for at least one hour.
— High intensity of service. Patients who are too unstable or ill to be observed. For example, difficult intoxicated or suicidal psychiatric patients, patients requiring frequent vital signs or treatments.
— Patients requiring admission. If inpatient admission is apparent in the initial treatment area, the patient should not enter for "observation." This type of patient is defined as a "hold" if they are simply waiting for a bed.
— Age less than 13 years old. These patients will be managed on the inpatient pediatric floor. Pediatric patients over the age of 13 who are transferred to the observation unit should not have significant underlying illness or comorbidities, which may require increased nursing care (high SI criteria).
— Obstetric patients more than 20 weeks pregnant. These patients should be managed on the Labor and Delivery (L&D) unit according to EC policy. If they have already been evaluated on L&D and sent back to EC, or cleared by their private obstetrician for management of a non-obstetrical condition (i.e., asthma), they may be managed in the observation unit.
— Anticipated observation length of stay less than three hours or more than 18 hours. The work of transferring, admitting, and discharging the patient is not efficiently spent if the patient stays for less than three hours. A regular audit of such admissions will be performed. Since most observed cases are discharged in 10 to 15 hours, cases that will clearly require more than 18 hours of care are unlikely to benefit from the unit.
— Nursing home placement. Patients must first have the feasibility of their observation placement plan approved by the continuing care or admissions transfer office nurse. This group often fails placement in a timely manner.
Source: Emergency Center Observation Unit Guidelines, William Beaumont Hospital, Royal Oak, MI.
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