Is the integration of urgent, emergent, inpatient and
care of patients with
acute medical conditions.
By William Mostow, MD, FACEP
Observation medicine is going to fill a large and growing portion of hospital beds in the near future. Whether or not the government takes over healthcare, one way that costs will be cut will be to apply more, more specific and stricter clinical criteria in order to "qualify" a patient for an inpatient admission. This, of course, won't change the absolute number of patients that we just can't send home. The patients who aren’t admitted but who can’t be released will often end up placed in observation. In addition, if plans are implemented to deny payment for certain patients who return within 30 days of discharge, a good number of those folks who show up again within the 30 day window will end up in observation.
Until this spring, patients placed in observation at our hospital, Banner Del Webb Medical Center, were boarded with the general inpatient population, and were cared for by the same group of internists and hospitalists as the inpatients. This inevitably led to increased lengths of stay, since, even though the observation patients were less sick, the admitting doctors still ordered lots of consults, tests and scans with no urgency in getting them completed or in rounding and discharging.
The Banner hospital system recognized this problem. In March of this year, they tasked each of their hospitals to develop a separate observation unit along with a plan to get patients worked up and dispositioned more efficiently. I’ve long believed that running an observation unit was something that we could do well, so I invited myself to the observation development committee and pitched the ED providers as expert "Observationists." We were told that a separate 29 bed unit in the hospital had been set aside and, "Could you start next week?!" I persuaded the hospital administration to give us a few months to hire providers, giving us enough time to implement new processes.
The past 3 months have been spent developing the program, which is scheduled to open August 1st. We will have 24-hour midlevel coverage, with an ED physician supervising each case. The plan for now is for every patient to also have a consult from a specialist or hospitalist, depending upon the case. The midlevel provider will aggressively pursue whatever testing and clinical outcome decisions are needed for a timely disposition. He or she will also round frequently and do discharge call-backs.
I believe that if we do this right, we will have provided yet another powerful tool to support hospital clients, and we will ultimately be providing higher quality, lower cost care for our patients.
Dr. William Mostow, MD, FACEP is the ED Medical Director at Banner Del Webb Medical Center. He earned his Medical Degree from Northwestern University at the Feinberg School of Medicine.
Observation units WILL play a major role in the future of Hospitals and more importantly Emergency Medicine Providers. As Dr Mostow mentioned, the majority of EM providers consistently strive for rapid, efficient, quality care. Thus, observation units are a natural extension. And while most I work with, including myself will desire baby steps, I feel there is still room to expand locally and nationally. "Hybrid Observation Units." I am talking 6-48 hr ED Holds, ED MRI's, Scheduled Procedures, and Skilled Nursing Placement. This will only serve to maximize space, meet secondary service needs, and overall enhance ED satisfaction/thorough put.
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