Abstract
BackgroundObservation 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.MethodsRetrospective 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.ResultsIn 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).ConclusionsOne-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.
Highlights
We analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2001 to 2008 in order to 1) describe the prevalence of dedicated EDOUs and hospital observation units (HOUs) in US hospitals, 2) describe the clinical conditions most frequently evaluated with observation services after emergency department (ED) visits and 3) describe patient and hospital characteristics that are associated with use of observation services after ED visits
The hospital characteristics associated with the presence of a dedicated OU included ownership status, non-teaching status and hospitals with longer average ED length of visit. (Table 1)
ED visits with subsequent observation care increased from 642,000 in 2001 (0.60% of all ED visits, 95%confidence intervals (CI): 0.43–0.76%) in 2001 to 2,318,000 in 2008 (1.87% of all ED visits, 95%CI: 1.49%– 2.26%%)
Summary
Emergency department (ED) use has increased while the number of inpatient hospital beds has decreased presenting a bottleneck for patients in need of acute care services.[1,2] The Center for Disease Control (CDC) estimated 124 million ED visits in 2008, which represents an increase of more than 20% in the last decade despite the closure of 9% of EDs and nearly 200,000 hospital beds. Hospitals have shifted to billing patients for observation services rather than inpatient care for short stays.[8,9,10] This policy change combined with expanded CMS reimbursement for observation services [11]. 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
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