Protocol-Driven Emergency Department Observation Units Offer Savings, Shorter Stays, And Reduced Admissions

Abstract

Many patients who seek emergency department (ED) treatment are not well enough for immediate discharge but are not clearly sick enough to warrant full inpatient admission. These patients are increasingly treated as outpatients using observation services. Hospitals employ four basic approaches to observation services, which can be categorized by the presence or absence of a dedicated observation unit and of defined protocols. To understand which approach might have the greatest impact, we compared 2010 data from three sources: a case study of observation units in Atlanta, Georgia; statewide discharge data for Georgia; and national survey and discharge data. Compared to patients receiving observation services elsewhere in the hospital, patients cared for in "type 1" observation units-dedicated units with defined protocolshave a 23-38 percent shorter length-of-stay, a 17-44 percent lower probability of subsequent inpatient admission, and $950 million in potential national cost savings each year. Furthermore, we estimate that 11.7 percent of short-stay inpatients nationwide could be treated in a type 1 unit, with possible savings of $5.5-$8.5 billion annually. Policy makers should have hospitals report the setting in which observation services are provided and consider payment incentives for care in a type 1 unit.

From ‘Solution Shop’ Model To ‘Focused Factory’ In Hospital Surgery: Increasing Care Value And Predictability

“…New workforce models, 22 stratification of the patient population in primary care, 23 putting similar patients together in place or time (or co-location), 23,24 and the power of health IT tools to support work models and care delegation 25 have been identified as ways to improve care value. Most notably, Michael Porter and coauthors proposed a primary care strategy that emphasized the need to stratify a heterogeneous population into subgroups having different needs, 23 with that stratification serving as a foundation for differing work models and metrics.…”

National Cost Savings From Observation Unit Management of Syncope

“…Hospitals are reacting by increasing the use of observation status, but this usually does not change the setting or model of care delivery, which is critical to realizing cost savings. 10,11 Cost savings are typically reported with respect to the hospital, not patient out-of-pocket costs; but since observation billing is outpatient and cumulative, patients are generally at lower risk for excessive personal expense if their stays are shorter with more limited, evidence-based diagnostic and therapeutic interventions. Shorter hospitalizations are more likely to occur in dedicated observation units under protocols than with unstructured hospitalization on inpatient teams and simply billing status changes to observation.…”

“…Additionally, care in observation units facilitates the use of protocols, which enables several efficiencies. 11 Patient and provider communication around expectations for the observation stay are transparent; the endpoint for discharge is explicit and set in advance. 27,28 Providers staffing an observation unit typically do not use a fixed rounding schedule and are more likely to discharge a patient home at certain times, such as the evening or overnight.…”

“…For example, patients can be managed in a dedicated observation unit using evidence-based protocols; alternatively, they can be distributed among inpatient providers throughout the hospital and managed without protocols. 10 Recently, Ross et al 11 introduced the concept of four different types of observation care, with the setting of care and use of protocols distinguishing each type. While most observation care is currently delivered in inpatient settings without the use of protocols (type 4), the best practice to optimize outcomes is care delivered in a dedicated unit using a specific protocol tailored to the patient's condition, the best available evidence, and local institutional resources (type 1).…”

Evidence-based Standardization and ED Admission Rate Variation in US Children’s Hospitals

“…In general purpose EDs, observation units have been shown to be safe and effective in reducing admission rates. 7 Standardization can also include outpatient protocols in which children can be reevaluated by their own pediatrician, if available, or return to the ED. However, it will be important to test these protocols, including their impact not only on admissions but also on measures of safety and patient-centeredness.…”