The impact of emergency department observation units on United States emergency department admission rates

Abstract

OBJECTIVE: Prior studies suggesting that the presence of emergency department (ED) observation units decrease overall ED hospital admissions have been either singlecenter studies or based on model simulations. The objective of this preliminary national study is to determine if the presence of ED observation units is associated with hospitals having lower ED admission rates. METHODS:We conducted a retrospective cross-sectional analysis using the 2010 National Hospital Ambulatory Care Survey and estimated ED risk-standardized hospital admission rates (RSHAR) for each center. The following were excluded from the study: ages <18 years, leaving prior to completion of ED visit, died in the ED, transferred to another facility, and missing disposition. Hospitals with less than 30 ED visits or unknown observation unit status were also excluded. We used linear regression analysis to determine the association between ED RSHAR and presence of observation units.RESULTS: There were 24,232 ED visits in 315 hospitals in the United States. Of these, 82 (20.6%) hospitals had an ED observation unit. The average ED risk-standardized hospital admission rates for hospitals with observation units and without hospital observation units were 13.7% (95% confidence interval [CI]: 11.3-16.0) and 16.0% (95% CI: 14.1-17.7), respectively. The difference of 2.3% was not statistically significant. CONCLUSIONS:In this preliminary study, we did not find an association between the presence of observation units and ED hospital admission rates. Further studies with larger sample sizes should be performed to further evaluate the impact of ED observation units on ED hospital admission rates. Journal of Hospital Medicine 2015;10:738-742. V C 2015 Society of Hospital Medicine Today more than one-third of emergency departments (EDs) in the United States have affiliated observation units, where patients can stay 24 to 48 hours without being admitted to the hospital. 1 Observation units experienced significant growth in the United States from 2005 to 2007, secondary to policy changes involving the Centers for Medicare and Medicaid Services (CMS), which expanded reimbursement for observation services to include any clinical condition. Furthermore, CMS implemented the Recovery Audit Contractor process, which was able to fine providers and facilities for inappropriate claims, with the principle method for charge recovery being "inappropriate" charges for short inpatient stays.ED observation units (EDOUs) vary in the number of beds, but are often located adjacent to the emergency department. 2 It is estimated that EDOUs have the capacity for caring for 5% to 10% of any given ED volume. 2 Almost half of EDOUs are protocol driven, allowing these units to discharge up to 80% of all patients within 24 hours. 1,2 Some studies have suggested that EDOUs are associated with a decrease in overall hospitalization rates, leading to cost savings. 1 However, these studies were limited by their single-center design or simulated in nature. In addition, other studies show tha...

Implementation of a Rapid, Protocol-based TIA Management Pathway

“…Others have studied the use of EDOUs, typically structured as an ED or inpatient unit but designed for patients who need more than an initial ED workup, but less than 24 hours of observation or evaluation. These can be lower cost (to the healthcare system) than an inpatient admission, and are increasing in popularity in the U.S. 23 Some have found that these EDOUs can minimize inpatient admission for lower risk TIA patients in a safe manner. 19 , 22 Our results are consistent with these findings.…”

“… 17 , 21 , 22 While less common in other countries, EDOUs are increasingly used in the U.S. for patients who require more than a brief ED stay but less than 24 hours of observation or urgent diagnostics. 23 Our EDOU was managed by a nurse practitioner (NP) who was empowered to guide patients who would likely require more than 24 hours for their workup, based on availability of hospital resources at the time. In this analysis, we evaluated whether we could use this pathway to provide consistent streamlined care with shorter LOS without increasing 90-day stroke risk.…”

Resting Borg score as a predictor of safe discharge of chronic obstructive pulmonary disease from the emergency department observation unit

“…In the United States, ED-Obs units are increasingly utilized for COPD patients as a short-term 24-to 36-hour stay for evaluation and treatment before deciding the final disposition. 9,21 In an ideal situation ED-Obs setting is best utilized to treat non-life-threatening eCOPD that require short-term monitored care to ensure patient safety and potentially prevent costly hospitalization. A subset of these patients will, however, end up requiring hospitalization.…”

The utility of emergency department physical therapy and case management consultation in reducing hospital admissions

“…1 Emergency departments are using observation units as efficient modalities for implementing clinical pathways that allow for more rapid evaluation, testing, treatment, and disposition of patients while avoiding inpatient hospital admission. [2][3][4] A significant number of patients who present to the ED may be unsafe to return home in their current state-whether it be from a fall, deconditioning, or illness-and could benefit from evaluation by a physical therapist. Traditionally, once emergent conditions requiring inpatient hospitalization and treatment were excluded in the ED, these patients were admitted to the hospital primarily for evaluation by a physical therapist.…”