Emergency Department Observation Unit Patients Research Articles

The benefits of a virtual emergency department observation unit for hospital observation patients

BackgroundThe benefit of virtual emergency department observation unit (EDOU) care relative to traditional observation care in an inpatient bed is unknown. ObjectiveTo determine if virtual observation care in an EDOU is associated with improved length of stay, cost, inpatient admission rate, and adverse events relative to traditional observation care in non-observation unit (NOU) inpatient bed. MethodsThis is a retrospective observational cohort study of observation patients managed over 24 months in two urban teaching hospitals. Following an ED visit, observation care occurred in a virtual-EDOU or NOU inpatient setting based on bed availability, physician discretion, and observation guidelines. Primary outcomes were length of stay, total cost, inpatient admission rate, and adverse events (death or ICU admission). Hospital cost and clinical databases were used. Analysis with a doubly-robust regression with entropy balancing and propensity scores was used to control for subgroup differences. Results30,191 observation patients were divided into 13,753 NOU patients and 16,438 EDOU patients with similar distributions for age and gender, and differences in health insurance and diagnosis. For both discharged and admitted patients, the mean cost was higher in the NOU setting at $7989 than the virtual-EDOU setting at $4876 with an adjusted difference of $1951 (95% CI: $1762 - $2133). The mean total length of stay was higher in the NOU setting (60.5 h) than the virtual-EDOU setting (36.4 h) with an adjusted difference of 20.4 h (95% CI: 19.2 h – 21.3 h). NOU inpatient admission rates were higher (25.3% vs 18.4%). Cost and length of stays were lower in discharged observation patients, with differences favoring the virtual-EDOU group. Adverse events were higher in the NOU setting (2.1% vs 0.8%). 30-day ED recidivism did not differ significantly between NOU and virtual-EDOU study groups. The virtual-EDOU saved the two hospitals $16,036,913 and 6986 bed-days annually. ConclusionManagement of observation patients in a virtual-EDOU setting is superior to care in a traditional inpatient setting in terms of costs, length of stays, inpatient admission and adverse events rates.

An Electronic Medical Record Intervention to Increase Pharmacologic Prophylaxis for Venous Thromboembolism in Emergency Department Observation Patients

The role of venous thromboembolism (VTE) prophylaxis among patients receiving emergency department (ED) observation unit care is unclear. We investigated an electronic health record-based clinical decision support tool aimed at increasing pharmacologic VTE prophylaxis use among at-risk patients placed in ED observation units. We conducted an interrupted time-series study of an Epic-based best practice advisory implemented in May 2019 at a health care system comprising 2 academic medical centers and 4 community hospitals with dedicated ED observation units. The best practice advisory alerted staff at 24 hours to conduct a risk assessment and linked to a VTE prophylaxis order set. We used an interrupted time series, Bayesian structured time series, and a multivariable mixed-effect regression model to estimate the intervention effect. Prior to the best practice advisory implementation, there were 8,895 ED observation unit patients with a length of stay more than or equal to 24 hours, and 0.9% received pharmacologic VTE prophylaxis. Afterward, there were 12,664 ED observation unit patients with a length of stay more than or equal to 24 hours, and 4.8% received pharmacologic VTE prophylaxis. The interrupted time series and causal impact analysis showed a statistically significant increase in VTE prophylaxis (eg, absolute percent difference 3.8%, 95% confidence interval 3.5 to 4.1). In a multivariable model, only the intervention was significantly associated with receiving VTE prophylaxis (odds ratio 4.56, 95% confidence interval 2.22 to 9.37). An electronic health record-based alert helped to prompt staff caring for ED observation unit patients at risk for VTE with prolonged visits to order recommended pharmacologic prophylaxis. The best risk assessment model to use and the true incidence of VTE events in this population are unclear.

Emergency Department Observation Unit Patients Want Evaluation and Treatment for Hypercholesterolemia: A Health Belief Model Study.

Hypercholesterolemia (HCL) is common among emergency department (ED) and ED observation unit (EDOU) patients with chest pain but is not typically addressed in these settings. The objective of this study was to assess patient attitudes towards EDOU-based HCL care using the Health Belief Model. We conducted a cross-sectional survey study among 100 EDOU patients ≥18 years-old evaluated for chest pain in the EDOU of a tertiary care center from September 1, 2020, to November 01, 2021. Five-point Likert-scale surveys were used to assess each Health Belief Model domain: Cues to Action, Perceived Susceptibility, Perceived Barriers, Perceived Self-Efficacy, and Perceived Benefits. Responses were categorized as agree or do not agree. The participants were 49.0% (49/100) female, 39.0% (39/100) non-white, and had a mean age of 59.0 ± 12.4 years. Most (83.0% [83/100, 95% confidence interval (CI), 74.2%-89.8%]) agreed the EDOU is an appropriate place for HCL education and 52.0% (52/100, 95% CI, 41.8%-62.1%) were interested in talking with their EDOU care team about HCL. Regarding Perceived Susceptibility, 88.0% (88/100, 95% CI, 80.0%-93.6%) believed HCL to be bad for their health, while 41.0% (41/100, 95% CI, 31.3%-51.3%) believed medication costs could be a barrier. For Perceived Self-Efficacy, 76.0% (76/100, 95% CI, 66.4%-84.0%) were receptive to taking medications. Overall, 95.0% (95/100, 95% CI, 88.7%-98.4%) believed managing HCL would benefit their health. This Health Belief Model-based survey indicates high patient interest in EDOU-initiated HCL care. Patients reported high rates of Perceived Susceptibility, Self-Efficacy, and Benefits and a minority found HCL therapy costs a barrier.

Rarely tested or treated but highly prevalent: Hypercholesterolemia in ED observation unit patients with chest pain

BackgroundHypercholesterolemia (HCL) is common among Emergency Department (ED) patients with chest pain but is typically not addressed in this setting. This study aims to determine whether a missed opportunity for Emergency Department Observation Unit (EDOU) HCL testing and treatment exists. MethodsWe conducted a retrospective observational cohort study of patients ≥18 years old evaluated for chest pain in an EDOU from 3/1/2019–2/28/2020. The electronic health record was used to determine demographics and if HCL testing or treatment occurred. HCL was defined by self-report or clinician diagnosis. Proportions of patients receiving HCL testing or treatment at 1-year following their ED visit were calculated. HCL testing and treatment rates at 1-year were compared between white vs. non-white and male vs. female patients using multivariable logistic regression models including age, sex, and race. ResultsAmong 649 EDOU patients with chest pain, 55.8% (362/649) had known HCL. Among patients without known HCL, 5.9% (17/287, 95% CI 3.5–9.3%) had a lipid panel during their index ED/EDOU visit and 26.5% (76/287, 95% CI 21.5–32.0%) had a lipid panel within 1-year of their initial ED/EDOU visit. Among patients with known or newly diagnosed HCL, 54.0% (229/424, 95% CI 49.1–58.8%) were on treatment within 1-year. After adjustment, testing rates were similar among white vs. non-white patients (aOR 0.71, 95% CI 0.37–1.38) and men vs. women (aOR 1.32, 95% CI 0.69–2.57). Treatment rates were similar among white vs. non-white (aOR 0.74, 95% CI 0.53–1.03) and male vs. female (aOR 1.08, 95% CI 0.77–1.51) patients. ConclusionsFew patients were evaluated for HCL in the ED/EDOU or outpatient setting after their ED/EDOU encounter and only 54% of patients with HCL were on treatment during the 1-year follow-up period after the index ED/EDOU visit. These findings suggest a missed opportunity to reduce cardiovascular disease risk exists by evaluating and treating HCL in the ED or EDOU.

Small bowel obstruction managed without hospital admission: A safe way to reduce both cost and time in the hospital?

BackgroundSmall bowel obstruction management has evolved to incorporate the Gastrografin challenge. We expanded its use to the emergency department observation unit, potentially avoiding hospital admission for highly select small bowel obstruction patients. We hypothesized that the emergency department observation unit small bowel obstruction protocol would reduce admissions, costs, and the total time spent in the hospital without compromising outcomes. MethodsWe reviewed patients who presented with small bowel obstruction from January 2015 to December 2018. Patients deemed to require urgent surgical intervention were admitted directly and excluded. The emergency department observation unit small bowel obstruction guidelines were introduced in November 2016. Patients were divided into pre and postintervention groups based on this date. The postintervention group was further subclassified to examine the emergency department observation unit patients. Cost analysis for each patient was performed looking at number of charges, direct costs, indirect cost, and total costs during their admission. ResultsIn total, 125 patients were included (mean age 69 ± 14.3 years). The preintervention group (n = 62) and postintervention group (n = 63) had no significant difference in demographics. The postintervention group had a 51% (36.7 hours, P < .001) reduction in median duration of stay and a total cost reduction of 49% (P < .001). The emergency department observation unit subgroup (n = 46) median length of stay was 23.6 hours. The readmission rate was 16% preintervention compared to 8% in the postintervention group (P = .18). ConclusionManagement of highly selected small bowel obstruction patients with the emergency department observation unit small bowel obstruction protocol was associated with decreased length of stay and total cost, without an increase in complications, surgical intervention, or readmissions.

Use of Endocrine Consultation for Hemoglobin A1C ≥9.0% as a Standardized Practice in an Emergency Department Observation Unit

ObjectiveSeverely uncontrolled diabetes mellitus (DM) is associated with poor long-term outcomes and may remain unrecognized. A high frequency of uncontrolled DM has been identified in the acute-care setting, including the emergency department observation unit (EDOU). We assess the use of standardized endocrine consultation in the EDOU for hemoglobin A1C (HbA1C) levels ≥9%. MethodsStandard practice in our EDOU includes universal HbA1C screening and endocrine consultation for HbA1C levels ≥9.0%. As part of a quality improvement program, EDOU patients with HbA1C levels ≥9.0% had an endocrinology consult. One-month follow-up phone calls assessed the effects of consultation after discharge. ResultsHbA1C tests were administered to 3688 (95.7%) of 3853 EDOU patients, of which 7.0% (n = 258) were found to have an HbA1C level ≥9% (mean ± SD, 11.7 ± 1.8%; range, 9%-16.6%). Endocrine consults were completed for 73.6% (190/258) patients with severely uncontrolled DM. Among the 190 patients, 92.1% (n = 175) had discharge DM medication adjustments. For known patients with DM (n = 142), injectable diabetes medication prescriptions increased from 47.2% (67/142) on EDOU arrival to 78.2% (111/142) upon discharge. Newly diagnosed DM injectable prescriptions increased from 0% (0/48) on arrival to 72.9% (35/48) upon discharge. A total of 72.6% (n = 138) were contacted at a 1-month follow-up and 94.9% (n = 131) reported taking DM medications, compared with 68.2% (n = 94) before consult. ConclusionHbA1C screening coupled with endocrine consultation for HbA1C levels ≥9.0% was assessed as a performance improvement study and is shown to have valuable results. Further investigation is required to determine the long-term clinical impact and cost analysis for this novel approach.

Prevalence and Significance of Renal Dysfunction Among Emergency Department Observation Patients With Chest Pain.

Previous studies have demonstrated increased risk of acute coronary syndrome among patients with chest pain and renal dysfunction. The objective of this study was to investigate the impact of renal dysfunction on cardiac outcomes in patients with chest pain in an emergency department observation unit (EDOU). We conducted a 5-year prospective evaluation of patients evaluated in the EDOU for chest pain. We collected baseline information and data from the emergency department visit, EDOU stay, inpatient admission, and the 30-day period after presentation to the emergency department. We calculated glomerular filtration rate (GFR) using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. We stratified patients as having mild (GFR 60-89 mL/min per 1.73 m) or at least moderate (GFR <60) renal dysfunction. We evaluated the rate of major adverse cardiac events (MACE: myocardial infarction, stent, coronary artery bypass graft, and death). Of 1067 enrolled EDOU patients, the majority had at least mild renal dysfunction: 39% [95% confidence interval (95% CI): 36.1%-42%] had a GFR between 60 and 89, and 16% (95% CI: 14%-18.4%) had a GFR <60. MACE rates increased with decreasing GFR: 3.3% (95% CI: 2.1%-5.3%) for GFR ≥90, 7.3% (95% CI: 5.2%-10.2%) for GFR 60-89, and 9.1% (95% CI: 5.7%-14.3%) for GFR <60 (P = 0.005). In multivariate analysis, patients with at least mild renal dysfunction (GFR < 90) were at greater risk of MACE (P = 0.028). We noted a high prevalence of renal dysfunction among EDOU patients evaluated for chest pain. Even those with mild renal dysfunction demonstrated an increased risk of MACE. Clinicians may wish to consider renal dysfunction in selecting appropriate patients for EDOU placement.

Performance of an emergency department observation unit protocol in reducing length of stay for acetaminophen overdose: a retrospective study

IntroductionAcetaminophen is one of the most common causes of poisoning among developed countries. The emergency department observation unit (EDOU) has been increasingly used in the management of various conditions to reduce hospitalisation but its efficacy in not well studied in management of poisoned patients. In this study, we aim to study the effectiveness of our EDOU in the management of acetaminophen overdosed patients.ResultsMedical records of patients admitted from the emergency department from 2012 to 2016 for acetaminophen overdose were reviewed. One hundred ninety-five patients presenting with acetaminophen overdose were admitted to the EDOU while 184 were admitted to the general ward. Of these, 27 patients admitted to EDOU did not meet the admission criteria for it while 71 patients who met EDOU criteria were admitted to the ward instead. For patients who fulfilled EDOU admission criteria, median length of stay for EDOU patients was 23 h (IQR 19–24) while that for those admitted to the ward was 66 h (IQR 62.5–88.3).ConclusionThe EDOU is a safe alternative to hospitalisation for patients presenting with acetaminophen poisoning. It is also associated with a shorter length of stay for such patients. Further studies need to be done to assess the cost-effectiveness of EDOU for management of patients presenting with acetaminophen overdose.

Evaluating the Emergency Department Observation Unit for the management of hyperglycemia in adults

ObjectiveTo determine whether hyperglycemic patients can be successfully managed in the Emergency Department Observation Unit (EDOU), as determined by the frequency of inpatient admission following their EDOU stay. MethodsThis was a retrospective chart review of patients≥18years presenting to an academic tertiary care ED between May 1, 2014 and May 31, 2016, found to have a glucose≥300mg/dL, and selected for EDOU admission. Patient demographic information, lab results including an HbA1c, disposition, and hospital revisits within 30days of discharge were recorded. ResultsThere were 124 EDOU patients meeting criteria. A total of 98/124 (79.0%) had a history of type 1 or 2 diabetes, and 26/124 (21.0%) were newly diagnosed with diabetes in the EDOU. The mean initial ED serum glucose was 467±126mg/dL. Of the 119 patients with HbA1c analyzed, the mean value was 12.1±2.2% (109±24mmol/mol) and in 112/119 (94.1%) the level was ≥9.0% (75mmol/mol). Overall, 104/124 (83.9%) were discharged from the EDOU, 18/124 (14.5%) were admitted to the inpatient service, and 2/124 (1.6%) left the EDOU against medical advice. A total of 7/124 (5.6%) patients returned to the ED within 30days of discharge with hypoglycemia, hyperglycemia, or diabetic ketoacidosis, 6/7 (85.7%) of whom had been discharged from the EDOU. ConclusionsResults suggest hyperglycemic patients selected by ED physicians can be managed in the EDOU setting. Nearly all patients managed in the EDOU for hyperglycemia had an HbA1c≥9.0%, suggesting unrecognized or poorly controlled chronic diabetes as the basis for hyperglycemia.

Antibiotic-associated diarrhoea in emergency department observation unit patients.

Clostridium difficile diarrhoea is an urgent threat to patients, but little is known about the role of antibiotic administration that starts in emergency department observation units (EDOUs). We studied risk factors for antibiotic-associated diarrhoea (AAD) and C. difficile infection (CDI) in EDOU patients. This prospective cohort study enrolled adult patients discharged after EDOU antibiotic treatment between January 2013 and 2014. We obtained medical histories, EDOU treatment and occurrence of AAD and CDI over 28 days after discharge. We enrolled and followed 275 patients treated with antibiotics in the EDOU. We found that 52 (18·6%) developed AAD and four (1·5%) had CDI. Patients treated with vancomycin [relative risk (RR) 0·52, 95% confidence interval (CI) 0·3-0·9] were less likely to develop AAD. History of developing diarrhoea with antibiotics (RR 3·11, 95% CI 1·92-5·03) and currently failing antibiotics (RR 1·90, 95% CI 1·14-3·16) were also predictors of AAD. Patients with CDI were likely to be treated with clindamycin. In conclusion, AAD occurred in almost 20% of EDOU patients with risk factors including a previous history of diarrhoea with antibiotics and prior antibiotic therapy, while the risk of AAD was lower in patients receiving treatment regimens utilizing intravenous vancomycin.

419 Health Care Effectiveness Data and Information Set Criteria for Lower Back Pain Imaging in Emergency Department Observation Unit Patients: Compliance and Association With Early Intervention

419 Health Care Effectiveness Data and Information Set Criteria for Lower Back Pain Imaging in Emergency Department Observation Unit Patients: Compliance and Association With Early Intervention

Treatment of bacterial skin infections in ED observation units: factors influencing prescribing practice

ObjectiveThe Infectious Disease Society of America (IDSA) publishes evidence-based guidelines for the treatment of skin and soft tissue infections. How closely physicians follow these guidelines is unknown, particularly in the emergency department observation unit (EDOU) where increasing numbers of patients are treatment for these infections. Our objectives were to describe (1) the antibiotic treatment patterns EDOU patients, (2) physicians' adherence to the IDSA guidelines, and (3) factors that influence physician's prescribing practices. MethodsThis prospective cohort enrolled adult patients discharged from an EDOU at an academic medical center after treatment for a skin or soft tissue infection. Information was collected from chart review and patient interview pertaining to the patient's sociodemographic characteristics, presenting illness, and antibiotic treatment regimens. Treatment regimens were compared with national guidelines. ResultsThe study included 193 patients of which only 43% were treated according to IDSA guidelines, 42% were overtreated, and 15% were undertreated. Women were more likely to be undertreated (relative risk, 1.58; 95% confidence interval, 1.21-2.06), whereas patients 50 years and older were at risk for overtreatment (relative risk, 1.44; 95% confidence interval, 1.03-2.02). Women also received shorter courses of antibiotic therapy with an average of 9.6 days of treatment compared with 10.6 days for men. ConclusionsPhysician antibiotic prescribing practices demonstrated poor adherence to IDSA guidelines and were influenced by the patient's age and sex. Standardized antibiotic protocols for treatment of skin and soft tissue infections to IDSA guidelines in the EDOU would minimize physician bias.

Imaging utilization from the ED: no difference between observation and admitted patients

ObjectivesThis study aims to determine the use of diagnostic imaging in emergency department (ED) observation units, particularly relative to inpatients admitted from the ED. Study DesignRetrospective, descriptive analysis. MethodsOur 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. ResultsEighty (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%). ConclusionThere 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.

Discharge from an emergency department observation unit and a surgical assessment unit: experiences of patients with acute abdominal pain

To investigate the experiences of patients with acute abdominal pain at discharge from an emergency department observation unit compared with discharge from a surgical assessment unit. The increase in emergency department observation units has increased short-term admissions and changed the patient journey from admission and discharge from specialised wards staffed by specialist nurses to admission and discharge from units staffed by emergency nurses. A comparative qualitative interview study. The study included 20 patients: 10 from an emergency department observation unit and 10 from a surgical assessment unit, and took a phenomenological-hermeneutic approach. Patients were interviewed at discharge and three months later. More patients from the emergency department observation unit experienced readiness for discharge and had plans for follow-up, compared with patients from the surgical assessment unit. In the surgical assessment unit, more patients were readmitted, had unanswered questions after three months and experienced a follow-up visit at the general practitioner as insufficient. More patients from the surgical assessment unit reported receiving useful self-care advice, compared with those from the emergency department observation unit. The experience of emergency department observation unit patients on discharge and follow-up was that the health professionals were more supportive, compared with surgical assessment unit patients, who felt discharge occurred too early, but with more preparation for independent home self-care. These results are an important factor in the patient experience of discharge from hospital and may reflect differences in specialisation of the nurses. Units discharging patients with acute abdominal pain could be inspired by scheduled fast-track surgery programmes with structured information about admission, treatment and follow-up and easy access to relevant health professionals after discharge.

Abstract T P183: Transient Neurological Symptoms with MRI Evidence of Infarction in an Emergency Department Observation Unit

Background: Transient symptoms with infarction (TSI) is distinguished from transient ischemic attack (TIA) by the presence of diffusion-weighted imaging (DWI) lesions on MRI. We report a series of patients with DWI lesions identified in an emergency department observation unit (EDOU) TIA protocol. Methods: Patients were treated in the ED of a tertiary care center (annual census=100,000 visits). In the first 3 months of operation of an EDOU for TIA, 50 patients met inclusion criteria of sudden/transient neurological deficit in the absence of known metabolic or cardiac source. Patients were excluded from the study if they demonstrated: persistent or stuttering deficits; fever &gt;100.4F, heart rate &lt;60 or &gt;100 bpm; SBP &gt;180 or &lt;100mmHg; pulse ox &lt;93%; or positive CT. Evaluation included: laboratory analyses; CT/MRI/MRA of the head/neck; EKG; echocardiogram, and neurology consult. MR data (ED 1.5T MR unit) include: DWI, ADC, GRE, and T2FLAIR images. Patients with TSI, were identified by the presence of 1 or more DWI bright and ADC dark lesions on ED MRI. All patients completed CT and MR imaging within &lt; 24 hours of admission. This study was approved by the hospital IRB. Results: TSI was identified in 10/50 EDOU patients (Mdn age 72.5, ABCD2 score 5). Two patients demonstrated infarcts in multiple vascular territories. Table 1 illustrates patient demographics, comorbidities, presentations, and outcome. Fifty percent of TSI patients were admitted from EDOU, 3 patients returned to the ED within 30 days , and no 30 day distinct recurrent events, such as recurrent stroke were identified. Conclusions: EDOU for TIA including DW-MRI resulted in TSI diagnosis in 20% of patients. In the TSI cases identified, infarct locations were heterogeneous; vascular and/or cardiac etiology must be considered. Longitudinal analysis is recommended to further assess the relationship between presentation, TSI risk, risk of recurrent stroke, and need for hospital admission.

Prospective Evaluation of a Simplified Risk Stratification Tool for Patients With Chest Pain in an Emergency Department Observation Unit

The Thrombolysis in Myocardial Infarction score has been validated as a risk stratification tool in the emergency department (ED) setting, but certain aspects of the scoring system may not be applicable when applied to patients with chest pain selected for ED observation unit (EDOU) stay. We evaluated a simplified, 3-point risk stratification tool for patients in EDOU, which we termed the CARdiac score: Coronary disease [previous myocardial infarction (MI), stent, or coronary artery bypass graft (CABG)], Age (65 years or older), and Risk factors (at least 3 of 5 cardiac risk factors). We performed a prospective, observational study with 30-day phone follow-up for all patients with chest pain admitted to our EDOU over a 36-month period. Baseline data, outcomes related to EDOU stay, inpatient admission, and 30-day outcomes were recorded. CARdiac scores were calculated based on patient history and were used to evaluate the risk of the composite outcome of MI, stent/CABG, or death during the EDOU stay. CARdiac scores were also used to evaluate the risk of inpatient admission. The CARdiac score was not used during the EDOU stay and was calculated blinding to patient outcomes. One thousand two hundred seventy-six patients were evaluated. Average age was 54.1 years (18-92 years) and 46% were male. Forty patients experienced composite outcomes: stent (32), CABG (4), MI and stent (2), MI and CABG (1), and MI (1). Risk of the composite outcome generally increased by CARdiac score: 0 (1.5%), 1 (3.6%), 2 (9%), and 3 (5.4%). Patients with a CARdiac score of 2 or 3 (moderate risk) were significantly more likely to experience MI, stent, or CABG than those with a score of 0 or 1 (low risk): 16/193 moderate-risk patients (8.3%) had the composite outcome versus 24/1083 low-risk patients (2.2%, P < 0.001, relative risk = 3.8). Those at moderate risk by the CARdiac score were also more likely to require inpatient admission from the EDOU (17.6% vs. 9.8%, P < 0.001). The CARdiac score may prove to be a simple tool for risk stratification of patients with chest pain in an EDOU. Patients at moderate risk by CARdiac score may be appropriate for more intensive evaluation in the EDOU or consideration for inpatient admission rather than EDOU placement.

EDOU staffing by PAs: What are the effects on patient outcomes?

An emergency department observation unit (EDOU) opened in April 2006 staffed by physician assistants (PAs) and nurse practitioners (NPs). This study describes the complexity and outcomes of the EDOU patients to determine the effectiveness of staffing by PAs. A retrospective chart review was performed of chest pain and trauma patients in the EDOU from April 2006 through May 2007. Patient characteristics, length of stay (LOS), and admission rates were recorded. Adverse events were monitored, and trauma patients were followed for 30 days to evaluate for missed injuries. 531 chest pain patients and 364 trauma patients were admitted to the EDOU during the study period. Average chest pain patient LOS was 14 hours and 32 minutes, and 12.2% of patients were admitted from the EDOU to an inpatient unit. For trauma patients, average LOS was 12 hours and 46 minutes, and 11.5% of patients were admitted to an inpatient unit. There were no deaths, intubations, or loss of vital signs. In 30-day follow-up, there were no significant missed injuries among trauma patients. PAs effectively cared for patients of moderate complexity in the two largest groups of utilizers of the EDOU.

Primary spontaneous pneumothorax—the role of the emergency observation unit

Objective The objective of this study was to compare an expedited 24-hour management pathway against traditional inpatient ward management of patients with primary spontaneous pneumothorax (PSP) and recurrent spontaneous pneumothorax (RSP). Method This was a retrospective chart review of all patients who presented with either PSP or RSP to an urban tertiary university hospital in 2007. Results Eighty-two patients were included in the study, of which approximately a third (27) were managed in the emergency department observation unit (EDOU). Five of the EDOU patients were admitted to the ward. Emergency department observation unit treatment failures as defined by recurrences within a week were comparable to those managed in the ward. One of 5 PSP patients receiving only oxygen therapy managed in the EDOU had their pneumothorax recur within a week on discharge, whereas none of the 15 receiving needle aspiration recurred within a week. For the RSP patients managed in the EDOU, 1 of 3 managed with oxygen therapy alone and discharged recurred within a week, whereas with needle aspiration, 1 of 4 recurred within a week. The success rate of aspiration in our study was comparable with that of published rates (75% versus 50%-60%). Conclusions Small to moderate PSPs can be safely and efficiently managed within 24 hours in an EDOU.

The Recidivism Characteristics of an Emergency Department Observation Unit

We describe the recidivism characteristics of an adult emergency department (ED) observation unit population and determine whether rates differ according to demographic or clinical features. This prospective observational cohort study of a protocol-driven ED observation unit reviewed all discharged ED observation unit patients who returned within 14 days of discharge for an unscheduled ED visit or direct inpatient admission to the study hospital, or a proximate affiliated hospital, during 6 consecutive months. Age, sex, initial ED observation unit diagnosis, ED observation unit length of stay, and return visit disposition were determined from hospital databases and confirmed by chart review. All return visits were classified as related or unrelated to the index visit. There were 55,727 ED visits, with 4,348 patients admitted to the ED observation unit, of whom 80.7% (3,509) were discharged. Patients with or without a return visit were similar in terms of age (56.9 years [standard deviation (SD) 19.5 years]), percentage of male patients (40.0%), or initial ED observation unit length of stay (15.0 hours [SD 6.0 hours]). Of discharged ED observation unit patients, 375 (10.8%) had a return visit, of which 277 (7.9%) were related. Of return visits, 86.3% of patients had only 1 return visit, 11.6% had 2, and 2.1% had 3 or more; 4.2% of returns occurred at an affiliated hospital. Time to first return visit was clustered within the first week for related visits, with a mean time to return of 4.5 days (SD 3.9 days). On return visit, 40.2% of patients were treated and discharged from the ED, 36.2% were treated in the ED and admitted, 14.4% were treated in the ED and then the ED observation unit and discharged home, 12.3% were directly admitted to the hospital, and 2.5% were treated in the ED and then the ED observation unit and admitted. Among common conditions, related return visit rates were highest for headache (16.1%), back pain (13.8%), and abdominal pain (12.7%) and lowest for chest pain (3.6%). As a group, therapeutic protocols, and specifically painful conditions, had significantly higher related return visit rates than diagnostic protocols (10.8% versus 5.1%). Patients who return after an ED observation unit visit are similar to patients who do not return in terms of age, sex, or initial length of stay. However, ED observation unit recidivism rates do differ according to observation category, with painful conditions showing the highest recidivism rates.

A Prospective, Randomized Trial of an Emergency Department Observation Unit for Acute Onset Atrial Fibrillation

An emergency department (ED) observation unit protocol for the management of acute onset atrial fibrillation is compared with routine hospital admission and management. Adult patients presenting to the ED with atrial fibrillation of less than 48 hours' duration without hemodynamic instability or other comorbid conditions requiring hospitalization were enrolled. Participants were randomized to either ED observation unit care or routine inpatient care. The ED observation unit protocol included pulse rate control, cardiac monitoring, reassessment, and electrical cardioversion if atrial fibrillation persisted. Patients who reverted to sinus rhythm were discharged with a cardiology follow-up within 3 days, whereas those still in atrial fibrillation were admitted. All cases were followed up for 6 months and adverse events recorded. Of the 153 patients, 75 were randomized to the ED observation unit and 78 to routine inhospital care. Eighty-five percent of ED observation unit patients converted to sinus rhythm versus 73% in the routine care group (difference 12%; 95% confidence interval [CI] -1% to 25%]; P=.06). The median length of stay was 10.1 versus 25.2 hours (difference 15.1 hours; 95% CI 11.2 to 19.6; P<.001) for ED observation unit and inhospital care respectively. Nine ED observation unit patients required inpatient admission. Eleven percent of the ED observation unit group had recurrence of atrial fibrillation during follow-up versus 10% of the routine inpatient care group (difference 1%; 95% CI -9% to 11%; P=.93). There was no significant difference between the groups in the frequency of hospitalization or the number of tests, and the number of adverse events during follow-up was similar in the 2 groups. An ED observation unit protocol that includes electrical cardioversion is a feasible alternative to routine hospital admission for acute onset of atrial fibrillation and results in a shorter initial length of stay.