Valorie Sweigart, DNP g, Samuel Shartar, RN, CEN Emory Healthcare

Valorie Sweigart, DNP g, Samuel Shartar, RN, CEN Emory Healthcare

Why build Principles of observational medicine ROI ED Hospital Clinical implications Define intended d use Open, closed or mixed use Impact on ED and hospital capacity

How to get started Research Site Visits Assemble multi-disciplinary team Submit proposal for funding Assemble protocols before opening unit Start small and add as you expand and or become more comfortable

18 Teaching Hospital ED Observation Unit (EDOU) Characteristics Average # ED Patients Observed 4,430 (± 3,478) Average # Beds in the EDOU 13.33 (± 74) 7.4) % of EDOUs Located Within / Adjacent to ED 82.3% % of CLOSED* Units (EM only) 93.8% Average ED Length of Stay for EDOU Patients Average EDOU Length of Stay 4.2 hours ((± 1.6 hrs) 15.7 hours (± 3.8 hrs) % Discharged From EDOU 82.4% (± 4.3%)

EDOU Utilization Characteristics Percent of ED census that is admitted (inpatient) t) - a surrogate of case mix acuity 22.9% (± 8.7%) Percent of ED census that is observed 7.2% (+ 6.7%) Number of EDOU beds per ED beds Number of EDOU beds per ED visits 4.25 EDOU beds / 1 ED bed 1 EDOU bed / 7,461 ED visits # EDOU patients / EDOU bed / day 1.14 patient / bed / day

Determining Size Planned use Formula: 4.25 observations per ED bed or 1.1414 patients/bed/day based on LOS Future growth Ross M et al. The impact of an ED observation bed on inpatient bed availability. Acad Emerg Med. May 2001;8:576.

Emory University CDU CDU 3. Appropriate Site of Service Entrance ED entrance

NFPA 101 Life Safety Codes Healthcare Guidelines Always defer to local code requirements Defines space definition, e.g. suite versus a room or floor Size Entrances and exits Windows

Medical Direction Collaborate with specialties Cardiology Neurology Radiology

Multi-system units EUH, EUHM, Grady Protocols Exclusion criteria i Performance Improvement

Single problem principle: Only one acute problem Well defined problem and plan Goal oriented: High probability of success within observation time frame Time limited 24 hours or less (ave. 15 hrs)

CHEST PAIN TRANSFER CRITERIA Risk of adverse event is low (Goldman algorithm see intro) Chest discomfort is potentially due to cardiac ischemia Acceptable vital signs Low intensity of service. No comorbidities requiring active nursing care. Examples: some patients with ESRD, poorly controlled diabetes, nursing home patients, COPD, AIDS, active cancer. CDU Patient selection is key!!! EXCLUSION CRITERIA Patient does not qualify on Goldman adverse event algorithm Chest pain is clearly not cardiac ischemia Previous CDU visit or PET scan negative within the last 5 years, unless known coronary disease (in that case consider cardiology consult re: cath) Private attending chooses hospital admission POTENTIAL INTERVENTIONS: Continue saline lock, O2, ST segment monitor, nitrates, no caffeine if potential persantine use Obtain 2 and 6 hour Troponin I levels (no 6-hour level if patient has already had negative provocative test). Provocative testing if initial and delta troponin are negative Perform EKG based on symptoms or ST monitor alert. Show EKG to CDU physician STAT Consult CDU physician if patient has change in condition for potential additional diagnostic testing, e.g. CT chest, trans-esophageal echocardiogram Consult CDU physician if technical problems with initially ordered provocative test (e.g. PET scanner down, etc.) DISPOSITION Home Acceptable VS Normal biomarkers and EKGs Negative provocative test New information indicating benign diagnosis (e.g. previous PET scan, negative workup elsewhere, community acquired pneumonia) Hospital Unstable VS Positive biomarker or EKG Positive provocative test CDU or personal physician discretion Serious alternative diagnosis, e.g. PE, aortic dissection

EEMR assists Practitioners to provide a clear Diagnosis

Incomplete chart Inadequately documented ED H/P, diagnosis, plan, and orders High severity of illness too sick High intensity of service too complicated Anticipated CDU length of stay - <4 hours or > 24 hours Patients for whom inpatient admission is clearly needed Age <15 years old Obstetric patients > 20 weeks pregnant with obstetric issue Patients at risk of self harm suicidal, acutely psychotic, or significantly intoxicated Patients with (1) an acute gait disturbance, (2) rule out hip fracture, or (3) back pain over >65 yr old

CMS Guidance Document Department of Health & Human Services (DHHS) Pub 100-04 Medicare Claims Processing Centers for Medicare & Medicaid Services (CMS) Executive Guidance Number 0183 Date: December 28, 2007 Web Site Address http://www.cms.hhs.gov/manuals/ Release planned: January 14, 2008 Facility Billing Provider billing Transmittal 1466 Date: February 22, 2008 Documentation requirements UR Processes: precertification of testing

Monthly Summary Report FY Summary Report CDU LOS by Hour of Arrival CP CDU LOS by Hour of Arrival CDU Arrival and Departure CDU Individual Diagnosis CDU LOS CDU LOS by Hr of Arrival Physician FY Summary Report CDU Monthly Census CDU Monthly Census

Monthly Summary Report Condition No. of encounters %ofcensus % Discharge ED ALOS (hrs) CDU ALOS Total ALOS CDU Admit/Discharge

Condition/Complaint Chest Pain Syncope Dehydration/Vomiting TIA Cellulitis No. of Encounters/%Discharge 140/80 % 16/88% 13/77% 12/100% 9/89% Total Visits 250

Budget Patient Satisfaction Press Gainey Follow up Phone Calls Staff/Physician Satisfaction