This document discusses observation units in emergency departments. It begins with introducing observation units and their objectives, then discusses the rationale and design features of such units. Key points covered include having clearly defined policies and staffing, focusing on conditions that can be better managed over a longer period of time than a traditional emergency department visit allows. The document also outlines potential pros and cons, as well as evidence from studies showing observation units can provide faster, better, cheaper care for certain patients.

1. By : Saad Al Juma
R3

2.  Introduction
 Objectives
 Terminology
 Rationale
 Pros and Cons
 Mechanics
 Evidence
 conclusion

3.  risks, benefits, and requirements to develop
an ED observation unit or clinical decision
unit
 Recognize what is required to develop and
manage these units and programs
 Recognize the conditions that can be better
managed through these programs

4.  ED Observation Unit (EDOBS)
 Clinical Decision Unit (CDU)
 Rapid Diagnostic Unit (RDU)

5.  dedicated area within or directly adjacent to
the ED
 defined nursing and physician staffing.
 clearly defined written policies and
procedures for management of certain
medical problems within specific time limits.
It must be provided with equipment and
supplies appropriate for the kinds of patients
treated.

6.  dedicated area within or directly adjacent to
the ED
 defined nursing and physician staffing.
 clearly defined written policies and
procedures for management of certain
medical problems within specific time limits.
It must be provided with equipment and
supplies appropriate for the kinds of patients
treated.

7.  dedicated area within or directly adjacent to
the ED
 defined nursing and physician staffing.
 clearly defined written policies and
procedures for management of certain
medical problems within specific time limits.
It must be provided with equipment and
supplies appropriate for the kinds of patients
treated.

8.  Clearly defined admission criteria
 Well planned policies and procedures
 Clear chain of command
 Proper staffing, location, and equipment
 Carefully developed programs for quality
assurance and utilization review.

10.  What is the current context of Emergency
Medicine?
 Crowding / Increasing volume
 Saturated inpatient bed capacity/ Decreasing
access inpatient beds
 EMS diversion
 Problem with missed MIs, TIAs that return as a
stroke, or door-to balloon times.
 Increasing Length of Stay (LOS)

15.  No

16.  No

17.  Services are an extension of ED evaluation and
stabilization services beyond the traditional two-
to three-hour limit
 Benefit
 better definition of the patient's problem with
reduction in both costs and inappropriate
dispositions.
 Ultimate goal
 improve the quality of medical
 reducing inappropriate admissions and health care
costs.

18.  PROS :
 Allow additional time , extensive ED care before
discharge
 Enlarge the emergency physician's scope of
practice providing a longer period of time to
observe the effects of ED treatments and changes
in the patient's clinical condition;
 Add an educational experience for medical
students and residents that is not available in the
traditional outpatient setting;

19.  PROS : (Cont’)
 Reduce hospitalization and health care costs for some
patients , while allowing a more comfortable area for
patient care;
 Reduce the ED workload and improve patient flow;
 Reduce physicians' liability risks by allowing more
time to make difficult disposition decisions and, thus,
allow more certainty of diagnosis. While the patient is
still in an observation setting, outpatient
management strategies can be initiated and
examined to ensure appropriateness.

20.  CONS:
 Lack of clearly defined admission criteria, policies
and procedures, and direct lines of command may
prolong decision making and disposition
 Dumping Area
 An inadequately staffed facility will overload the
emergency staff

21.  CONS : (cont’)
 Carelessly organized and equipped unit will be
unacceptable to the patient because of commotion
and lack of privacy
 Patient care may suffer from the lack of continuity of
care as emergency physicians change from one shift
to the next if signout procedures are not followed.
 Lack of control/agreement over extent of work up
 sensitivity vs. specificity in the ED/ The Drive for
Specificity

22.  Stop Counting Visits and start counting
 “BED HOURS”
 We must get paid for what we do
 Time increases diagnostic accuracy
 EP can no longer be forced into ‘home vs
admit’ dichotomy

23.  EDOBS/Rationale
 Why is this maxim true?
 Because we know that certain patients will
benefit From
 FURTHER TESTING
 F URTHER TREATMENT
 More time will allow us to apply more specificity
to the decision yielding a benefit to the patient,
the institution and the professional staff

24.  What are the important design features?
 The unit should be contiguous to the Emergency
Department
▪ resuscitate any person who is admitted to the unit.
▪ cardiac monitoring
▪ IVAC capabilities
▪ inhalation therapy equipment, depending upon the unit.
 curtain vs. cubicles vs. Rooms
 real hospital beds
 some provision for food
 TV

26.  The number of beds range from four to 20
beds on the unit
 equal to 10% to 40% of the ED bed capacity

27.  Both Physicians and Nurses need to have
broad-based knowledge and experience in
the management of a wide variety of disease
processes

28.  The average staff is one registered nurse per
four to six patients in monitored beds and
one registered nurse per six to nine patients
in non-monitored beds
 Calculations of the physician staffing for the
amount of additional services will be
approximately one full-time equivalent for
every 2000 patients observed per year

29.  ancillary personnel:
 depend on the size and type of services
 Adequate secretarial and clerical staff

30.  Basic Rules
 Have to be able to walk
 Stable condition
 80% chance of going home
 Safety reasons
 Social/Financial reasons
 Pt. Satisfaction reasons
 Role of age

31.  a focused goal of the period of observation.
 Low probability but high mortality
▪ Chest pain
▪ RIF pain
 short-term therapy for an emergency conditions
▪ asthma
▪ dehydration

32.  The intensity of service needs should be
limited and consistent with the staffing
pattern of the unit

33.  the patient's severity of illness should be
limited
 one organ system
 must not preclude the expectation that the
patient will be discharged within established time
limits

34.  The patient should have a clinical condition
that is appropriate for observation

35. Diagnostic Evaluation Short Term Therapy Psychosocial Needs
Abdominal Pain Allergic reactions Alcohol intoxication
Vaginal bleeding, threatened Asthma Adjustment reaction
abortion
Chest pain (low probability of Acute exacerbation of chronic CHF Depression
myocardial infarction)
Syncope, negative initial evaluation Dehydration Psychosis
Flank pain, rule-out renal colic Hyperglycemia, mild to moderate Social disposition problems
GI bleed with initial evaluation Hypertensive urgencies
Chest trauma, normal initial Selected infections (e.g.,
evaluation and chest X-ray pyelonephritis)
Abdominal trauma, normal initial Seizure disorder requiring
evaluation and lavage anticonvulsant loading
Drug overdose, clinically stable Sickle cell pain crisis
Transfusion of blood

36.  Physician can not identify a goal of patient
care that can reasonably be expected to be
met within a time limit
 unstable vital signs
 myocardial infarction
 comatose condition

37.  Discrete end-point yields success
 When observation beds are permitted
 Written policies and procedures address the
 type of patient use
 the maximum time period of use
 the mechanism for providing appropriate
surveillance
 the type of nurse/patient system to be used

38.  A time limit is most important and should be
carefully monitored and strictly enforced.
 Many ED observation unit have time limits of
12 or 24 hours.

39.  An admission note
 the reason for the period of observation
 working diagnosis
 treatment plan
 clearly defining the end point for patient
disposition is mandatory.
 The ED personnel (physician, nurse, PA, etc.)
should examine the patient and write regular
progress notes.

41.  “OBS resets the attention clock” And
Reduces exposure to hazard by short LOS

46.  Good studies for
 Asthma
 Chest Pain
 Unstable Angina
 A Fib
 Same conclusion
 Faster, Better, Cheaper

49.  Marx: Rosen's Emergency Medicine, 7th ed.
 CHAPTER 196 – Observation Medicine and Clinical
Decision Units
 American College of Emergency Physicians,
www.acep.org
 National Library of Medicine–National
Institutes of Health, www.nlm.nih.gov