In reply:

Abstract

We appreciate the thoughtful comments of Drs. Suri and Baugh, which reiterate several important limitations of our study.1Blecker S. Gavin N.P. Park H. et al.Observation units as substitutes for hospitalization or home discharge.Ann Emerg Med. 2016; 67: 706-713Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar We recognize that our study was an imperfect attempt to assess the clinical use of observation units. Chest pain patients were the subject of our published analysis because chest pain is the most common diagnosis in observation,2Venkatesh A.K. Geisler B.P. Gibson Chambers J.J. et al.Use of observation care in US emergency departments, 2001 to 2008.PloS One. 2011; 6: e24326Crossref PubMed Scopus (103) Google Scholar so there were a large number of these patients in the National Hospital Ambulatory Medical Care Survey (NHAMCS) data set. Although not included in the manuscript due to smaller sample size, we applied the same analysis to syncope and cellulitis patients and found that the majority of these patients admitted to an observation would have been discharged home had the unit not been available. Although we agree that appropriateness of hospitalization is best decided by the bedside clinician, both clinical and nonclinical factors can influence clinician triage decisions.3Stelfox H.T. Hemmelgarn B.R. Bagshaw S.M. et al.Intensive care unit bed availability and outcomes for hospitalized patients with sudden clinical deterioration.Arch Intern Med. 2012; 172: 467-474Crossref PubMed Scopus (159) Google Scholar, 4Lewis Hunter A.E. Spatz E.S. Bernstein S.L. et al.Factors influencing hospital admission of non-critically ill patients presenting to the emergency department: a cross-sectional study.J Gen Intern Med. 2016; 31: 37-44Crossref PubMed Scopus (31) Google Scholar Our study suggests that the availability of an observation unit may have an effect on the variability in clinical decisionmaking. The recent increase in observation units is partly attributable to policy changes, including the Readmission Reduction Program and the Two Midnight Rule, that are intended to reduce overuse of hospitalizations. Although our study is by no means definitive, it points to a possibility of an unintended consequence of such policies: the potential for overuse related to observation units. We agree with Drs. Suri and Baugh that our results should not be interpreted to suggest that observation units are inherently problematic. Nonetheless, as our profession moves toward accountability for value provided, we must be conscious of the potential for overuse. We believe more definitive studies are needed to address both the benefits and unintended consequences of the increase in observation units. Observation Units as Substitutes for Hospitalization or Home DischargeAnnals of Emergency MedicineVol. 67Issue 6PreviewThe study titled “Observation Units as Substitutes for Hospitalization or Home Discharge” by Blecker et al1 is a data-driven analysis of a phenomenon demonstrated in previous investigations: the availability of an observation unit decreases direct discharges to home after an emergency department (ED) visit, specifically for patients with chest pain. Although today’s observation units largely evolved from chest pain units, during the past 3 decades most have expanded their scope to include dozens of other conditions such as asthma, syncope, and transient ischemic attack. Full-Text PDF