Brief ReportsA Five-Year Experience of a Short Stay Observation Unit in Saudi Arabia Emmanuel UdezueFRCPI, FACTM Emmanuel Udezue Address reprint requests and correspondence to Dr. Udezue: Saudi Aramco-Al-Hasa Health Center, PO Box 6030, Mubarraz 31311, Saudi Arabia. From the Internal Medicine Unit, Al-Hasa Specialty Services Division, Saudi Aramco-Al-Hasa Health Center, Saudi Arabia. Search for more papers by this author Published Online:1 Jan 2003https://doi.org/10.5144/0256-4947.2003.72SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionMany hospitals have Observation Wards (OWs) attached to their Emergency Rooms (ERs), whose utilization varies from one country to another. In the US, these Observation Wards have evolved mostly into Chest Pain Observation Units (CPOUs) for patients whose clinical features of chest pain are suspicious but not diagnostic, and of acute myocardial infarction patients who can be observed further before either being discharged home or admitted to hospital. In the UK and other countries, they are used for more variable purposes including trauma, psychiatric observation, geriatric assessment, pediatric emergencies and cases of drug overdose.1-6Observation Wards have multiple functions, therefore, their cost impact on other medical services varies according to the circumstances of use. However, even for CPOUs with specific roles,7 it has been more difficult to assess cost impact. CPOUs have been shown to be cost-effective in the US8,9 and in the UK, hospital beds have been saved as a result.1,10,11 This report describes the utilization of a short-stay observation unit (Stabilization Unit) in a Saudi Arabian health center, where the circumstances are unique.BackgroundSaudi Aramco-Al-Hasa Health Center (SA-AHHC) is part of Saudi Aramco Medical Services Organization (SAMSO), which is responsible for providing health care services to eligible employees and dependents of the Saudi Arabian Oil Company, Saudi Aramco. It has a busy outpatient service where 400,000 patient visits are made annually, mostly to general medical practitioners, supported by specialist pediatricians, obstetricians, internists, radiologists and anesthetists. It has 80 beds for pediatrics, obstetrics and gynecology, as well as an emergency service, which is open 24 hours daily.The Stabilization Unit (SU) is a 3-bed observation area attached to the Emergency Room, where patients can be kept for up to 36 hours. This time duration is utilized to separate such patients from inpatients who usually stay for 48 or more hours, in accordance with Joint Commission for International Accreditation (JOA) standards. The SU opened in August 1993 under the supervision of the Internal Medicine Unit for utilization by the three main specialties—medicine, pediatrics and obstetrics/gynecology—enabling further care and observation of patients who require more than the 6-hour period allowed for patients in the ER. Division of available space into cubicles allowed flexibility in admission of patients of either gender. Nurses are assigned to the SU as needed, from the ER nursing staff to which they belong.Medical patients requiring hospitalization are usually transferred to the Saudi Aramco-Dhahran Health Centre (SA-DHC), about 140 kilometers (90 minutes) distance from SA-AHHC by ambulance. The round trip takes approximately 5 hours, including handover and ambulance waiting time. Many of these patients require some initial treatment to stabilize their condition to make them fit and safe for their transfer to SA-DHC. The SU was expected to play an active role in this process, as well as in reducing both the numbers of short stay admissions to SA-DHC and transfers to local hospitals. The usage of the SU function was monitored and studied from September 1993 to September 1998, and compared with the experiences of similar units elsewhere. The findings are believed to have implications for other health care institutions in this era of greater awareness of healthcare delivery cost and efficiency.Description of ServiceAdult patients (aged 14 years and over) with significant internal medicine problems who presented to the emergency service of SA-AHHC were initially evaluated by ER physicians and referred to the Internal Medicine service, as necessary. About 3500 such referrals were made each year of which 40% needed further care. Most of these patients requiring further care were admitted directly to SA-DHC and the remainders were treated in the SU. Patients were admitted into the SU for one or more of the following reasons:initiation of stabilizing treatment requiring several hours, prior to transfer to SA-DHCself-limiting acute problems, e.g., dehydration from gastroenteritisexpected short-term stay, e.g., control of painful sickle cell disease crisisinitiation of parenteral antibiotic treatment in severe uncomplicated infections, e.g., pneumoniainitiation of treatment in ambulatory patients too ill for routine outpatient treatmentmanagement of miscellaneous clinical problems, where intensive care or further special care and investigations available only at SA-DHC are not required.Patients in the SU were reassessed frequently, approximately every 6 hours, to consider final disposition, with main decision being made between 18 and 36 hours after admission. Those making only slow progress, or whose problems became complicated, were transferred to the base hospital, SA-DHC. Transfers were made as soon as the need for them became obvious, and in any case, before the expiry of the maximum allowed time of 36 hours. Cost analysis is outlined in Table 1 at the company’s rates available for 1998, assuming a mean short-stay period of 3 days per patient. This conservative estimate of length of stay offset the small inflationary element inherent in pricing the 5-year activities at 1998 prices.Table 1. Patient admission and disposal, 1993-1998.Table 1. Patient admission and disposal, 1993-1998.Table 2. Top admissions to stabilization unit, 1993-1998.Table 2. Top admissions to stabilization unit, 1993-1998.Table 3. Cost of health service items (1998).Table 3. Cost of health service items (1998).RESULTSThe extra clerical work and routine documentation involved in first discharging patients from the ER, and then admitting them to the SU for stabilization of their condition, before transfer to SA-DHC became obvious during the first year of operation. In subsequent years, therefore, those patients needing this type of care were generally treated in the ER before being transferred. Thus, the SU ended up being, in practice, a short-stay ward. Similarly, although pediatric and gynecological patients could be admitted into the SU, patients of these two services were mostly admitted to their respective wards, since these were available at SA-AHHC Thus, nearly all SU patients (97.5%) were medical.During the five years of this report, 1764 out of 2255 patients (78%) were discharged home from the SU. These patients would have been short-term admissions to the base hospital, if there were no SUs. The Health Center cost savings included those on ambulance trips, nurse escorts, hospitalization with daily physician attendance, and feeding.Table 1 and 2 summarizes the results of patient categories and usage. Both sexes were equally represented with 51% males and 49% females. The mean age of patients was 48.5 (range 14-92) years. Ninety percent (90%) of all the medical admissions to the SU were accounted for by seven main diagnostic categories, while nearly three quarters of them (73%) were from the top five. Sickle cell disease (SCD) vaso-occlusive pain crisis was the most common single admission entity, with nearly one-quarter (22.3%) of all the admissions. These proportions did not vary much from year to year. About 80% of the patients were discharged home, with little year-to-year variation. Sickle cell disease again topped the list of those eventually transferred to hospital, making up about 30% of the total number.Patients spent an average of 21.4 hours in the SU, with little difference between those discharged home (21.7 hours) and those transferred to hospital (20.5 hours). SCD patients stayed longer, but the pattern was the same, with mean stay period of 25.3 hours, and 25.2 hours, respectively. In some cases, the transfers occurred less than 12 hours after admission, indicating prompt clarification of the clinical problem. The use of the SU significantly reduced the number of patient transfers to other hospitals during the study period.DISCUSSIONThe SU discharge rate of cases that would have been short-stay admissions to hospital was approximately 80%. This seems to be the pattern in the use of most OWs1,7,12-15 including the elderly, among whom 71% were discharged home in one report.1 This was a major saving for SAMSO, which ensured acute SA-DHC bed availability for more needy patients requiring all the expert support and services of a major hospital. The total saving of almost $3 million (SR11 million) over five years or $0.6 million (SR2.2 million) per year from such a small unit of 3 beds is substantial. If ambulance and nurse escort costs are excluded, the savings would still be significant at $2.14 million (SR 8 million). Treatment in the SU was also more convenient for our patients as it was nearer their homes, enabling friends and relatives to visit.OWs vary greatly in capacity and usage. For example, in the UK, unit bed space varies from 6 to 20,6 while one unit in Hong Kong has over 34 beds.12 The SA-AHHC SU of three beds is at the lower end of capacity and it is currently being expanded to 6 beds. For the period of study, our SU was not used for trauma or surgical cases, but this is about to change. The main observation drawn from this comparison is that successful OWs are flexible in bed capacity and usage, and both factors usually operate in response to local need.The success of the SU in saving hospital beds and reducing the number of short-stay admissions and transfers to non-SAMSO hospitals was in part responsible for SAMSO’s decision to double the SU capacity to 6 beds and increase the scope of its usage to include observation of surgical patients by ER staff. Other authors found that not only did OWs save hospital beds, but they also led to more prompt medical attention and earlier discharge from hospital.1,16,17,18The increased proportion (30%) of sickle cell disease patients transferred to hospital, compared with that admitted to the SU (22%), suggested that more than 36 hours was needed to control the pain of vaso-occlusive crisis of these patients, or that the Internal Medicine Service pain management approach needed review, or both. This prompted further examination, leading to the issue being subsequently addressed. Time in the SU was extended to 47 hours when the unit reopened, and the Internal Medicine Service pain management protocol for sickle cell disease crisis was revised.The prominent contribution of SCD to the SU admissions is a local phenomenon due to the prevalence of the disorder in the area of practice. It provided the opportunity to study the disease that led to modifications in practice. The trend for SCD patients to use the ER for most of their medical care was noted, and led to the commencement of a special SCD clinic which encourages continuity of care for these patients. In this clinic, patients and their families receive health education and counseling on how to look after themselves. This has resulted in reduction of both ER visits by SCD patients and loss of school time for the younger ones. It is currently the subject of further study. This opportunity to gain experience in the management of a specific disorder is similar to that of an OW in Wales, UK, where nearly two-thirds of cases were found to be drug overdoses and minor head injuries.19In summary, the SU:saved money and valuable hospital bedsincreased patient satisfaction by enabling patients to be treated nearer their homesgave the opportunity to study and gain experience in a specific disease entityhighlighted the multiple roles such a unit could play in the current search for quality but cost-efficient healthcareThere could be roles for units like the SU in diabetic management (e.g., initiating insulin treatment), patient dehydration where diarrhoeal diseases are common, minor medical and surgical procedures, post-trauma observation, self poisoning and other self-limiting conditions.ARTICLE REFERENCES:1. Khan SA, Millington H, Miskelly FG. "Benefits of an accident and emergency short stay ward in the staged hospital care of elderly patients" . 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Google Scholar Previous article Next article FiguresReferencesRelatedDetailsCited byUdezue E and Girshab A (2019) Observations on the management of acute pain crisis in adult sickle cell disease in eastern Saudi Arabia, Annals of Saudi Medicine , 25:2, (115-119), Online publication date: 1-Mar-2005.Udezue E, Nashwan R, Azim A, Hasweh M, Al Nuaim A and Al Dossary I (2019) The Impact of a Multi-disciplinary Management Approach on Diabetic Control in Young Saudi Patients, Annals of Saudi Medicine , 25:2, (85-89), Online publication date: 1-Mar-2005.Udezue E and Girshab A (2019) Differences between males and females in adult sickle cell pain crisis in eastern Saudi Arabia, Annals of Saudi Medicine , 24:3, (179-182), Online publication date: 1-May-2004. Volume 23, Issue 1-2January-March 2003 Metrics History Received4 June 2002Accepted1 January 2003Published online1 January 2003 ACKNOWLEDGEMENTSI am grateful to the physicians and staff of Emergency Receiving Room and Stabilization Unit of SA-AHHC, as well as my colleagues in the Internal Medicine Unit whose devotion and skill made this study possible. The author acknowledges the secretarial help of Angela Harwood and Veronica Moore, and the use of Saudi Aramco Medical Services Organization facilities for the data and study that resulted in this paper. The author was employed by SAMSO during the time the study was conducted.InformationCopyright © 2003, Annals of Saudi MedicinePDF download