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Wright B, O'Shea AM, Glasgow JM, Ayyagari P, Vaughan-Sarrazin M. Patient, hospital, and local health system characteristics associated with the use of observation stays in veterans health administration hospitals, 2005 to 2012. Medicine (Baltimore) 2016; 95:e4802. [PMID: 27603391 PMCID: PMC5023914 DOI: 10.1097/md.0000000000004802] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Recent studies have documented that a significant increase in the use of observation stays along with extensive variation in patterns of use across hospitals.The objective of this longitudinal observational study was to examine the extent to which patient, hospital, and local health system characteristics explain variation in observation stay rates across Veterans Health Administration (VHA) hospitals.Our data came from years 2005 to 2012 of the nationwide VHA Medical SAS inpatient and enrollment files, American Hospital Association Survey, and Area Health Resource File. We used these data to estimate linear regression models of hospitals' observation stay rates as a function of hospital, patient, and local health system characteristics, while controlling for time trends and Veterans Integrated Service Network level fixed effects.We found that observation stay rates are inversely related to hospital bed size and that hospitals with a greater proportion of younger or rural patients have higher observation stay rates. Observation stay rates were nearly 15 percentage points higher in 2012 than 2005.Although we identify several characteristics associated with variation in VHA hospital observation stay rates, many factors remain unmeasured.
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Affiliation(s)
- Brad Wright
- Department of Health Management and Policy
- Public Policy Center, University of Iowa
- Correspondence: Brad Wright, Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, IA (e-mail: )
| | - Amy M.J. O'Shea
- Iowa City Veterans Affairs Healthcare System, The Comprehensive Access and Delivery Research and Evaluation Center (CADRE)
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Justin M. Glasgow
- Christiana Care Health System Department of Internal Medicine and Christiana Care Health System Value Institute, Wilmington, DE
| | | | - Mary Vaughan-Sarrazin
- Iowa City Veterans Affairs Healthcare System, The Comprehensive Access and Delivery Research and Evaluation Center (CADRE)
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA
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Das BB, Ronda J, Trent M. Pelvic inflammatory disease: improving awareness, prevention, and treatment. Infect Drug Resist 2016; 9:191-7. [PMID: 27578991 PMCID: PMC4998032 DOI: 10.2147/idr.s91260] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Pelvic inflammatory disease (PID) is a common disorder of the reproductive tract that is frequently misdiagnosed and inadequately treated. PID and its complications, such as infertility, ectopic pregnancy, and chronic pelvic pain, are preventable by screening asymptomatic patients for sexually transmitted infections (STIs) and promptly treating individuals with STIs and PID. Recent findings The rates of adverse outcomes in women with PID are high and disproportionately affect young minority women. There are key opportunities for prevention including improving provider adherence with national screening guidelines for STIs and PID treatment recommendations and patient medication adherence. Nearly half of all eligible women are not screened for STIs according to national quality standards, which may increase the risk of both acute and subclinical PID. Moreover, in clinical practice, providers poorly adhere to the Centers for Disease Control and Prevention recommendations for treatment of PID. Additionally, patients with PID struggle to adhere to the current management strategies in the outpatient setting. Conclusion Novel evidence-based clinical and public health interventions to further reduce the rates of PID and to improve outcomes for affected women are warranted. We propose potential cost-effective approaches that could be employed in real-world settings.
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Affiliation(s)
- Breanne B Das
- Division of General Pediatrics and Adolescent Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jocelyn Ronda
- Division of General Pediatrics and Adolescent Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maria Trent
- Division of General Pediatrics and Adolescent Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Intravenous Home Infusion Therapy Instituted From a 24-Hour Clinical Decision Unit For Patients With Cellulitis. Am J Emerg Med 2016; 34:1273-5. [PMID: 27182030 DOI: 10.1016/j.ajem.2016.04.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 04/13/2016] [Accepted: 04/13/2016] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The objective of the study is to evaluate whether patients with cellulitis can be safely discharged from a 24-hour clinical decision unit (CDU) with home infusion of intravenous (IV) antibiotics. METHODS Clinical decision unit patients receiving IV antibiotics for cellulitis were screened for enrollment in a home infusion therapy (HIT) program. Inclusion criteria were patient ability and willingness to administer IV antibiotics at home and insurers' approval of home infusion services. Patients were discharged home with a peripheral IV and care coordinated with a home infusion provider. RESULTS Of 213 patients with cellulitis transferred from the emergency department to the CDU over an 8-month study period, a total of 32 (15%) were discharged from the CDU with HIT. The average duration of home IV antibiotic treatment was 3.4 days. There were a total of 9 complications (28%), including IV infiltration (n = 5), allergic reactions (n = 2), nontolerance to the antibiotic (n = 1, this patient developed severe nausea and was switched to oral antibiotics after 2 days of HIT), and 1 patient required readmission for lack of clinical improvement. Among the 181 patients with cellulitis who did not receive HIT, 39 (22%) were hospitalized from the CDU, and 1 additional patient refused admission. CONCLUSIONS We avoided admission for 31 (97%) of 32 patients who were enrolled in HIT. Home infusion therapy has the potential to prevent hospitalizations, alleviate overcrowding of hospital beds, and decrease health care costs. Further studies are needed to determine the full impact of HIT on CDU patients with acute cellulitis.
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Wheatley M, Baugh C, Osborne A, Clark C, Shayne P, Ross M. A Model Longitudinal Observation Medicine Curriculum for an Emergency Medicine Residency. Acad Emerg Med 2016; 23:482-92. [PMID: 26806664 DOI: 10.1111/acem.12909] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 10/20/2015] [Accepted: 10/30/2015] [Indexed: 11/29/2022]
Abstract
The role of observation services for emergency department patients has increased in recent years. Driven by changing health care practices and evolving payer policies, many hospitals in the United States currently have or are developing an observation unit (OU) and emergency physicians are most often expected to manage patients in this setting. Yet, few residency programs dedicate a portion of their clinical curriculum to observation medicine. This knowledge set should be integrated into the core training curriculum of emergency physicians. Presented here is a model observation medicine longitudinal training curriculum, which can be integrated into an emergency medicine (EM) residency. It was developed by a consensus of content experts representing the observation medicine interest group and observation medicine section, respectively, from EM's two major specialty societies: the Society for Academic Emergency Medicine (SAEM) and the American College of Emergency Physicians (ACEP). The curriculum consists of didactic, clinical, and self-directed elements. It is longitudinal, with learning objectives for each year of training, focusing initially on the basic principles of observation medicine and appropriate observation patient selection; moving to the management of various observation appropriate conditions; and then incorporating further concepts of OU management, billing, and administration. This curriculum is flexible and designed to be used in both academic and community EM training programs within the United States. Additionally, scholarly opportunities, such as elective rotations and fellowship training, are explored.
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Affiliation(s)
| | | | - Anwar Osborne
- Department of Emergency Medicine; Emory University; Atlanta GA
| | - Carol Clark
- Department of Emergency Medicine; William Beaumont Health System; Troy MI
| | - Philip Shayne
- Department of Emergency Medicine; Emory University; Atlanta GA
| | - Michael Ross
- Department of Emergency Medicine; Emory University; Atlanta GA
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Beckmann M, Merollini K, Kumar S, Flenady V. Induction of labor using prostaglandin vaginal gel: cost analysis comparing early amniotomy with repeat prostaglandin gel. Eur J Obstet Gynecol Reprod Biol 2016; 199:96-101. [PMID: 26914400 DOI: 10.1016/j.ejogrb.2016.01.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Accepted: 01/29/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND In a randomized controlled trial of two policies for induction of labor (IOL) using Prostaglandin E2 (PGE2) vaginal gel, women who had an earlier amniotomy experienced a shorter IOL-to-birth time. OBJECTIVE To report the cost analysis of this trial and determine if there are differences in healthcare costs when an early amniotomy is performed as opposed to giving more PGE2 vaginal gel, for women undergoing IOL at term. STUDY DESIGN Following an evening dose of PGE2 vaginal gel, 245 women with live singleton pregnancies, ≥37+0 weeks, were randomized into an amniotomy or repeat-PGE2 group. Healthcare costs were a secondary outcome measure, sourced from hospital finance systems and included staff costs, equipment and consumables, pharmacy, pathology, hotel services and business overheads. A decision analytic model, specifically a Markov chain, was developed to further investigate costs, and a Monte Carlo simulation was performed to confirm the robustness of these findings. Mean and median costs and cost differences between the two groups are reported, from the hospital perspective. RESULTS The healthcare costs associated with IOL were available for all 245 trial participants. A 1000-patient cohort simulation demonstrated that performing an early amniotomy was associated with a cost-saving of $AUD289 ($AUD7094 vs $AUD7338) per woman induced, compared with administering more PGE2. Propagating the uncertainty through the model 10,000 times, early amniotomy was associated with a median cost savings of $AUD487 (IQR -$AUD573, +$AUD1498). CONCLUSIONS After an initial dose of PGE2 vaginal gel, a policy of administering more PGE2 when the Modified Bishop's score is <7 was associated with increased healthcare costs compared with a policy of performing an amniotomy, if technically possible. Length of stay was the main driver of healthcare costs.
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Affiliation(s)
- Michael Beckmann
- Mater Health Services, Department of Obstetrics and Gynecology, Brisbane, Queensland, Australia; Mater Research Institute - The University of Queensland, Brisbane, Queensland, Australia; School of Medicine - The University of Queensland, Brisbane, Australia.
| | - Katharina Merollini
- Institute of Health and Biomedical Innovation, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Sailesh Kumar
- Mater Research Institute - The University of Queensland, Brisbane, Queensland, Australia; Mater Health Services, Department of Obstetrics and Gynecology, Brisbane, Queensland, Australia; School of Medicine - The University of Queensland, Brisbane, Australia
| | - Vicki Flenady
- Mater Research Institute - The University of Queensland, Brisbane, Queensland, Australia
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Bellew SD, Bremer ML, Kopecky SL, Lohse CM, Munger TM, Robelia PM, Smars PA. Impact of an Emergency Department Observation Unit Management Algorithm for Atrial Fibrillation. J Am Heart Assoc 2016; 5:JAHA.115.002984. [PMID: 26857070 PMCID: PMC4802469 DOI: 10.1161/jaha.115.002984] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Atrial fibrillation (AF) is a common, growing, and costly medical condition. We aimed to evaluate the impact of a management algorithm for symptomatic AF that used an emergency department observation unit on hospital admission rates and patient outcomes. Methods and Results This retrospective cohort study compared 563 patients who presented consecutively in the year after implementation of the algorithm, from July 2013 through June 2014 (intervention group), with 627 patients in a historical cohort (preintervention group) who presented consecutively from July 2011 through June 2012. All patients who consented to have their records used for chart review were included if they had a primary final emergency department diagnosis of AF. We observed no significant differences in age, sex, vital signs, body mass index, or CHADS2 (congestive heart failure, hypertension, age, diabetes mellitus, and prior stroke or transient ischemic attack) score between the preintervention and intervention groups. The rate of inpatient admission was significantly lower in the intervention group (from 45% to 36%; P<0.001). The groups were not significantly different with regard to rates of return emergency department visits (19% versus 17%; P=0.48), hospitalization (18% versus 16%; P=0.22), or adverse events (2% versus 2%; P=0.95) within 30 days. Emergency department observation unit admissions were 40% (P<0.001) less costly than inpatient hospital admissions of ≤1 day's duration. Conclusions Implementation of an emergency department observation unit AF algorithm was associated with significantly decreased hospital admissions without increasing the rates of return emergency department visits, hospitalization, or adverse events within 30 days.
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Affiliation(s)
- Shawna D Bellew
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | - Merri L Bremer
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | - Christine M Lohse
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Thomas M Munger
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Paul M Robelia
- Department of Family Medicine, Mayo Clinic, Rochester, MN
| | - Peter A Smars
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
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Silverman RA, Schleicher MG, Valente CJ, Kim M, Romanenko Y, Schulman RC, Tiberio A, Greenblatt B, Rentala M, Salvador-Kelly AV, Kwon NS, Jornsay DL. Prevalence of undiagnosed dysglycemia in an emergency department observation unit. Diabetes Metab Res Rev 2016; 32:82-6. [PMID: 26104580 DOI: 10.1002/dmrr.2674] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 05/19/2015] [Accepted: 06/11/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND The proposed 2015 US Preventive Services Task Force guidelines recommend diabetes screening for individuals ≥45 years or demonstrating other risk factors for dysglycemia. Still, many patients with dysglycemia remain undiagnosed, and opportunities for early intervention are lost. METHODS To test novel approaches for diagnosis using the haemoglobin A1c (HbA1c ) test, we screened adult patients who were admitted to an observation unit from the emergency department with no known history of pre-diabetes or diabetes. RESULTS Of 256 subjects, 9% were newly diagnosed with diabetes and 52% were newly diagnosed with pre-diabetes. Of those aged 18-29 years, 33% were newly diagnosed with dysglycemia, while 55% of those aged 30-44 years and 70% of those aged ≥45 years were newly diagnosed with dysglycemia. CONCLUSIONS Our results suggest that regardless of age, a large proportion of patients in the emergency department observation unit have undiagnosed dysglycemia, an important finding given the large number of observation admissions. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Robert A Silverman
- Department of Emergency Medicine, North Shore-LIJ Health System, New Hyde Park, NY, USA
- Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA
- The Feinstein Institute for Medical Research, North Shore-LIJ Health System, Manhasset, NY, USA
| | | | - Christopher J Valente
- Department of Emergency Medicine, North Shore-LIJ Health System, New Hyde Park, NY, USA
| | - Mark Kim
- Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA
| | | | - Rifka C Schulman
- Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA
- Division of Endocrinology, Department of Medicine, North Shore-LIJ Health System, New Hyde Park, NY, USA
| | - Allison Tiberio
- Department of Emergency Medicine, North Shore-LIJ Health System, New Hyde Park, NY, USA
| | - Benjamin Greenblatt
- Department of Emergency Medicine, North Shore-LIJ Health System, New Hyde Park, NY, USA
- Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA
| | - Manju Rentala
- Department of Emergency Medicine, North Shore-LIJ Health System, New Hyde Park, NY, USA
- Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA
| | - Annabella V Salvador-Kelly
- Department of Emergency Medicine, North Shore-LIJ Health System, New Hyde Park, NY, USA
- Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA
| | - Nancy S Kwon
- Department of Emergency Medicine, North Shore-LIJ Health System, New Hyde Park, NY, USA
- Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA
| | - Donna L Jornsay
- Division of Endocrinology, Department of Medicine, North Shore-LIJ Health System, New Hyde Park, NY, USA
- Department of Nursing Education, Long Island Jewish Medical Center, New Hyde Park, NY, USA
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Capp R, Sun B, Boatright D, Gross C. The impact of emergency department observation units on United States emergency department admission rates. J Hosp Med 2015; 10:738-42. [PMID: 26503082 DOI: 10.1002/jhm.2447] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 07/09/2015] [Accepted: 07/22/2015] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Prior studies suggesting that the presence of emergency department (ED) observation units decrease overall ED hospital admissions have been either single-center studies or based on model simulations. The objective of this preliminary national study is to determine if the presence of ED observation units is associated with hospitals having lower ED admission rates. METHODS We conducted a retrospective cross-sectional analysis using the 2010 National Hospital Ambulatory Care Survey and estimated ED risk-standardized hospital admission rates (RSHAR) for each center. The following were excluded from the study: ages <18 years, leaving prior to completion of ED visit, died in the ED, transferred to another facility, and missing disposition. Hospitals with less than 30 ED visits or unknown observation unit status were also excluded. We used linear regression analysis to determine the association between ED RSHAR and presence of observation units. RESULTS There were 24,232 ED visits in 315 hospitals in the United States. Of these, 82 (20.6%) hospitals had an ED observation unit. The average ED risk-standardized hospital admission rates for hospitals with observation units and without hospital observation units were 13.7% (95% confidence interval [CI]: 11.3-16.0) and 16.0% (95% CI: 14.1-17.7), respectively. The difference of 2.3% was not statistically significant. CONCLUSIONS In this preliminary study, we did not find an association between the presence of observation units and ED hospital admission rates. Further studies with larger sample sizes should be performed to further evaluate the impact of ED observation units on ED hospital admission rates.
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Affiliation(s)
- Roberta Capp
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Benjamin Sun
- Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon
| | - Dowin Boatright
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado
| | - Cary Gross
- Robert Wood Johnson Foundation Clinical Scholars Program, Section of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
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Fahimi J, Hsia RY. Emergency department observation units: Less than we bargained for? J Hosp Med 2015; 10:762-3. [PMID: 26503083 DOI: 10.1002/jhm.2475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 08/07/2015] [Indexed: 11/07/2022]
Affiliation(s)
- Jahan Fahimi
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Institute of Health Policy, University of California, San Francisco, San Francisco, California
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Rathlev NK, Bryson C, Samra P, Garreffi L, Li H, Geld B, Wu RY, Visintainer P. Reducing patient placement errors in emergency department admissions: right patient, right bed. West J Emerg Med 2015; 15:687-92. [PMID: 25247044 PMCID: PMC4162730 DOI: 10.5811/westjem.2014.5.21663] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 05/04/2014] [Accepted: 05/27/2014] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Because lack of inpatient capacity is associated with emergency department (ED) crowding, more efficient bed management could potentially alleviate this problem. Our goal was to assess the impact of involving a patient placement manager (PPM) early in the decision to hospitalize ED patients. The PPMs are clinically experienced registered nurses trained in the institution-specific criteria for correct unit and bed placement. METHODS We conducted two pilot studies that included all patients who were admitted to the adult hospital medicine service: 1) 10/24 to 11/22/2010 (30 days); and 2) 5/24 to 7/4/2011 (42 days). Each pilot study consisted of a baseline control period and a subsequent study period of equal duration. In each pilot we measured: 1) the number of "lateral transfers" or assignment errors in patient placement, 2) median length of stay (LOS) for "all" and "admitted" patients and 3) inpatient occupancy. In pilot 2, we added as a measure code 44s, i.e. status change from inpatient to observation after patients are admitted, and also equipped all emergency physicians with portable phones in order to improve the efficiency of the process. RESULTS In pilot 1, the number of "lateral transfers" (incorrect patient placement assignments) during the control period was 79 of the 854 admissions (9.3%) versus 27 of 807 admissions (3.3%) during the study period (P<0.001). We found no statistically significant differences in inpatient occupancy or ED LOS for "all" or for "admitted" patients. In pilot 2, the number of "lateral transfers" was 120 of 1,253 (9.6%) admissions in the control period and 42 of 1,229 (3.4%) admissions in the study period (P<0.001). We found a 49-minute (352 vs. 401 minutes) decrease in median LOS for "admitted" ED patients during the study period compared with the control period (P=0.04). The code 44 rates, median LOS for "all" patients and inpatient occupancy did not change. CONCLUSION Inclusion of the PPM in a three-way handoff conversation between emergency physicians and hospitalist providers significantly decreased the number of "lateral transfers." Moreover, adding status determination and portable phones for emergency physicians improved the efficiency of the process and was associated with a 49 (12%) minute decrease in LOS for admitted patients.
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Affiliation(s)
| | | | - Patty Samra
- Baystate Medical Center, Springfield, Massachusetts
| | | | - Haiping Li
- Baystate Medical Center, Springfield, Massachusetts
| | - Bonnie Geld
- Baystate Medical Center, Springfield, Massachusetts
| | - Roger Y Wu
- Rhode Island Hospital, Department of Emergency Medicine, Providence, Rhode Island
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Wright B, O’Shea AMJ, Ayyagari P, Ugwi PG, Kaboli P, Vaughan Sarrazin M. Observation Rates At Veterans’ Hospitals More Than Doubled During 2005–13, Similar To Medicare Trends. Health Aff (Millwood) 2015; 34:1730-7. [DOI: 10.1377/hlthaff.2014.1474] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Brad Wright
- Brad Wright ( ) is an assistant professor in the Department of Health Management and Policy and at the Public Policy Center, both at the University of Iowa, in Iowa City
| | - Amy M. J. O’Shea
- Amy M. J. O’Shea is a research health specialist at the Iowa City Veterans Affairs Healthcare System and a research associate in the Department of Internal Medicine, Carver College of Medicine, at the University of Iowa
| | - Padmaja Ayyagari
- Padmaja Ayyagari is an assistant professor in the Department of Health Management and Policy at the University of Iowa
| | - Patience G. Ugwi
- Patience G. Ugwi is a doctoral student in the Department of Health Management and Policy at the University of Iowa
| | - Peter Kaboli
- Peter Kaboli is an investigator at the Iowa City Veterans Affairs Healthcare System and a professor in the Department of Internal Medicine, Carver College of Medicine, at the University of Iowa
| | - Mary Vaughan Sarrazin
- Mary Vaughan Sarrazin is an investigator at the Iowa City Veterans Affairs Healthcare System and an associate professor in the Department of Internal Medicine, Carver College of Medicine, at the University of Iowa
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Cafardi SG, Pines JM, Deb P, Powers CA, Shrank WH. Increased observation services in Medicare beneficiaries with chest pain. Am J Emerg Med 2015; 34:16-9. [PMID: 26490388 DOI: 10.1016/j.ajem.2015.08.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 08/26/2015] [Accepted: 08/31/2015] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION We examined trends in the use of observation services and the relationship between index service type (observation services, emergency department [ED] visits, inpatient stays) and both clinical outcomes and Medicare payments. METHODS We created a yearly cohort panel of Medicare beneficiaries with chest pain. We evaluate the relationships between index service type and 30-day clinical outcomes using a multinomial logit model and between index service type and Medicare payments using generalized linear models. RESULTS In 2009, 24% of patients with chest pain received observation services; this rose to 29% in 2011. Conversely, 20% were treated as hospital inpatients in 2009; this fell to 16% in 2011. In the adjusted analysis, the risk of 30-day return to the hospital was 7% less (95% confidence interval, 5%-8%) for those receiving observation services as compared with inpatients. Average Medicare payments ranged from $3032 for beneficiaries initially treated in the ED to $3885 for those initially treated in observation to $6545 for those initially treated as inpatients. DISCUSSION Patients treated in observation are less likely than those treated in the ED or as inpatients to have an adverse event within 30 days. Adjusted Medicare payments, including the index stay and the subsequent 30 days, were substantially less for those treated in observation as compared with those treated as inpatients, but more than for those treated and released from the ED. Higher rates of observation service use do not appear to be negatively affecting patient outcomes and may lower costs relative to inpatient treatment.
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Affiliation(s)
- Susannah G Cafardi
- Research and Rapid-Cycle Evaluation Group, Centers for Medicare & Medicaid Innovation, Centers for Medicare & Medicaid Services, Baltimore, MD.
| | - Jesse M Pines
- Department of Emergency Medicine, The George Washington University, Washington, DC; Department of Health Policy, The George Washington University, Washington, DC
| | - Partha Deb
- Department of Economics, Hunter College, New York, NY; Centers for Medicare & Medicaid Services, Center for Medicare & Medicaid Innovation, Baltimore, MD
| | - Christopher A Powers
- Office of Information Products and Data Analytics, Center for Medicare & Medicaid Services, Baltimore, MD
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Shanley LA, Hronek C, Hall M, Alpern ER, Fieldston ES, Hain PD, Shah SS, Macy ML. Structure and Function of Observation Units in Children's Hospitals: A Mixed-Methods Study. Acad Pediatr 2015; 15:518-25. [PMID: 26344718 DOI: 10.1016/j.acap.2014.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 12/08/2014] [Accepted: 12/10/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Observation unit (OU) use has been promoted recently to decrease resource utilization and costs for select patients, but little is known about the operations of pediatric OUs. This study aimed to characterize the infrastructure and function of OUs within freestanding children's hospitals and to compare characteristics between hospitals with and without OUs. METHODS All 43 freestanding children's hospitals that submit data to the Pediatric Health Information System were contacted in 2013 to identify OUs that admitted unscheduled patients from their emergency department (ED) in 2011. Semistructured interviews were conducted with representatives at hospitals with these OUs. Characteristics of hospitals with and without OUs were compared. RESULTS Fourteen (33%) of 43 hospitals had an OU during 2011. Hospitals with OUs had more beds and more annual ED visits compared to those without OUs. Most OUs (65%) were located in the ED and had <12 beds (65%). Staffing models and patient populations differed between OUs. Nearly 60% were hybrid OUs, providing scheduled services. OUs lacked uniform outcome measures. Themes included: admissions were intuition based, certain patients were not well suited for OUs, OUs had rapid-turnover cultures, and the designation of observation status was arbitrary. Challenges included patient discontent with copayments and payer-driven utilization reviews. CONCLUSIONS OUs were located in higher volume hospitals and varied by location, size, and staffing. Most functioned as hybrid OUs. OUs based admissions on intuition, had staffing cultures centered on rapid turnover of patient care, lacked consistent outcome measures, and faced challenges regarding utilization review and patient copayments.
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Affiliation(s)
- Leticia A Shanley
- Department of Pediatrics, Children's Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, Tex.
| | - Carla Hronek
- Children's Hospital Association, Overland Park, Kans
| | - Matthew Hall
- Children's Hospital Association, Overland Park, Kans
| | - Elizabeth R Alpern
- Department of Pediatrics, Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Evan S Fieldston
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Paul D Hain
- Department of Pediatrics, Children's Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Samir S Shah
- Department of Pediatrics, Cincinnati Children's Hospital and Medical Center, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Michelle L Macy
- Departments of Emergency Medicine and Pediatrics, Child Health Evaluation and Research (CHEAR) Unit, University of Michigan Medical School, Ann Arbor, Mich
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Galipeau J, Pussegoda K, Stevens A, Brehaut JC, Curran J, Forster AJ, Tierney M, Kwok ESH, Worthington JR, Campbell SG, Moher D. Effectiveness and safety of short-stay units in the emergency department: a systematic review. Acad Emerg Med 2015. [PMID: 26201285 DOI: 10.1111/acem.12730] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Overcrowding is a serious and ongoing challenge in Canadian hospital emergency departments (EDs) that has been shown to have negative consequences for patient outcomes. The American College of Emergency Physicians recommends observation/short-stay units as a possible solution to alleviate this problem. However, the most recent systematic review assessing short-stay units shows that there is limited synthesized evidence to support this recommendation; it is over a decade old and has important methodologic limitations. The aim of this study was to conduct a more methodologically rigorous systematic review to update the evidence on the effectiveness and safety of short-stay units, compared with usual care, on hospital and patient outcomes. METHODS A literature search was conducted using MEDLINE, the Cochrane Library, Embase, ABI/INFOM, and EconLit databases and gray literature sources. Randomized controlled trials of ED short-stay units (stay of 72 hours or less) were compared with usual care (i.e., not provided in a short-stay unit), for adult patients. Risk-of-bias assessments were conducted. Important decision-making (gradable) outcomes were patient outcomes, quality of care, utilization of and access to services, resource use, health system-related outcomes, economic outcomes, and adverse events. RESULTS Ten reports of five studies were included, all of which compared short-stay units with inpatient care. Studies had small sample sizes and were collectively at a moderate risk of bias. Most outcomes were only reported by one study and the remaining outcomes were reported by two to four studies. No deaths were reported. Three of the four included studies reporting length of stay found a significant reduction among short-stay unit patients, and one of the two studies reporting readmission rates found a significantly lower rate for short-stay unit patients. All four economic evaluations indicated that short-stay units were a cost-saving intervention compared to inpatient care from both hospital and health care system perspectives. Results were mixed for outcomes related to quality of care and patient satisfaction. CONCLUSIONS Insufficient evidence exists to make conclusions regarding the effectiveness and safety of short-stay units, compared with inpatient care.
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Affiliation(s)
- James Galipeau
- Ottawa Hospital Research Institute; Ottawa Ontario Canada
| | | | | | - Jamie C. Brehaut
- The Faculty of Medicine; University of Ottawa; Ottawa Ontario Canada
| | | | - Alan J. Forster
- Ottawa Hospital Research Institute; Ottawa Ontario Canada
- The Faculty of Medicine; University of Ottawa; Ottawa Ontario Canada
| | | | - Edmund S. H. Kwok
- The Faculty of Medicine; University of Ottawa; Ottawa Ontario Canada
- The Ottawa Hospital; Ottawa Ontario Canada
| | | | | | - David Moher
- Ottawa Hospital Research Institute; Ottawa Ontario Canada
- The Faculty of Medicine; University of Ottawa; Ottawa Ontario Canada
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Baugh CW, Liang LJ, Probst MA, Sun BC. National cost savings from observation unit management of syncope. Acad Emerg Med 2015. [PMID: 26204970 DOI: 10.1111/acem.12720] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Syncope is a frequent emergency department (ED) presenting complaint and results in a disproportionate rate of hospitalization with variable management strategies. The objective was to estimate the annual national cost savings, reduction in inpatient hospitalizations, and reduction in hospital bed hours from implementation of protocolized care in an observation unit. METHODS We created a Monte Carlo simulation by building a model that reflects current clinical practice in the United States and uses inputs gathered from the most recent available peer-reviewed literature and national survey data. ED visit volume was adjusted to reflect observation unit availability and the portion of observation visits requiring subsequent inpatient care. A recent multicenter randomized controlled study informed the cost savings and length of stay reduction per observation unit visit model inputs. The study population included patients aged 50 years and older with syncope deemed at intermediate risk for serious 30-day cardiovascular outcomes. RESULTS The mean (±SD) annual cost savings was estimated to be $108 million (±$89 million) from avoiding 235,000 (±13,900) inpatient admissions, resulting in 4,297,000 (±1,242,000) fewer hospital bed hours. CONCLUSIONS The potential national cost savings for managing selected patients with syncope in a dedicated observation unit is substantial. Syncope is one of many conditions suitable for care in an observation unit as an alternative to an inpatient setting. As pressure to decrease hospital length of stay and bill short-stay hospitalizations as observation increases, syncope illustrates the value of observation unit care.
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Affiliation(s)
| | - Li-Jung Liang
- Division of General Internal Medicine and Health Services Research; David Geffen School of Medicine at UCLA; Los Angeles CA
| | - Marc A. Probst
- Department of Emergency Medicine; Ichan School of Medicine at Mount Sinai; New York NY
| | - Benjamin C. Sun
- Department of Emergency Medicine; Oregon Health & Science University; Portland OR
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Prabhakar AM, Misono AS, Harvey HB, Yun BJ, Saini S, Oklu R. Imaging utilization from the ED: no difference between observation and admitted patients. Am J Emerg Med 2015; 33:1076-9. [PMID: 25957145 DOI: 10.1016/j.ajem.2015.04.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 04/11/2015] [Accepted: 04/15/2015] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES This study aims to determine the use of diagnostic imaging in emergency department (ED) observation units, particularly relative to inpatients admitted from the ED. STUDY DESIGN Retrospective, descriptive analysis. METHODS Our database of ED patients was retrospectively reviewed to identify patients managed in the observation unit or admitted to inpatient services. In February 2014, we randomly selected 105 ED observation patients and 108 patients admitted to inpatient services from the ED. Electronic medical records were reviewed to assess diagnosis as well as type and quantity of imaging tests obtained. RESULTS Eighty (76%) ED observation patients underwent imaging tests (radiographs, 39%; computed tomography, 25%; magnetic resonance imaging (MRI), 24%; ultrasound, 8%; other, 4%); 85 inpatients (79%) underwent imaging tests while in the ED (radiographs, 52%; computed tomography, 30%; MRI, 8%; ultrasound, 9%; other, 1%). There was no significant difference in overall imaging use between ED observation patients and inpatients, but ED observation patients were more likely to undergo MRI (P=.0243). The most common presenting diagnoses to the ED observation unit were neurologic complaints (25%), abdominal pain (17%), and cardiac symptoms (16%). CONCLUSION There is no difference in the overall use of imaging in patients transferred to the ED observation unit vs those directly admitted from the ED. However, because ED observation unit patients tend to be accountable for a higher proportion of their health care bill, the impact of imaging in these patients is likely substantive.
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Affiliation(s)
- Anand M Prabhakar
- Division of Cardiovascular Imaging and Emergency Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Alexander S Misono
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - H Benjamin Harvey
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Brian J Yun
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Sanjay Saini
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Rahmi Oklu
- Division of Vascular Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Abstract
BACKGROUND An upward trend in the number of hospital emergency department (ED) visits frequently results in ED overcrowding. The concept of the emergency department observation unit (EDOU) was introduced to allow patients to transfer out of the ED and remain under observation for up to 24 hours before making a decision regarding the appropriate disposition. No study has yet been completed to describe physical therapist practice in the EDOU. OBJECTIVE The objectives of this study were: (1) to describe patient demographics, physical therapist management and utilization, and discharge dispositions of patients receiving physical therapy in the EDOU and (2) to describe these variables according to the most frequently occurring diagnostic groups. DESIGN This was a descriptive study of patients who received physical therapist services in the EDOU of Massachusetts General Hospital during the months of March, May, and August 2010. METHODS Data from 151 medical records of patients who received physical therapist services in the EDOU were extracted. Variables consisted of patient characteristics, medical and physical therapist diagnoses, and physical therapist management and utilization derived from billing data. Descriptive statistics were used to analyze data. RESULTS The leading EDOU medical diagnoses of individuals receiving physical therapist services included people with falls without fracture (n=30), back pain (n=27), falls with fracture (n=22), and dizziness (n=22). There were significant differences in discharge disposition, age, and total physical therapy time among groups. LIMITATIONS This was a retrospective study, so there was no ability to control how data were recorded. CONCLUSIONS This study provides information on common patient groups seen in the EDOU, physical therapist service utilization, and discharge disposition that may guide facilities in anticipated staffing needs associated with providing physical therapist services in the EDOU.
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Ribeiro S, Petrini C, Marino L, Brandao-Neto R. Implementation of a horizontal intensive care team can impact efficiency in an emergency observation unit in Brazil. Crit Care 2015. [PMCID: PMC4472277 DOI: 10.1186/cc14600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Designing a Data-Driven Decision Support Tool for Nurse Scheduling in the Emergency Department: A Case Study of a Southern New Jersey Emergency Department. J Emerg Nurs 2015; 41:30-5. [DOI: 10.1016/j.jen.2014.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 07/09/2014] [Accepted: 07/19/2014] [Indexed: 11/21/2022]
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Jules A, Grijalva CG, Zhu Y, Talbot HK, Williams JV, Poehling KA, Chaves SS, Edwards KM, Schaffner W, Shay DK, Griffin MR. Influenza-related hospitalization and ED visits in children less than 5 years: 2000-2011. Pediatrics 2015; 135:e66-74. [PMID: 25489015 PMCID: PMC4279064 DOI: 10.1542/peds.2014-1168] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In the United States, recommendations for annual influenza vaccination gradually expanded from 2004 to 2008, to include all children aged ≥6 months. The effects of these policies on vaccine uptake and influenza-associated health care encounters are unclear. The objectives of the study were to examine the annual incidence of influenza-related health care encounters and vaccine uptake among children age 6 to 59 months from 2000-2001 through 2010-2011 in Davidson County, TN. METHODS We estimated the proportion of laboratory-confirmed influenza-related hospitalizations and emergency department (ED) visits by enrolling and testing children with acute respiratory illness or fever. We estimated influenza-related health care encounters by multiplying these proportions by the number of acute respiratory illness/fever hospitalizations and ED visits for county residents. We assessed temporal trends in vaccination coverage, and influenza-associated hospitalizations and ED visit rates. RESULTS The proportion of fully vaccinated children increased from 6% in 2000-2001 to 38% in 2010-2011 (P < .05). Influenza-related hospitalizations ranged from 1.9 to 16.0 per 10 000 children (median 4.5) per year. Influenza-related ED visits ranged from 89 to 620 per 10 000 children (median 143) per year. Significant decreases in hospitalizations (P < .05) and increases in ED visits (P < .05) over time were not clearly related to vaccination trends. Influenza-related encounters were greater when influenza A(H3N2) circulated than during other years with median rates of 8.2 vs 3.2 hospitalizations and 307 vs 143 ED visits per 10 000 children, respectively. CONCLUSIONS Influenza vaccination increased over time; however, the proportion of fully vaccinated children remained <50%. Influenza was associated with a substantial illness burden particularly when influenza A(H3N2) predominated.
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Affiliation(s)
| | | | | | | | - John V. Williams
- Pediatrics, and,Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Katherine A. Poehling
- Departments of Pediatrics and Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina; and
| | - Sandra S. Chaves
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - David K. Shay
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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Schultz H, Qvist N, Mogensen CB, Pedersen BD. Perspectives of patients with acute abdominal pain in an emergency department observation unit and a surgical assessment unit: a prospective comparative study. J Clin Nurs 2014; 23:3218-3229. [PMID: 25453126 DOI: 10.1111/jocn.12570] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2024]
Abstract
AIMS AND OBJECTIVES To investigate the patient perspective when admitted with acute abdominal pain to an emergency department observation unit compared with the perspective when admitted to a surgical assessment unit. BACKGROUND An increase in emergency department observation units has led to more short-term admissions and has changed the patient journey from admission to specialised wards staffed by specialist nurses to stays in units staffed by emergency nurses. DESIGN A comparative field study. METHODS The study included 21 patients. Participant observation and qualitative interviews were performed, and the analyses were phenomenological-hermeneutic. RESULTS Emergency department observation unit patients had extensive interaction with health professionals, which could create distrust. Surgical assessment unit patients experienced lack of interaction with nurses, also creating distrust. Emergency department observation unit patients had more encounters with fellow patients than the surgical assessment unit patients did, which was beneficial when needing assistance, but disturbing when needing rest. The limited contact with other patients in the surgical assessment unit revealed the opposite effect. In both units, there was nonpersonalised care, making it difficult for patients to make informed decisions. CONCLUSION The multibedded rooms in the emergency department observation unit had a positive influence on patient–nurse interaction, but a negative influence on privacy; the opposite was found in the surgical assessment unit with its rooms with fewer beds. The extensive professional–patient interactions in the emergency department observation unit created distrust. The limited professional–patient interaction in the surgical assessment unit did the same. That the emergency department observation unit was staffed by emergency nurses seemed to have a positive influence on the length of patient–nurse interactions, while the surgical assessment unit staffed by specialist nurses seemed to have the opposite effect. There was lack of information and personalised care in both units. RELEVANCE TO CLINICAL PRACTICE Units receiving acute patients need to provide personalised care and information about how the unit functions and about care and treatment to improve the patients' ability to make decisions during admission.
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A new charging scheme in an emergency department observation unit under Beijing’s basic medical insurance. Chin Med J (Engl) 2014. [DOI: 10.1097/00029330-201409200-00017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Mathematical Modeling of the Impact of Hospital Occupancy: When Do Dwindling Hospital Beds Cause ED Gridlock? ACTA ACUST UNITED AC 2014. [DOI: 10.1155/2014/904807] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives. The time emergency department (ED) patients spend from presentation to admittance is known as their length of stay (LOS). This study aimed to quantify the inpatient occupancy rate (InptOcc)/ED LOS relationship and develop a methodology for identifying resource-allocation triggers using InptOcc-LOS association-curve inflection points. Methods. This study was conducted over 200 consecutive days at a 700-bed hospital with an annual ED census of approximately 50,000 using multivariate spline (piecewise) regression to model the InptOcc/LOS relationship while adjusting for confounding covariates. Nonlinear modeling was used to assess for InptOcc/LOS associations and determine the inflection point where InptOcc profoundly impacted LOS. Results. At lower InptOcc, there was no association. Once InptOcc reached ≥88%, there was a strong InptOcc/LOS association; each 1% InptOcc increase predicted a 16-minute (95% CI, 12–20 minutes) LOS prolongation, while the confounder-adjusted analysis showed each 1% InptOcc increase >89% precipitating a 13-minute (95% CI, 10–16 minutes) LOS prolongation. Conclusions. The study hospital’s InptOcc was a significant predictor of prolonged ED LOS beyond the identified inflection point. Spline regression analysis identified a clear inflection point in the InptOcc-LOS curve that potentially identified a point at which to optimize inpatient bed availability to prevent increased costs of prolonged LOS.
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Wright B, Jung HY, Feng Z, Mor V. Hospital, patient, and local health system characteristics associated with the prevalence and duration of observation care. Health Serv Res 2014; 49:1088-107. [PMID: 24611617 DOI: 10.1111/1475-6773.12166] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To examine the association between hospital, patient, and local health system characteristics and the likelihood, prevalence, and duration of observation care among fee-for-service Medicare beneficiaries. DATA SOURCES The 100 percent Medicare inpatient and outpatient claims and enrollment files for 2009, supplemented with 2007 American Hospital Association Survey and 2009 Area Resource File data. STUDY DESIGN Using a lagged cross-sectional design, we model the likelihood of a hospital providing any observation care using logistic regression and the conditional prevalence and duration of observation care using linear regression, among 3,692 general hospitals in the United States. PRINCIPLE FINDINGS Critical access hospitals (CAHs) have 97 percent lower odds of providing observation care compared to other hospitals, and they conditionally provide three fewer observation stays per 1,000 visits. The provision of observation care is negatively associated with the proportion of racial minority patients, but positively associated with average patient age, proportion of outpatient visits occurring in the emergency room, and diagnostic case mix. Duration is between 1.5 and 2.8 hours shorter at government-owned, for-profit hospitals, and CAHs compared to other nonprofit hospitals. CONCLUSIONS Variation in observation care depends primarily on hospital characteristics, patient characteristics, and geographic measures. By contrast, local health system characteristics are not a factor.
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Affiliation(s)
- Brad Wright
- Department of Health Management and Policy, University of Iowa College of Public Health, 100 College of Public Health Building N240, Iowa City, IA 52242
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Komindr A, Baugh CW, Grossman SA, Bohan JS. Key operational characteristics in emergency department observation units: a comparative study between sites in the United States and Asia. Int J Emerg Med 2014; 7:6. [PMID: 24499641 PMCID: PMC3922480 DOI: 10.1186/1865-1380-7-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 01/11/2014] [Indexed: 11/22/2022] Open
Abstract
Background To improve efficiency, emergency departments (EDs) use dedicated observation units (OUs) to manage patients who are unable to be discharged home, yet do not clearly require inpatient hospitalization. However, operational metrics and their ideal targets have not been created for this setting and patient population. Variation in these metrics across different countries has not previously been reported. This study aims to define and compare key operational characteristics between three ED OUs in the United States (US) and three ED OUs in Asia. Methods This is a descriptive study of six tertiary-care hospitals, all of which are level 1 trauma centers and have OUs managed by ED staff. We collected data via various methods, including a standardized survey, direct observation, and interviews with unit leadership, and compared these data across continents. Results We define multiple key operational characteristics to compare between sites, including OU length of stay (LOS), OU discharge rate, and bed turnover rate. OU LOS in the US and Asian sites averaged 12.9 hours (95% CI, 8.3 to 17.5) and 20.5 hours (95% CI, -49.4 to 90.4), respectively (P = 0.39). OU discharge rates in the US and Asia averaged 84.3% (95% CI, 81.5 to 87.2) and 88.7% (95% CI, 81.5 to 95.8), respectively (P = 0.11), and the bed turnover rates in the US and Asian sites averaged 1.6 patients/bed/day (95% CI, -0.1 to 3.3) and 0.9 patient/bed/day (95% CI, -0.6 to 2.4), respectively (P = 0.27). Conclusions Prior research has shown that the OU is a resource that can mitigate many of problems in the ED and hospital, while simultaneously improving patient care and satisfaction. We describe key operational characteristics that are relevant to all OUs, regardless of geography or healthcare system to monitor and maximize efficiency. Although measures of LOS and bed turnover varied widely between US and Asian sites, we did not find a statistically significant difference. Use of these metrics may enable hospitals to establish or revise an ED OU and reduce OU LOS, increase bed turnover, and discharge rates while simultaneously improving patient satisfaction and quality of care.
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Affiliation(s)
- Atthasit Komindr
- Emergency Unit, King Chulalongkorn Memorial Hospital, 1873 Rama 4 Road, Pathumwan, Bangkok 10330, Thailand.
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Hockenberry JM, Mutter R, Barrett M, Parlato J, Ross MA. Factors associated with prolonged observation services stays and the impact of long stays on patient cost. Health Serv Res 2013; 49:893-909. [PMID: 24344860 DOI: 10.1111/1475-6773.12143] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Patients are treated using observation services (OS) when their care needs exceed standard outpatient care (i.e., clinic or emergency department) but do not qualify for admission. Medicare and other private payers seek to limit this care setting to 48 hours. DATA SOURCE/STUDY SETTING Healthcare Cost and Utilization Project data from 10 states and data collected from two additional states for 2009. STUDY DESIGN Bivariate analyses and hierarchical linear modeling were used to examine patient- and hospital-level predictors of OS stays exceeding 48 (and 72) hours (prolonged OS). Hierarchical models were used to examine the additional cost associated with longer OS stays. PRINCIPAL FINDINGS Of the 696,732 patient OS stays, 8.8 percent were for visits exceeding 48 hours. Having Medicaid or no insurance, a condition associated with no OS treatment protocol, and being discharged to skilled nursing were associated with having a prolonged OS stay. Among Medicare patients, the mean charge for OS stays was $10,373. OS visits of 48-72 hours were associated with a 42 percent increase in costs; visits exceeding 72 hours were associated with a 61 percent increase in costs. CONCLUSION Patient cost sharing for most OS stays of less than 24 hours is lower than the Medicare inpatient deductible. However, prolonged OS stays potentially increase this cost sharing.
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Affiliation(s)
- Jason M Hockenberry
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA; Center for Comprehensive Access Delivery Research and Evaluation, Iowa City Veterans Health Care System, Atlanta, GA
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Impact of case exposures on physician behavior responses in childhood poisoning: quality and cost implications. Pediatr Emerg Care 2013; 29:1255-9. [PMID: 24257586 DOI: 10.1097/pec.0000000000000023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES When measuring physicians' competencies, there is no consensus as to what would constitute an optimum exposure in unintentional pediatric poisoning. In the absence of universal protocols and poison centers' support, the behavior responses of the physicians can vary depending on their exposure to cases. We sought to determine if there was a correlation between the case exposure and physicians' behavior choices that could affect quality and cost of care. METHODS A cross-sectional study was conducted in 2010, and a self-reporting survey questionnaire was given to the physicians in the pediatric emergency departments and primary care centers in the city of Al Ain. The physicians' responses were plotted against (a) the number of cases the physicians have had managed in the preceding 12 months and (b) the number of years the physicians have had been in practice RESULTS One hundred seven physicians partook in the survey. We found that the physicians who had managed more than 2 cases of childhood poisoning in the preceding year chose significantly more positive behavior responses when compared with those who had managed 2 cases or less. There was no significant difference when the responses were measured against the physicians' number of years of practice. CONCLUSIONS Physicians' practice effectiveness may improve if they manage at least 3 cases of childhood poisoning in a year. Physicians training modules could be developed for those physicians who do not get the optimum exposure necessary in improving physicians' behaviors associated with effective quality and cost efficiency.
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Pareja-Sierra T, Hornillos-Calvo M, Rodríguez-Solís J, Sepúlveda-Moya DL, Bassy-Iza N, Martínez-Peromingo FJ, Rodríguez-Couso M, Esteban-Dombriz MJ, Jiménez-Jiménez P. Implementation of an emergency department observation unit for elderly adults in a university-affiliated hospital in Spain: a 6-year analysis of data. J Am Geriatr Soc 2013; 61:1621-2. [PMID: 24028361 DOI: 10.1111/jgs.12433] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Teresa Pareja-Sierra
- Department of Geriatrics, University Hospital of Guadalajara, Health Service of Castilla-La Mancha, Guadalajara, Spain
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Lafta RK, Al-Nuaimi MA. National perspective on in-hospital emergency units in Iraq. Qatar Med J 2013; 2013:19-27. [PMID: 25003053 PMCID: PMC3991050 DOI: 10.5339/qmj.2013.4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 05/29/2013] [Indexed: 12/02/2022] Open
Abstract
Background: Hospitals play a crucial role in providing communities with essential medical care during times of disasters. The emergency department is the most vital component of hospitals' inpatient business. In Iraq, at present, there are many casualties that cause a burden of work and the need for structural assessment, equipment updating and evaluation of process. Objective: To examine the current pragmatic functioning of the existing set-up of services of in-hospital emergency departments within some general hospitals in Baghdad and Mosul in order to establish a mechanism for future evaluation for the health services in our community. Methods: A cross-sectional study was employed to evaluate the structure, process and function of six major hospitals with emergency units: four major hospitals in Baghdad and two in Mosul. Results: The six surveyed emergency units are distinct units within general hospitals that serve (collectively) one quarter of the total population. More than one third of these units feature observation unit beds, laboratory services, imaging facilities, pharmacies with safe storage, and ambulatory entrance. Operation room was found only in one hospital's reception and waiting area. Consultation/track area, cubicles for infection control, and discrete tutorial rooms were not available. Patient assessment was performed (although without adequate privacy). The emergency specialist, family medicine specialist and interested general practitioner exist in one-third of the surveyed units. Psychiatrist, physiotherapists, occupational therapists, and social work links are not available. The shortage in medication, urgent vaccines and vital facilities is an obvious problem. Conclusions: Our emergency unit's level and standards of care are underdeveloped. The inconsistent process and inappropriate environments need to be reconstructed. The lack of drugs, commodities, communication infrastructure, audit and training all require effective build up.
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A “Top Five” list for emergency medicine: a policy and research agenda for stewardship to improve the value of emergency care. Am J Emerg Med 2013; 31:1520-4. [DOI: 10.1016/j.ajem.2013.07.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 06/05/2013] [Accepted: 07/17/2013] [Indexed: 01/08/2023] Open
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Can all cause readmission policy improve quality or lower expenditures? A historical perspective on current initiatives. HEALTH ECONOMICS POLICY AND LAW 2013; 9:193-213. [PMID: 23987089 DOI: 10.1017/s1744133113000340] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
All-cause readmission to inpatient care is of wide policy interest in the United States and a number of other countries (Centers for Medicare and Medicaid Services, in the United Kingdom by the National Centre for Health Outcomes Development, and in Australia by the Australian Institute of Health and Welfare). Contemporary policy efforts, including high powered incentives embedded in the current US Hospital Readmission Reduction Program, and the organizationally complex interventions derived in anticipation of this policy, have been touted based on potential cost savings. Strong incentives and resulting interventions may not enjoy the support of a strong theoretical model or the empirical research base that are typical of strong incentive schemes. We examine the historical broad literature on the issue, lay out a 'full' conceptual organizational model of patient transitions as they relate to the hospital, and discuss the strengths and weaknesses of previous and proposed policies. We use this to set out a research and policy agenda on this critical issue rather than attempt to conduct a comprehensive structured literature review. We assert that researchers and policy makers should consider more fundamental societal issues related to health, social support and health literacy if progress is going to be made in reducing readmissions.
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Wright B, Jung HY, Feng Z, Mor V. Trends in observation care among Medicare fee-for-service beneficiaries at critical access hospitals, 2007-2009. J Rural Health 2013; 29 Suppl 1:s1-6. [PMID: 23944275 PMCID: PMC3752707 DOI: 10.1111/jrh.12007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE Observation care is used to evaluate patients prior to admission or discharge. Often beneficial, such care also imposes greater financial liability on Medicare beneficiaries. While the use of observation care has increased recently, critical access hospitals (CAHs) face different policies than prospective payment (PPS) hospitals, which may influence their observation care use. METHODS We used 100% Medicare inpatient and outpatient claims files and enrollment data for years 2007 to 2009, and the 2007 American Hospital Association data to compare trends in the likelihood, prevalence and duration of observation stays between CAHs and PPS hospitals in metro and non-metro areas among fee-for-service Medicare beneficiaries over age 65. FINDINGS While PPS hospitals are more likely to provide any observation care, the 3-year increase in the proportion of CAHs providing any observation care is approximately 5 times as great as the increase among PPS hospitals. Among hospitals providing any observation care in 2007, the prevalence at CAHs was 35.7% higher than at non-metro PPS hospitals and 72.8% higher than at metro PPS hospitals. By 2009, these respective figures had increased to 63.1% and 111%. Average stay duration increased more slowly for CAHs than for PPS hospitals. CONCLUSIONS These data suggest that a growing proportion of CAHs are providing observation care and that CAHs provide relatively more observation care than PPS hospitals, but they have shorter average stays. This may have important financial implications for Medicare beneficiaries.
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Affiliation(s)
- Brad Wright
- Center for Gerontology and Health Care Research, Brown University, 121 S. Main St., Providence, RI 02912, USA.
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84
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Pena ME, Fox JM, Southall AC, Dunne RB, Szpunar S, Kler S, Takla RB. Effect on efficiency and cost-effectiveness when an observation unit is managed as a closed unit vs an open unit. Am J Emerg Med 2013; 31:1042-6. [DOI: 10.1016/j.ajem.2013.03.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 03/12/2013] [Accepted: 03/19/2013] [Indexed: 10/26/2022] Open
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Dinh MM, Bein KJ, Byrne CM, Gabbe B, Ivers R. Deriving a prediction rule for short stay admission in trauma patients admitted at a major trauma centre in Australia. Emerg Med J 2013; 31:263-7. [PMID: 23407379 DOI: 10.1136/emermed-2012-202222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The aim of this study was to derive and internally validate a prediction rule for short stay admissions (SSAs) in trauma patients admitted to a major trauma centre. METHODS A retrospective study of all trauma activation patients requiring inpatient admission at a single inner city major trauma centre in Australia between 2007 and 2011 was conducted. Logistic regression was used to derive a multivariable model for the outcome of SSA (length of stay ≤2 days excluding deaths or intensive care unit admission). Model discrimination was tested using area under receiver operator characteristic curve analyses and calibration was tested using the Hosmer-Lemeshow test statistic. Validation was performed by splitting the dataset into derivation and validation datasets and further tested using bootstrap cross validation. RESULTS A total of 2593 patients were studied and 30% were classified as SSAs. Important independent predictors of SSA were injury severity score ≤8 (OR 7.8; 95% CI 5.0 to 11.9), Glasgow coma score 14-15 (OR 3.2; 95% CI 1.8 to 5.4), no need for operative intervention (OR 2.2; 95% CI 1.6 to 3.2) and age < 65 years. (OR 1.7; 95% CI 1.2 to 2.6). The overall model had an area under receiver operator characteristic curve of 0.84 (95% CI 0.82 to 0.87) for the derivation dataset. After bootstrap cross validation the area under the curve of the final model was 0.83 (95% CI 0.81 to 0.84). CONCLUSIONS We report a prediction rule that could be used to establish admission criteria for a trauma short stay unit. Further studies are required to prospectively validate the prediction rule.
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Affiliation(s)
- Michael M Dinh
- Emergency Department, Royal Prince Alfred Hospital, , Sydney, New South Wales, Australia
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86
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Abstract
An increasing number of emergency departments (EDs) are providing extended care and monitoring of patients in ED observation units (EDOUs). EDOUs can be useful for older adults as an alternative to hospitalization and as a means of risk stratification for older adults with unclear presentations. They can also provide a period of therapeutic intervention and reassessment for older patients in whom the appropriateness and safety of immediate outpatient care are unclear. This article discusses the general characteristics of EDOUs, reviews appropriate entry and exclusion criteria for older adults in EDOUs, and discusses regulatory implications of observation status for patients with Medicare.
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Affiliation(s)
- Mark G. Moseley
- Associate Professor, Department of Emergency Medicine, The Ohio State University, Columbus, OH
| | - Miles P. Hawley
- Assistant Professor, Department of Emergency Medicine, The Ohio State University, Columbus, OH
| | - Jeffrey M. Caterino
- Associate Professor, Department of Emergency Medicine, The Ohio State University, Columbus, OH
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Can Selected Patients With Newly Diagnosed Pulmonary Embolism Be Safely Treated Without Hospitalization? A Systematic Review. Ann Emerg Med 2012; 60:651-662.e4. [DOI: 10.1016/j.annemergmed.2012.05.041] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 05/25/2012] [Accepted: 05/31/2012] [Indexed: 11/22/2022]
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Baugh CW, Venkatesh AK, Hilton JA, Samuel PA, Schuur JD, Bohan JS. Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year. Health Aff (Millwood) 2012; 31:2314-23. [PMID: 23019185 DOI: 10.1377/hlthaff.2011.0926] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Using observation units in hospitals to provide care to certain patients can be more efficient than admitting them to the hospital and can result in shorter lengths-of-stay and lower costs. However, such units are present in only about one-third of US hospitals. We estimated national cost savings that would result from increasing the prevalence and use of observation units for patients whose stay there would be shorter than twenty-four hours. Using a systematic literature review, national survey data, and a simulation model, we estimated that if hospitals without observation units had them in place, the average cost savings per patient would be $1,572, annual hospital savings would be $4.6 million, and national cost savings would be $3.1 billion. Future policies intended to increase the cost-efficiency of hospital care should include support for observation unit care as an alternative to short-stay inpatient admission.
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Abstract
Acute decompensated heart failure is a common reason for presentation to the emergency department and is associated with high rates of admission to hospital. Distinguishing between higher-risk patients needing hospitalization and lower-risk patients suitable for discharge home is important to optimize both cost-effectiveness and clinical outcomes. However, this can be challenging and few validated risk stratification tools currently exist to help clinicians. Some prognostic variables predict risks broadly in those who are admitted or discharged from the emergency department. Risk stratification methods such as the Emergency Heart Failure Mortality Risk Grade and Acute Heart Failure Index clinical decision support tools, which utilize many of these predictors, have been found to be accurate in identifying low-risk patients. The use of observation units may also be a cost-effective adjunctive strategy that can assist in determining disposition from the emergency department.
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Affiliation(s)
- Edwin C. Ho
- Institute for Clinical Evaluative Sciences, Division of Cardiology, University Health Network, Room G-106, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
| | - Michael J. Schull
- Institute for Clinical Evaluative Sciences, Division of Cardiology, University Health Network, Room G-106, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
- Sunnybrook and Institute for Clinical Evaluative Sciences, and the Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Canada
| | - Douglas S. Lee
- Institute for Clinical Evaluative Sciences, Division of Cardiology, University Health Network, Room G-106, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
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Schull MJ, Vermeulen MJ, Stukel TA, Guttmann A, Leaver CA, Rowe BH, Sales A. Evaluating the effect of clinical decision units on patient flow in seven Canadian emergency departments. Acad Emerg Med 2012; 19:828-36. [PMID: 22805630 DOI: 10.1111/j.1553-2712.2012.01396.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the effect of emergency department (ED) clinical decision units (CDUs) on overall ED patient flow in a pilot project funded in 2008 by the Ontario Ministry of Health and Long-Term Care (MOHLTC). METHODS A retrospective analysis of unscheduled ED visits at seven CDU pilot and nine control sites was conducted using administrative data. The authors examined trends in CDU utilization and compared outcomes between pilot-CDU and control sites 1 year prior to implementation, with the first 18 months of CDU operation. Sites that were unsuccessful in their applications for CDU program funding served as controls. Outcomes included ED length of stay (LOS), admission rates, and ED revisit rates. RESULTS At CDU sites, roughly 4% of ED patients were admitted to CDUs. The presence of a pilot-CDU was independently associated with a small reduction in ED LOS for all low-acuity patients (-0.14 hour, 95% confidence interval [CI]=-0.22 to -0.07) and nonadmitted patients (-0.11 hour, 95% CI=-0.16 to -0.07). A small independent effect on absolute hospital admission rate for all high-acuity patients (-0.8%, 95% CI=-1.5% to -0.03%) and moderate-acuity patients (-0.6%, 95% CI=-1.1% to -0.2%) was also observed. Pilot-CDUs were not associated with changes in ED revisit rates. CONCLUSIONS With only 4% of ED patients admitted to CDUs, the potential for efficiency gains in these EDs was limited. Nonetheless, these findings suggest small improvements in the operation of the ED through CDU implementation. Although marginal, the observed effects of CDU operation were in the desired direction of reduced ED LOS, reduced admission rate, and no increase in ED revisit rate.
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Affiliation(s)
- Michael J Schull
- Institute for Clinical Evaluative Sciences, Toronto, Ontario; the Institute of Health Policy, Canada.
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Welch SJ. Using Data to Drive Emergency Department Design: A Metasynthesis. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2012; 5:26-45. [DOI: 10.1177/193758671200500305] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: There has been an uptick in the field of emergency department (ED) operations research and data gathering, both published and unpublished. This new information has implications for ED design. The specialty suffers from an inability to have these innovations reach frontline practitioners, let alone design professionals and architects. This paper is an attempt to synthesize for design professionals the growing data regarding ED operations. Methods: The following sources were used to capture and summarize the research and data collections available regarding ED operations: the Emergency Department Benchmarking Alliance database; a literature search using both PubMed and Google Scholar search engines; and data presented at conferences and proceedings. Results: Critical information that affects ED design strategies is summarized, organized, and presented. Data suggest an optimal size for ED functional units. The now-recognized arrival and census curves for the ED suggest a department that expands and contracts in response to changing census. Operational improvements have been clearly identified and are grouped into three categories: input, throughput, and outflow. Applications of this information are suggested. Conclusion: The sentinel premise of this meta-synthesis is that data derived from improvement work in the area of ED operations has applications for ED design. EDs can optimize their functioning by marrying good processes and operations to good design. This review paper is an attempt to bring this new information to the attention of the multidisciplinary team of architects, designers, and clinicians.
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Venkatesh AK, Geisler BP, Gibson Chambers JJ, Baugh CW, Bohan JS, Schuur JD. Use of observation care in US emergency departments, 2001 to 2008. PLoS One 2011; 6:e24326. [PMID: 21935398 PMCID: PMC3173457 DOI: 10.1371/journal.pone.0024326] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 08/05/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Observation care is a core component of emergency care delivery, yet, the prevalence of emergency department (ED) observation units (OUs) and use of observation care after ED visits is unknown. Our objective was to describe the 1) prevalence of OUs in United States (US) hospitals, 2) clinical conditions most frequently evaluated with observation, and 3) patient and hospital characteristics associated with use of observation. METHODS Retrospective analysis of the proportion of hospitals with dedicated OUs and patient disposition after ED visit (discharge, inpatient admission or observation evaluation) using the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2001 to 2008. NHAMCS is an annual, national probability sample of ED visits to US hospitals conducted by the Center for Disease Control and Prevention. Logistic regression was used to assess hospital-level predictors of OU presence and polytomous logistic regression was used for patient-level predictors of visit disposition, each adjusted for multi-level sampling data. OU analysis was limited to 2007-2008. RESULTS In 2007-2008, 34.1% of all EDs had a dedicated OU, of which 56.1% were under ED administrative control (EDOU). Between 2001 and 2008, ED visits resulting in a disposition to observation increased from 642,000 (0.60% of ED visits) to 2,318,000 (1.87%, p<.05). Chest pain was the most common reason for ED visit resulting in observation and the most common observation discharge diagnosis (19.1% and 17.1% of observation evaluations, respectively). In hospital-level adjusted analysis, hospital ownership status (non-profit or government), non-teaching status, and longer ED length of visit (>3.6 h) were predictive of OU presence. After patient-level adjustment, EDOU presence was associated with increased disposition to observation (OR 2.19). CONCLUSIONS One-third of US hospitals have dedicated OUs and observation care is increasingly used for a range of clinical conditions. Further research is warranted to understand the quality, cost and efficiency of observation care.
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Affiliation(s)
- Arjun K Venkatesh
- Brigham and Women's Hospital-Massachusetts General Hospital-Harvard Affiliated Emergency Medicine Residency, Boston, Massachusetts, United States of America.
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