Emergency Department Observation Unit Research Articles

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.

Abstract T MP74: The Diagnosis, Etiologic Classification, and Safe Discharge of Ischemic Strokes with Transient Symptoms from an Emergency Department Observation Unit

Background: Patients with a clinical diagnosis of transient ischemic attack (TIA) who have imaging evidence of infarction portend a high risk of short-term recurrent stroke. Emergency Department Observation Units (EDOU) offer an alternative to hospital admission and are becoming increasingly utilized for acute cerebrovascular emergencies. Hypothesis: We sought to determine whether an EDOU protocol emphasizing etiologic determination and individualized secondary prevention could be a safe alternative to hospital admission for suspected TIA patients with and without brain infarction. Methods: We prospectively studied 189 patients admitted to the TIA EDOU of a single tertiary care academic medical center. There was no ABCD2 cutoff for eligibility and exclusion criteria included persistent deficits or another diagnosis warranting hospitalization. Patients underwent DW-MRI/MRA of the head and neck unless contraindicated, transthoracic echocardiogram and bedside neurologist evaluation. Etiologic subtyping was determined using the Causative Classification System (CCS). 30-day follow-up was performed on all patients by telephone and/or review of medical records. This study was approved by the hospital IRB. Results: Acute ischemic stroke was diagnosed in 31 (16%) of patients, including 30 with DWI lesions and 1 in whom MRI was contraindicated, but had clinical worsening while in the EDOU. An evident or probable etiology was determined by CCS subtyping in 38% of strokes and 32% of TIAs (17% atherosclerosis, 12% cardioembolism, 5% small vessel). Of the total cohort, 84% were discharged from the EDOU including 16 (52%) with confirmed stroke. Median LOS was 22 hours (IQR: 17-25). At 30 days, one patient was found to have a small recurrent stroke (0.7%). There was 1 non-stroke related death. Twenty (11%) overall returned to the ED, the vast majority (70%) from the non-stroke cohort. Conclusions: Not all ischemic stroke patients require hospitalization. An EDOU is a safe and effective alternative for the complete diagnostic evaluation and management of patients with transient neurologic symptoms. Further study of cost and quality effectiveness in warranted.

Abstract W P185: Clinical Predictors of Stroke, TIA and Mimic among Patients with Transient Neurological Dysfunction Admitted to an Emergency Department Observation Unit

Background: In patients with resolved symptoms, transient ischemic attack (TIA) is distinguished from ischemic stroke by neuroimaging evidence of acute infarction. DW-MRI has been shown to be more sensitive at detecting infarction than CT, but is not uniformly available in the acute setting. Hypothesis: We sought to identify predictors of stroke diagnosis among a cohort of clinically suspected TIA patients undergoing an accelerated diagnostic protocol in an emergency department observation unit (EDOU). Methods: We prospectively studied 189 patients treated in the EDOU of a single tertiary care academic medical center. Patients underwent DW-MRI of the brain (unless contraindicated), and bedside neurologist evaluation. A CT scan of the brain was considered optional prior to EDOU admission. We compared the odds of extremity weakness, sensory loss, facial droop, visual disturbance, slurred speech, aphasia, dizziness, and headache between patients with final diagnosis of stroke, TIA and mimic. This study was approved by the hospital IRB. Results: Thirty-one patients (16%) were diagnosed with an acute ischemic stroke, 85 (45%) TIA, and 73 (39%) mimic. Mean age was 64.8 years (SD = 15.5; range = 30-90). DW-MRI was performed on 92% of patients. A CT scan was also performed in 80% of patients diagnosed with stroke and 0 were diagnostic. Median ABCD2 scores were 4 for stroke and TIA (IQR 3-5) and 3 for mimic (IQR 2-4). Only headache symptoms predicted lower odds of stroke (OR 0.22; 95% CI: 0.05-0.96). Both headache (OR 1.44; 95% CI: 1.03-2.03) and visual disturbance (OR 3.14; 95% CI: 1.49-6.65) increased the odds of mimic diagnosis, but were also present in 13% and 10% of stroke patients respectively. Slurred speech (OR 0.48: 95% CI: 0.25-0.93); aphasia (OR 0.34 95% CI: 0.15-0.76) and facial droop (OR 90.36: 95% CI: 0.14-0.94) significantly predicted lower odds of mimic diagnosis. Conclusions: In our investigation of patients with transient neurologic dysfunction in an EDOU, stroke diagnosis was common and could not be predicted by clinical variables alone. Early DW-MRI should be considered in all TIA patients, especially those reporting slurred speech, aphasia or facial droop.

Abstract W P196: Utility of Echocardiography in the Evaluation of Transient Ischemic Attack Patients

Background: Current guidelines recommend that patients presenting with transient ischemic attack (TIA) undergo echocardiography to evaluate for a cardiac source. The aim of this study was to determine the utility of transthoracic echocardiography (TTE) in TIA patients evaluated as part of an emergency department observation unit (EDOU) protocol. Methods: Prospectively identified TIA patients presenting to the Emory University Hospital EDOU from January 1, 2011 to July 31, 2013 were eligible for this analysis if they had a final discharge diagnosis of TIA. Baseline patient characteristics, diagnostic test results, and clinical outcome at 3 months were retrospectively collected. An abnormal TTE was defined as an ejection fraction (EF) ≤ 45%, significant regional wall motion (RWM) abnormality, significant diastolic dysfunction (DD), valvular mass, presence of clot, or positive bubble study. Results: Of 236 patients discharged with a diagnosis of TIA during the study period, mean age was 62 ±15 years, 68% were female, 57% were African American, 17% had a history of prior stroke, 27% had history of cardiac disease, and mean ABCD2 score was 3.8 ±1.5. Overall, 19 (8%) patients had an abnormal bedside cardiac exam, 44 (19%) patients had an abnormal ECG, and 51 (22%) patients had an abnormal TTE including 18 with EF ≤ 45%, 6 with significant RWM abnormality, 9 with significant DD, 2 with clot, and 32 with positive bubble study; no valvular masses were seen. At 3 months, there was no significant difference in outcomes among patients with and without abnormalities on TTE (stroke 1.5% vs 1.8%, p=1.0; myocardial infarction 0 vs 1.2%, p=1.0). Among the 125 patients with no history of stroke or coronary artery disease and normal cardiac exam and ECG, TTE identified 5 (4%) patients with EF ≤ 45%, 17 (14%) patients with positive bubble study and no patients with significant RWM abnormalities, diastolic dysfunction, valvular mass, or clot; at 3 months, 2 (1.6%) of these patients had a stroke and no patients had a myocardial infarction. Conclusion: Among TIA patients with no history of stroke or coronary artery disease, normal cardiac exam, and normal ECG, TTE has a low yield.

Abstract T P217: Sex Differences in Clinical Presentation and Outcome: Patients Admitted to a Transient Ischemic Attack Emergency Department Observation Unit

Background: There are known sex differences in presenting symptoms and outcomes of stroke patients, yet little is known about sex differences in patients with transient ischemic attack (TIA). Our aim is to conduct an exploratory study of sex differences in symptoms, clinical characteristics, and outcomes among patients admitted to an ED observation unit (OU). Methods: Patients seen in a large, urban, academic ED with a diagnosis of TIA and admitted to the ED OU between 4/13 and 3/14 were included. Patients were excluded if they had persistent neurological deficits, fever >100.4, heart rate <60 / >100 bpm, SBP >180 / < 100 mm Hg, pulse ox <93%, or other competing ED diagnoses. Patients were evaluated using standard blood tests, EKG, echocardiogram, ED MRI/A of the head and neck, and neurology consultation. Using bivariate analyses, women and men were compared with respect to presenting symptoms, risk factors, acute infarct on MRI/A, and recurrence of symptoms. The study was approved by the hospital IRB. Analyses were conducted using Stata 12.1. Results: 136 patients met inclusion criteria; 52.2% were women. Women and men were similar in mean age (63.8, 95% CI 59.2 - 68.4, vs. 65.4, 95%CI 61.7 - 69.0) and percent non-white (22.5% vs. 24.6%, p=0.78). More women than men reported motor symptoms (53.5% vs. 30.8%, p=0.007), while more men reported visual changes (24.6% vs. 9.9%, p=0.02), dizziness (30.8% vs. 19.7%, p = 0.14), and symptoms coded as ‘other’ (36.9% vs. 22.5%, p=0.07). Women had longer median times of symptom duration (60 min, IQR 10 - 120, vs. 30 min, IQR 10 - 90). 25.5% of women vs. 22.0% of men had acute infarcts on MRI/A (p=0.68), and 5.7% of women compared to 1.5% of men reported recurrence of symptoms at 30 days (p=0.21). Conclusions: In our exploratory study of sex differences in ED TIA patients, women were less likely to report “non-traditional” symptoms, a finding contrary to current literature in stroke patients. Although these findings should be investigated in future studies of TIA patients, this may suggest an inherent bias in those referred to an ED TIA OU. Future studies should investigate potential sex differences in disposition to admission versus observation unit after TIA, cerebral distribution of acute vascular event, and the recurrence of symptoms.

Implementation of a horizontal intensive care team can impact efficiency in an emergency observation unit in Brazil

Emergency department observation units are often used to monitor critical patients in a situation of constant emergency department overcrowding and lack of intensive care beds. However, those units are often understaffed and might not have enough personnel and equipment to provide the same quality of care as a conventional ICU.

Concurrent Spontaneous Sublingual and Intramural Small Bowel Hematoma due to Warfarin Use.

Introduction. We present a case of concurrent spontaneous sublingual and intramural small bowel hematoma due to warfarin anticoagulation. Case. A 71-year-old man presented to the emergency department complaining of a swollen, painful tongue. He was on warfarin therapy. Physical examination revealed sublingual hematoma. His international normalized ratio was 11.9. The computed tomography scan of the neck demonstrated sublingual hematoma. He was admitted to emergency department observation unit, monitored closely; anticoagulation was reversed with fresh frozen plasma and vitamin K. 26 hours after his arrival to the emergency department, his abdominal pain and melena started. His abdomen tomography demonstrated intestinal submucosal hemorrhage in the ileum. He was admitted to surgical floor, monitored closely, and discharged on day 4. Conclusion. Since the patient did not have airway compromise holding anticoagulant, reversing anticoagulation, close monitoring and observation were enough for management of both sublingual and spontaneous intramural small bowel hematoma.

Implementation of a Community Hospital-Based Fast Track Pathway for the Treatment of Acute Pain Episodes in Adults with Sickle Cell Disease

▪Background: A growing number of adult patients with sickle cell disease (SCD) receive care in a community setting and often lack access to physicians with sickle cell expertise. To address this healthcare disparity we are testing a co-management medical home model with Hematology/Oncology (H/O) and Family Medicine (FM) physicians to facilitate evidence-based acute and chronic care. An Emergency Department (ED) Observation Unit based pathway for treatment of sickle cell pain developed at an academic medical center with a Comprehensive Sickle Cell Center (CSCC) has been adopted and modified to fit the needs of a community multi-specialty hospital with an unopposed FM residency program. The hospital serves a large sickle cell population in a predominantly rural setting with the closest CSCC 180 miles away.Methods: Pathway development was facilitated by having a formal meeting for the community hospital physicians and staff at the academic medical center and sickle cell experts providing ongoing on site consultation at the community hospital. Protocols for the community hospital were produced with input from physicians, nurses, advanced practice providers, and support services at multiple meetings. Adult patients with SCD presenting to the ED with pain are triaged at Emergency Severity Index Level 2 for evaluation by the ED physician. The ED protocol uses specific criteria to identify patients with uncomplicated pain. Patients presenting with abnormal vital signs (other than mild tachycardia), fever, pregnancy, or apparent other sickle cell-related complications are excluded. Patients qualifying for the pathway are directly admitted to the SCD unit (a hospital room with 4 infusion chairs on the H/O floor exclusively designated for care of sickle cell patients). Following intake evaluation by the nurse, a clinician is notified to evaluate the patient and provide orders for intravenous fluids and opioid patient controlled analgesia (PCA) which is administered according to hospital guidelines. PCA by the subcutaneous route is used if intravenous access is not readily available. A CBC is obtained whereas other laboratory testing and imaging studies are ordered based on clinical indications. H/O physicians and nurse practitioners cover the unit weekdays 8:00am-5:00pm and FM residents cover nights and weekends with back up by the on call H/O physician. Patients can be treated in the SCD unit up to 23 hours. For patients discharged home a follow up phone call by an H/O nurse will be placed within 3 days and an outpatient clinic appointment is scheduled to be within 7 days. Monthly quality assurance meetings are attended by H/O, FM, and ED physicians as well as nursing, pharmacy and administrative staff from the ED and H/O inpatient service to review process issues and patient outcomes. Consultation is provided by academic physicians with sickle cell expertise (H/O and ED) who attend each meeting in person or by conference call.Results: From March 5-June 30, 2014, 67 patients accounted for 271 visits to the SCD unit. The mean time in the unit was 13.6 hours. The mean pain score on admission was 8.7/10 and reduced to 4.9 upon discharge. PCA drug, pump setting, and dosage are recorded to be used for future visits. Over the 4 months 91.1% of the patients were discharged home from the unit. Six patients accounted for 31% (84) of the visits with only 4 hospital admissions.Conclusions: A fast track pathway for the treatment of acute sickle cell pain coordinated between ED, H/O, and FM physicians has been implemented at a community hospital using an Observation Unit based treatment program. During the entire initial experience the majority of patients have been discharged home with adequate pain relief. In the future the impact of the program will be evaluated including effect on frequency of hospitalizations, outpatient follow up, patient satisfaction, and cost effectiveness. The pathway can be adapted to other community hospital settings where sickle cell expertise is not locally available. DisclosuresKutlar:NIH/NIMHD: Research Funding.

Abstract 16592: The Diamond-Forrester Criterion Significantly Overestimates the Risk of Obstructive Coronary Artery Disease in Patients Presenting to the Emergency Department With Low-Risk Chest Pain

Introduction: We sought to (1) classify patients who underwent stress echocardiography in an emergency department observation unit based on their pretest probabilities of obstructive CAD using the Diamond-Forrester criterion, (2) to compare observed versus expected frequencies of obstructive CAD based on the Diamond-Forrester risk categories of low (<25%), intermediate (25-75%), and high (>75%) pretest probability of disease, and (3) to test the association of traditional cardiovascular risk factors (age, gender, hypertension, diabetes, high cholesterol, and smoking) with obstructive CAD. METHODS: Retrospective review of the electronic medical record for patients who presented to the emergency department with chest pain and underwent observation followed by stress echocardiography between the period January 1, 2012 to December 31, 2012. Patients were classified as low, intermediate, or high risk for obstructive CAD using the Diamond-Forrester criterion. Main outcome measures were stress echocardiography results as well as receipt of cardiac catheterization and results. RESULTS: A total of 504 patients were included in the final analysis. Overall, 4.8% had a positive stress test and only 1.2% had angiographic evidence of obstructive CAD. In each category of risk, the observed frequency of obstructive CAD was significantly lower than expected. Having a high pretest probability as defined by the Diamond-Forrester criterion was significantly associated with obstructive CAD. Age, gender, diabetes, hypertension, high cholesterol, and smoking were not independently associated with evidence of obstructive CAD; nor were any composites of these risk factors. CONCLUSIONS: The traditional Diamond-Forrester criterion significantly overestimates the probability of obstructive CAD in ED observation unit patients. Reliance on the Diamond-Forrester criterion and other traditional risk factors associated with obstructive CAD in the outpatient setting could lead to faulty Bayesian reasoning, overuse of non-invasive imaging, and improper interpretation of test results in an ED population of low-risk chest pain patients. Further work is required to determine an optimal risk-assessment strategy for this patient population.

Dermatological consultations in an observation unit of an emergency department in Italy.

Dermatological emergencies exist and should not be underestimated. On the other hand, many accesses to the emergency department (ED) of patients with dermatological conditions are unjustified. Our main objective is to describe dermatological conditions seen in an ED observation unit (EDOU). Secondly, our aim is to identify alarm symptoms and signs of 'true emergencies'. We conducted a prospective study, including dermatological patients admitted to EDOU of the University Hospital of San Martino, Genoa, Italy, in 3 years. Overall 372 patients were studied. The most common condition seen was infection (41.67%) (mainly bacterial), followed by atypical exanthem (13.98%) and vasculitis (11.29%). The highest rate of cases peaked in May (13%); infectious diseases showed two peaks (spring and autumn). Given constraints involved in health care today, it is crucial to understand which dermatological presentations are 'true emergencies'. In such a scenario knowing the epidemiology of dermatological emergencies and the alarming skin signs and symptoms might be useful.

Physical Therapist Practice in the Emergency Department Observation Unit: Descriptive Study

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. 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. 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. 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. 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. This was a retrospective study, so there was no ability to control how data were recorded. 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.

PS-345 Reduction Of Paediatric Emergency Hospital Admissions By Modifications In Paediatric Emergency Department Policy

Background Reduction in admissions is an important aim of emergency department working policy to overcome the problems of a shortage of inpatient beds, rising costs and exhausted resources. A new policy was instituted in the paediatric emergency department (PED) of a hospital in Kuwait with the following components: (1) assigning senior doctor staff (2) implementation of new disease management guidelines; and (3) maximising the useof the paediatric emergency department observation unit. Objective To evaluate the effect of change in our policy on the admission rate. Methods The effects of this policy on reduction of admission rates for total paediatric admissions and for some selected common paediatric conditions were prospectively studied over a period of 3 years from institution of the policy and compared with the 3-year period before the policy was instituted. Results There was a significant reduction in admission rates after institution of the new policy. The proportion of hospital admissions to PED observation unit cases was significantly reduced as a whole from 64.9% ± 5.1% to 33.2 ± 0.6% and also for the common paediatric problems studied. Conclusion A multidisciplinary paediatric emergency department policy, using as much available evidence as possible, was successful in significantly reducing paediatric hospital admissions.

288 Evaluation of Syncope in a Dedicated Observation Unit

The purpose of this study is to 1) determine the clinical background of patients evaluated for syncope in the emergency department (ED) observation unit (EDOU) and 2) determine which characteristics predict appropriateness of an EDOU level of care versus direct inpatient admission. This is a retrospective analysis of the 171 patients placed in the EDOU between March 2013 and July 2013 following evaluation in the ED for syncope. The study site is located in a diverse urban setting with a volume of 130,000 visits per year. The EDOU receives an average of 450 patients per month for a variety of chief complaints with an admission conversion rate of approximately 25%. Each patient file was reviewed by two trained evaluators to ensure accuracy. Patients were assigned to two different groups: those admitted during the EDOU evaluation (admitted group) and those discharged home from the EDOU (not admitted group). Descriptive statistics were computed for study variables to ensure that all data values were within expected ranges and to eliminate any data errors that may have occurred. SPSS version 21 was used to conduct the analysis. Chi-square and independent sample t-test were used to determine significant differences between groups. The sample consisted of 171 patients. The demographics of the patients evaluated are representative of the patient population of the study site. Of the 171 patients, 142 were discharged from the EDOU while 29 were converted to inpatient admissions from the EDOU. There were no significant differences between groups based on age (P=.756), sex (P=.449) or race/ethnicity (P=.310). There was no significant difference in the average number of past medical diagnoses for the admitted group and those discharged home (P=.796). However, admitted patients had significantly higher rates of reported medical history of syncope (27.6% versus 11.3%), P=.021, diabetes mellitus (DM) (37.9% versus 19.7%), P=.033, and an abnormal result in initial cardiac enzymes (20.7% versus 5.7%), P=.007. Of the 29 admitted patients, 15 (8.8% of the overall sample) developed unstable arrhythmias or non-ST elevation myocardial infarction (NSTEMI) with a median time to admission of 24 hours. With the exception of cardiac enzyme testing, no objective lab data, ECG finding, nor diagnostic testing, obtainable in the initial ED evaluation predicted the need for inpatient evaluation. The only statistically significant independent predictors of inpatient evaluation are a positive initial cardiac enzyme result, previous episode of syncope, and a past medical history that includes diabetes mellitus (DM). These factors may be used to create the inclusion and exclusion criteria for transfer to an EDOU. After initial evaluation, a finding of positive cardiac enzymes or a history of DM or previous syncope may be deemed grounds for exclusion from the EDOU. Using these exclusion criteria may help expedite evaluation and allocation of resources appropriately thereby positively impacting patient safety. This study was limited by the retrospective analysis of data. Future research will evaluate the differences between patients directly admitted for syncope versus those transferred to the EDOU first and then subsequently admitted. Applying the data learned from this study can help guide the appropriate care and ED disposition of patients thereby improving patient safety, patient flow, and hospital reimbursement.

180 The Appropriate Utilization of Emergency Department Observation Units Analysis of Patients With the Ten Most Common Admission Diagnoses

180 The Appropriate Utilization of Emergency Department Observation Units Analysis of Patients With the Ten Most Common Admission Diagnoses

397 Outcomes of Unintentional Pediatric Ingestions in a Pediatric Emergency Department Observation Unit: Which Ingestion is Most Likely to Lead to an Admission?

397 Outcomes of Unintentional Pediatric Ingestions in a Pediatric Emergency Department Observation Unit: Which Ingestion is Most Likely to Lead to an Admission?

A new charging scheme in an emergency department observation unit under Beijing’s basic medical insurance

The new medical insurance policy (JRSYF(2010) No.255) was released by the Beijing Municipal Government and became effective on January 1, 2011. Medical expenses incurred during a stay in an emergency department (ED) observation unit can be reimbursed as a hospital admission. The aim of this study was to evaluate the impact of a new charging scheme during stays in ED observation unit under Beijing's Basic Medical Insurance. Data for those patients who had stayed in ED observation unit in 2010 (before the implementation of a new charging scheme) and 2012 (after the implementation of this policy) were retrospectively analyzed in terms of length of stay, patients who were observed (PO), and median medical costs. After the implementation of a new charging scheme, compared with the year of 2010, in year of 2012, there were statistically significant longer lengths of stay at the observation unit (6 (4-9) vs. 5 (4-7) days; P < 0.001), more PO (2 257 vs. 1 783; P < 0.001), and more median medical costs (RMB 6 026 vs. 3 650 Yuan; P < 0.01). The proportion of elderly patients (≥ 60 years of age) in 2012 was larger than that in 2010 (70.22% vs. 63.71%; P < 0.01). It was performed on those patients who were admitted after the implementation of a new charging scheme. Compared with patients who were not admitted had stayed in ED observation units, the patients who were admitted had stayed in ED observation units that had a higher proportion for >15 days (36.22% vs. 5.61%; P < 0.01); they had higher median medical costs RMB (9 186 vs. 5 668 Yuan; P < 0.001) and they were more elderly (≥ 60 years of age) (86.10% vs. 66.39%; P < 0.01). The new charging scheme under Beijing's Basic Medical Insurance allows patients to get access to inpatient admission more easily. It lowers patients' financial burden in ED observation unit. Since more people stay at ED observation unit, it increases ED payments by the insurance system. However, it slows the turnover rate of ED observation unit and causes overcrowding in ED. Hence, the advantages and disadvantages of the new policy are obvious.

False-positive rates of provocative cardiac testing in chest pain patients admitted to an emergency department observation unit.

Emergency department observation units (EDOUs) typically perform routine cardiac stress testing or coronary computed tomography (CCTA) to rule out ischemic cardiac chest pain. Some have questioned the utility of routine stress testing and advanced anatomic imaging in the low-risk chest pain patients. EDOU chest pain patients undergoing stress testing or CCTA prior to cardiac catheterization between June 1, 2009 and May 31, 2012 were studied in a prospective, observational manner. Baseline data, EDOU-related outcomes, and testing results were recorded. Stress tests were treadmill echocardiogram or myocardial perfusion stress tests and were considered positive if a "positive" or "equivocal" interpretation by the reviewing cardiologist prompted cardiac catheterization. CCTA was considered positive if it led to subsequent cardiac catheterization. Cardiac catheterization was considered positive if subsequent stent placement, coronary artery bypass graft (CABG), or change in medical management occurred. Of 1276 patients evaluated, 112 (8.8%) underwent cardiac catheterization of which 56 underwent some modality of prior testing. Forty-two of 56 were subject to stress testing (30 stress echo and 12 myocardial perfusion) and 14 underwent CCTA prior to catheterization. False-positive rate overall was 62.5% (35/56, 95% CI, 48.5%-74.7%). False-positive rate for stress testing was 75% and 66.7% for perfusion and stress echo respectively. False-positive rate for CCTA was 42.9%. It must be acknowledged that while these findings do not directly impugn the utility of stress testing or CCTA, it may indicate the need for more appropriate patient selection to avoid unnecessary cardiac catheterization among EDOU chest pain patient cohorts.

Predictors of hospital admission after ED observation unit care

BackgroundEmergency department observation units (EDOUs) represent an opportunity to efficiently manage patients with common conditions requiring short-term hospital care. Understanding which patients are ultimately admitted to the hospital after care in an EDOU may enhance patient selection for EDOU care. MethodsWe conducted a retrospective analysis of US emergency department visits resulting in admission to observation status using the National Hospital Ambulatory Care Survey (NHAMCS) from 2009 to 2010, a nationally representative sample. We used survey-weighted logistic regression to identify predictors at the patient level, visit level, and hospital level for inpatient hospital admission after EDOU care. ResultsBetween 2009 and 2010, there were 4.65 million patient visits (95% confidence interval [CI], 3.68-5.63) to EDOUs in the United States. Of those evaluated in an EDOU, 40.4% (95% CI, 34.5%-46.6%) were admitted to the hospital after EDOU care. Progressively older patient age was a strong predictor of hospital admission: patients age older than 65 years were more than 5 times more likely to be admitted than patients age younger than 18 years (odds ratio, 5.36; 95% CI, 2.26-12.73). The only other visit-level factor associated with admission was a reason for visit of chest pain; this was associated with a lower rate of hospital admission (odds ratio, 0.61; 95% CI, 0.41-0.91). ConclusionAcross the United States in 2009 to 2010, older patient age was a strong predictor of admission after EDOU care, suggesting that older patients are more likely to require inpatient hospital services after EDOU care than younger patients.

Emergency department visits for heart failure and subsequent hospitalization or observation unit admission

Treatment of acute heart failure in the emergency department (ED) or observation unit is an alternative to hospitalization. Both ED management and observation unit management have been associated with reduced costs and may be used to avoid penalties related to rehospitalizations. The purpose of this study was to examine trends in ED visits for heart failure and disposition following such visits. We used the National Hospital Ambulatory Medical Care Survey, a representative sample of ED visits in the United States, to estimate rates and characteristics of ED visits for heart failure between 2002 and 2010. The primary outcome was the discharge disposition from the ED. Regression models were fit to estimate trends and predictors of hospitalization and admission to an observation unit. The number of ED visits for heart failure remained stable over the period, from 914,739 in 2002 to 848,634 in 2010 (annual change -0.7%, 95% CI -3.7% to +2.5%). Of these visits, 74.2% led to hospitalization, wheras 3.1% led to observation unit admission. The likelihood of hospitalization did not change during the period (adjusted prevalence ratio 1.00, 95% CI 0.99-1.01 for each additional year), whereas admission to the observation unit increased annually (adjusted prevalence ratio 1.12, 95% CI 1.01-1.25). We observed significant regional differences in likelihood of hospitalization and observation admission. The number of ED visits for heart failure and the high proportion of ED visits with subsequent inpatient hospitalization have not changed in the last decade. Opportunities may exist to reduce hospitalizations by increasing short-term management of heart failure in the ED or observation unit.

Factors Affecting the Length of Stay of Patients in Emergency Department Observation Units at Teaching and Research Hospitals in Turkey

SUMMARYObjectivesThis study aimed to determine the reasons for long stays in monitoring units and to propose a solution.MethodsThe patients who were followed in monitoring units of emergency service and the factors affecting the length of their hospital stay were analyzed retrospectively. Demographic features, their initial complaint that lead to monitoring, diagnosis, their means of arrival to emergency service, their admittance date and hour, medical history, basic vital signs, length of stay in emergency service, invasive interventions, intubation, mortality rates, consultations, and clinical results were evaluated.ResultsThe study included 603 patients. Average emergency service stay in monitoring unit was found to be 6.5 hours. In addition, 15 patients (2.5%) stayed 24 hours or longer, and 78 patients (12.9%) stayed 12 to 24 hours. Of the 15 patients who stayed in emergency service for 24 hours or more, 8 (53.3%) stayed because there wasn't enough space in intensive care units. The most prevalent complaint for admission to the emergency service was chest pain (25.5%), followed by dyspnea (21.9%) and tachycardia (11.6%).ConclusionsFor real emergency conditions, monitoring units are necessary to follow patients closely and to perform immediate interventions. The fullness of the intensive care units primarily affects the emergency service and leads to long stays in emergency service as patients are waiting to be admitted to the intensive care unit. As the number of consultations increases, the monitoring period is prolonged.