Emergency department observation beds improve patient care: Society for academic emergency medicine debate

CONCEPTS observation units

Emergency DepartmentObservationBeds Improve Patient Care: Society for Academic Emergency Medicine Debate Fromthe Department of Emergency Medicine, New Britain General Hospital, New Britain, Connecticut;* Loretto Hespital;t Department of Emergency Medicine, RushPresbyterian-St Luke's Medicine

Louis Graft, MD, FACP,FACEP* Leslie S Zun, MD, FACEP* Jerrold Leikin, MD, FACP,FACEP~ Brian Gibler, MD, FACEP§ Michael S Weinstock, MD, FAAP, FACEPII James Mathews, MD~ Georges C Benjamin, MD, FACEP**

Center;t and Department of Emergency Medicine, Northwestern Memorial Hospital, ~ Chicago, Illinois; Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio;§ Emergency Medical Services, North Shore University Hospital, Manhassett, New York;ll and PublicHealth District, Washington, DC. ** Receivedfor publication December 2, 1991. Revision received February 7, 1992. Acceptedfor publication February 17, 1992. This article does not represent the views of the Department of Human Services, Commission of Public Health, or the Government of the District of Columbia and is for debate purposes only.

[Graft L, Zun LS, Leikin J, Gibler B, Weinstock MS, Mathews J, Benjamin GC: Emergencydepartment observation beds improve patient care: Society for Academic EmergencyMedicine Debate. Ann ErnergMed August 1992;21:967-975.] Moderator~ Leslie S Zun, MD, FACEP Emergency department observation units provide extended service to patients in the ED. There are three categories of extended-observation services. One is the 23-hour-stay patient. This is for patients who are admitted to the floor, do not meet the criteria for admission, but need to be observed. Holding beds represent a second category. These beds are used for the patient who is admitted but for whom an inpatient hospital bed is not currently available. Patients are held in the ED or a holding area until the bed is available. The third category is the true ED observation unit. Patients are kept in these beds for prolonged treatment or observation with a later decision on hospital admission. Yeal~ et al's 1989 study surveyed 250 facilities and found that 27% had observation units, and 16% were developing an observation unit to open within the next year.~ In 1988, the American College of Emergency Physicians surveyed 224 college leaders from 52 chapters and found that 24% of responding facilities had an observation unit, and 17% planned to open an observation unit in the next year. 2 A complicating issue is hospital overcrowding. I n 1989, at the ACEP Scientific Assembly, representatives from all 50 states stated they were affected by some degree of overcrowding.3 A survey of the National Association of Public Hospitals and the Council of Teaching Hospitals found that 40% of those hospitals had to go on diversion status and 33% required transfers because of overcrowding, a Hospitals that do not wish to provide extended emergency services may be forced to offer observation or holding services when faced with overcrowding. The following question will be addressed by the speakers: Is it in the patient's best interest to be treated in an ED observation unit?

For the Proposition: Jerrold Leikin, MD, FACP, FACEP We have found at the University of Illinois and at other hospitals in Illinois that use of observation beds prevents payment

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denials. In 1986, s p u r r e d by denial of short-stay hospital admissions by government payers (peer review organizations), the use of observational unit beds increased in Illinois. A survey by the Illinois Association of Quality Assurance Professionals in July 1986 noted that 93 of 237 (40%) of Illinois hospitals (including 39 of 104 hospitals in metropolitan Chicago) intended to establish observation units. Most (if not all) of these units were being planned to decrease rates of government p a y e r denial. F o r example, of the 112 total admission denials by Medicare and Medicaid at the University of Illinois hospital between July 1985 and November 1986, 78 (70%) met observation unit patient criteria. As a result of an observation program in the last calend a r year (1990), the University of Illinois had fewer than 20 case denials. There was a temporal relationship between payment-denial reduction and the start of the program. In Illinois, most of the hospitals are starting their programs on the hospital floors. One of the major reasons for this location is the high startup costs for an ED observation unit. Our startup cost for a four-bed ED observation unit (38,000 patients per year at Rush-Presbyterian-St Luke) was $376,723; $76,723 of the cost was for supplies and equipment, $132,000 for construction, and $168,000 for five registered nurses' salaries. Startup cost for inhospital 23-hour-bed units are low to nonexistent as most beds are converted inpatient beds. Twenty-three-hour-bed observation units are defined by billing (per hour r a t h e r than p e r day) and an administrative p a p e r program. I ~MI focus the rest of my remarks on the observation needs of patients with toxicologic problems. It has been estimated that 94% of acute toxic exposure patients first present to the ED. Colt and Shapiro found that 9.4% of admissions from their ED were drug induced. 4 Other series have found that 2.9% to 10.4% of admissions are drug induced with higher levels in the geriatric population. Thus, drug induced admissions play a major role in hospital admissions and can play a major role in ED observation units. Because most toxicological presentations involve acute exposure, and the history of the exposure may not be reliable, observation of even the most minimally symptomatic patient may be necessary to provide p r o p e r disposition. In addition, the toxicological l a b o r a t o r y investigation may involve nonroutine and sometimes esoteric testing procedures, so it may take hours for the patient's data base to be complete. Acute poison management is almost exclusively under emergency medicine's domain. The basic components of acute poison management are demonstrated in toxicology textbooks. 5-1° Most research has focused on the initial stabilization and decontamination, which should occur in the ED. There are some antidotes (such as naloxone and the cyanide antidote kit) that should be administered as soon as possible for maximum effectiveness. After stabilization and decontamination, selected patients may be appropriate for monitoring in observation units. 11-13 Patients often need prolonged antidote administration (such

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as the use of naloxone drips) or noninvasive removal of absorbed toxins (such as in multiple dosing of activated charcoal or forced diuresis). In several ingestions a significant delay may exist from the time of exposure to the time of onset of symptoms. During this asymptomatic interval, the practitioner may have to rely on a dubious history and a nonspecific physical examination. F u r t h e r m o r e , in the case of acetaminophen ingestion, drug levels may not be properly interpretable for about four to six hours after evaluation. There has been little research and few treatment algorithms for the overdose/toxic patient who needs monitoring but not t h e ICU. 14-16 Tokarski et al noted that acute myocardial damage can occur in patients with cocaine-induced chest pain with normal or nondiagnostic ECGs. 16 Their algorithm studied patients who reported the onset of chest pain within six hours of cocaine abuse and presentation with normal or nondiagnostic ECGs. These patients were observed for 12 hours with three creatinine kinase isoenzyme levels obtained and used for admission criteria. Callaham, in a series of articles, devised admission and treatment algorithms for tricyclic antidepressant toxicity.17,18 Recently, Smith et al noted that narcotic overdose patients who are alert after antidote administration did not experience the delayed onset of pulmonary edema or recurrence of r e s p i r a t o r y depression. They concluded that admission and prolonged observation are not w a r r a n t e d for opiate overdose patients who are awake and alert. 19 The observation unit can play a critical role in the triage of the patient with gas inhalation. The toxic inhalants can be classified into four categories (physical asphyxiants, respiratory mucosal irritants, systemic toxicants, and pulmonary sensitizers). It is important for the emergency physician to recognize the category of the inhalant to begin a p p r o p r i a t e treatment. 2o-33 Pulmonary edema may not manifest itself from six to 72 hours after exposure in 25% of smoke-inhalation patients. Therefore, symptomatic patients should be observed for 24 to 48 hours (especially those with u p p e r airway burns or edema, hypoxemia, wheezes or rales, abnormal chest radiographs, or tracheobronchitis).21 Patients who have inhaled systemic toxicants are at particular risk and require observation if there is any history or evidence of neurologic, cardiac, or hemodynamic abnormalities or a metabolic acidosis. 26 Generally, any pregnant patient with a serious systemic toxicant inhalation (eg, carboxhemoglobin level above 20%) requires observation. Asymptomatic patients may be discharged after six hours of observation if their physical examination and chest radiograph are unremarkable. 6 In conclusion, ED-associated observation units can expand the domain of emergency medicine in a manner beneficial to our patients and fulfilling to those who practice the specialty.

For the Proposition: Brian Gibler, MD, FACEP The observation unit has multiple applications in emergency medicine. Abdominal pain, asthma exacerbations, head

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injury, and sickle cell crisis are all amenable to evaluation in an observation unit. My p a r t i c u l a r area of interest is chest pain. Lee and Goldman's Chest Pain Study Group has shown that while approximately 500,000 patients have myocardial infarction each year, 1.2 to 1.5 million patients with chest pain must be evaluated to identify those patients. The typical breakdown is that one third of chest pain patients (500,000) have a noncardiac diagnosis, one t h i r d (500,000) have a myocardial infarction, and one t h i r d (500,000) have unstable angina. The cost of the in-hospital examination of patients with chest pain was estimated in 1984 by Fineberg et al. 34 They estimated that the transfer of patients with a 5% p r o b a b i h t y of myocardial infarction (ie, a low-risk group) from a coronary care unit to an intermediate-care bed would result in significant cost savings. To keep the low-risk patient in the coronary care unit would cost $2.04 million p e r life saved or $139,000 for each year of life saved. The national cost for the United States to save 145 hves would be $297 million. Their estimated costs are $4,046 for the coronary care unit hospitalization, $3,574 for an intermediate-care bed, and $2,917 for the w a r d bed. Outpatient care would cost $1,343. Outpatient care translates closely to the cost of an ED observation unit admission with a 4 to 1 cost savings when compared with coronary care unit admission. In the United States, we are spending $8 billion p e r year to rule out myocardial infarction. If chest pain patients were treated as outpatients except for those who have obvious ST segment changes, the cost for evaluating chest pain patients would decrease $2 billion to $3 billion. The alternative side of this issue is the emergency physician's dilemma. Multiple studies, including Lee and Goldman's Chest Pain Study Group, 35 Jerris Hedges' group at the University of Cincinnati, 36 and Shor's group in Jerusalem 12 years ago 37 have shown a 4% to 8% missed myocardial infarction rate. Approximately 4% to 5% of patients with chest pain and acute myocardial infarction are being sent home. The resultant cost to emergency physicians and their malpractice carriers is 20% of the emergency medicine malpractice dollars paid. 3a If the false-negative rate equals 8%, in the United States 40,000 myocardial infarction patients are released inadvertently from the ED each year. Observation units have been shown to improve the physician's diagnosis of patients with chest pain. DeLeon's group in Tulsa, Oklahoma, used an observation w a r d to evaluate patients with chest pain. 39 The group they observed was judged clinically as low risk, did not have ECG changes, and did not have ongoing chest pain. Of the 495 patients, 327 (66%) were placed in the observation unit. There was an 80% reduction in costs with this a p p r o a c h compared with coronary care unit admission. Follow-up on 75% of patients found no complications with observation unit evaluation. The cost was $598 for their observation unit stay for an average of 11.1 hours. The cost for similar patients cared

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for in the coronary care unit was $3,103. This is a 5 to l cost savings. Lee and Goldman's Chest Pain Study Group looked at a low-risk group of 771 patients. ¢o They were treated in the ICU but were identified as low risk by.computer protocol. Three patients in the study group died. The authors did not address the cause of death for these patients nor did they discuss the use of provocative testing to identify patients with exercise-induced ischemia. While this low-risk group had only a 0.5% incidence of myocardial infarction, 23% of patients were found to have unstable angina. This illustrates the need to identify not only patients with myocardial infarctions but also those with unstable angina who may die within three to four days of a new infarction. The Emergency Medicine Cardiac Research Group (EMCREG) is the third group to examine the use of ED observation units for chest pain. They looked at early serum m a r k e r s that could bring the time frame of chest pain evaluation into the ED perspective. Using 0- and 3-hour CK-MB levels determined by immunochemical technology, they detected acute myocardial infarction with high sensitivity and specificity in patients who had nondiagnostic ECGs. 41 A follow-up multicenter study by their EMCREG group presented at the American College of Cardiology meeting in March 1991 demonstrated 80% sensitivity with a 95% specificity in patients with a nondiagnostic ECG and acute myocardial infarction using CK-MB samphng over three hours in the EI). 42 This r a p i d assessment of acute myocardial infarction risk can be performed in the ED. The patient is first ruled out for acute myocardial infarction in a monitored setring and then submitted to provocative testing to detect angina.

For the Proposition: Louis Graff, MD, FACP, FACEP ED observation beds improve diagnostic performance in critical diagnostic syndromes. We have found in our registry, which now has more than 4,500 patients, that nearly 50% of patients treated in ED observation units were evaluated for a critical diagnostic syndrome. W h a t the physician seeks to avoid in these patients is release of the patient with a serious or dangerous disease. In patients with abdominal pain, possibly due to appendicitis, there is a need for improved diagnostic accuracy. B r e n d e r et al a3 published their findings on the initial physician's delay in referring a patient to the surgeon. They showed that the rate of perforation is related to the time delay from the initial physician's evaluation to the patient obtaining surgery. When the physician misses the diagnosis and sends the patient home with reassurance, there is a 24hour d e l a y before the patient decides the physician was incorrect and comes back to the hospital. This usually results in perforation. Cacippio et al found similar false-negative rates for the initial physician's evaluation of adult patients at their hospital p r i o r to the implementation of prospective payment in 1983. 44 By the late 1980s, the false-negative rate had increased

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to 44% at their hospital. Restrictive diagnosis-related group admission criteria a p p e a r e d to inhibit physicians from referring patients to the surgeon. Patients whose physician sent them home inadvertently when they needed acute care hospital admission comprise 60% of emergency medicine malpractice. Failure to diagnose appendicitis comprises 5% of emergency medicine malpractice dollars awarded, as This occurs because the physician must rely on clinical judgment that Brender et al's and Cacippio et al's studies have shown is often poor. There is considerable overlap in clinical signs and symptoms between patients with and without appendicitis. There is no simple, safe, inexpensive, readily available test by which the physician can confirm the diagnosis in syndromes such as abdominal pain. We studied 252 patients observed for abdominal pain (44 had appendicitis). 46 There was considerable overlap between patients with and without appendicitis. We used the Alvarado clinical scoring system, which assigns 0, 1, or 2 points to the classic findings of appendicitis with 10 being the maximum score. 47 Most patients without appendicitis h a d low scores, indicating a low n u m b e r of the classic signs and symptoms of appendicitis. But many patients without appendicitis had an intermediate appendicitis score of 5 or 6, indicating a moderate number of the signs and symptoms of appendicitis. Most patients with appendicitis h a d high scores, indicating many of the signs and symptoms of appendicitis. But many did not have all of the classic signs and symptoms and had scores in the intermediate range of 5 or 6. A period of observation improves the physician's ability to discriminate between patients with and without appendicitis. 46,48 The patients with appendicitis h a d more signs and symptoms of appendicitis after observation (mean, 11 hours) with mean score increasing from 6.8 to 7.3. The patients without appendicitis h a d fewer signs and symptoms after observation with mean score decreasing from 3.8 to 1.6. Physicians can use these changes in clinical information to improve their decision making. We found physicians with a low threshold for using observation (ie, they observe patients with very few signs and symptoms) have a lower false-negative rate than those physicians who need more of the classic signs and symptoms before they refer (7.7% vs 17%). 48 We also found that physicians with high diagnostic performance (zero false-negative rate) compared with physicians who miss the diagnosis on many patients have a lower threshold at which they observe patients (4.56 vs 5.13, P < .05). 48 The difference between these two groups, although small, is statistically and clinically very significant. The overlap in clinical signs and symptoms between patients with and without appendicitis is in this intermediate range (4 to 6). Physicians who observe/refer only patients with more of the classic signs and symptoms of appendicitis will miss some patients with appendicitis. Complications will result. The patient's abscess risk correlates with the physician's false-negative rate (correlation coefficient, 0.89; P < .005). 48

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The threshold to observe/refer patients is influenced by the environment within which the physician practices. The emergency physician without an ED observation unit has to convince a resident or attending physician thht the patient with few signs and symptoms of appendicitis may have appendicitis. In contrast, the emergency physician with an El) observation unit has no roadblocks to observing the patient with low probability of disease without another physician's approval. Thus, I support the proposition. The physician who uses El) observation beds has better diagnostic performance, sends fewer patients home inadvertently who have serious disease, and provides better patient care.

Against the Proposition: James Mathews, MD There is no question that putting patients into a situation where you can monitor them will increase your yield of diagnosis. Yet, there are many problems with an observation program. T h i r d - p a r t y payors and hospitals give you very little provision to provide this service. We were quoted some figures about how much cheaper it is to monitor somebody with chest pain in the ED over 24 hours r a t h e r than in the critical care unit. But who is watching the patients? Is the nurse:patient ratio 1:1, 1:2, 1:3, or more likely 1:8, 1:15, or not at all? Will you be reimbursed? I work at a nonprofit hospital. W h a t patients are going to wind up in such a hospital observation unit? Will it be the patient with Traveler's full insurance or with an excellent HMO that pays 95% of costs? Or will it be the patients who are already in the ED-the alcoholic, the drug abuser, the overdose patient? Emergency nursing does not have the orientation for continuing patient care. Most emergency nurses left the floor because they couldn't stand managing patients for more than two or four hours. The biggest pressure on the emergency physician to get the patient out of the El) is p r o b a b l y not from the patient, the attending physician, or the insurance company. It's from the nurse who says please get this patient out of here. We h e a r d today that we could send a lot of people home without hospitalization with the use of observation beds. We've h e a r d that it can be done for many patients with hypertension, for many patients with abdominal pain, and for many patients with chest pain. Yet if these patients need to be observed, if they need services over a period of time, then they need to be admitted to the hospital. There has not been any evidence presented here that proves cost savings. The patients who cannot pay will be admitted to the observation unit. The patients who can pay will not be admitted to the observation unit. Those are the realities. Yet even if the observation unit is cost effective, won't the hospital see its generated income drop? If this occurs, won't the hospital increase its charges for the unit? We have to look at what we are as a specialty. Do we need another area of care? Do we want to go out and become

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managing physicians, absorbing all the risks of being a subsequent treater? We may avoid malpractice suits resulting from missing myocardial infarctions and unstable angina, but is this where our problems occur? Most myocardial infarctions and unstable angina do well in the first 12 to 24 hours. The ED is too busy for us to be doing diagnostic evaluations such as stress tests during this i2 to 24 hours. We have to look at the practice life of emergency physicians. It's rough. You're all busy when y o u ' r e on duty. D o you have time to follow another ten to 12 patients in another room, around the corner, across the hall, or down the way? It is unwise for our specialty to assume something that we really d o n ' t have to do. There are other solutions. Many of these solutions were mentioned today - - eg, in-hospital beds being used as observation sites. Observation units are not an improvement in patient care but another way of burdening the emergency physician and making emergency medicine an even bigger safety net.

Against the Proposition: Michael S Weinstock, MD, FAAP, FACEP Observation units are becoming popular in specific designated areas Within or juxtaposed to EDs. Yet do they improve patient care? At university teaching hospitals, at least in the Northeast, observation units do not improve patient care. They increase length of stay for those patients hospitalized. 49 These units delay early decision making, encourage different levels of care, promote poor physical conditions for the patient, and reduc e privacy tO nonexistent. There is confusion as to des= ignation of responsibility, and the units ultimately provide a nightmare for quality assurance. Due to overcrowding, most observation units have become hybridized, and what you have is a mixture of holding/observation beds. The question of who is resPonsible for each grou p become s diffuse, and this promotes a chaotic environment. Issues of the transfer of responsibility with the variety of practice disciplines make almos t impossible orderly patient flow and appropriate triage decisions. The emergency physician is focused on the patient's initial care: evaluation, stabilization, therapy, and disposition. I n contrast, the internist needs a far wider data base for evaluation. Our holding patients have their ED record incorporated within the permanent hospital record. This record leaves the department and is hard for us to retrieve to analyze whether the initial patient management was appropriate. The ED attending is supposed to be in complete control of th e observation patient, but this control is in jeopardy because of the transfer of care from shift to shift. The Joint Commission on Accreditation of Heahhcare Organizations has issued standards that address isolated observation units but in fact do not work in real life - - or at least where I work in these hybridized units. Some states, such as New York, have standards that do not recognize holding or observation units. New York State regulations specifically mandate that after eight hours within an

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ED you must move the patient to an inpatient bed. If you cannol, then you must provide that patient with the same services that you provide to an inpatient; they will not accept two levels of care. We've had the unfortunate experience of holding 30 patients, being out of stretchers and equipment, and the hospital r u n n i n g at 110% census. I n this situation, New York State "helped" us by levying monetary penalties because we were unable to get the patients out of the El). Taking all of these issues into consideration (dignity issues. levels of care, quality assurance issues), I am not inclined to use an observation unit. These issues are especially difficult in hospitals that have patients awaiting bed placement who have already been admitted.

Against the Proposition: Georges C Benjamin, MD, FACEP Observation units pose significant management and organizational problems for the ED. Hospital specialty units are designed to provide a unique service that improves service delivery or enhances the quality of care. This was the litmus test that clearly established El)s. critical care units, and other specialty areas of the hospital. No such benefits have been shown for ED observation units. From the bed use aspect, ED observation beds offer no foreseeable advantage over hospital admission or patient care in the main El). Most authorities recommend that no patient remain in the ED for more than 12 hours.5°, 51 Many studies that argue in favor of observation units show mean stay times in excess of this 12-hour rule. 52-55 It would be more appropriate to admit these patients for inpatient care rather than create the false impression of increased bed use. The need for dedicated equipment and supplies in an ED observation unit requires an additional outlay of hospital financial resources for maintenance and inventory control. Because of the wide variety of ED patients suitable for ED observation units, the units must be appropriately stocked for all forms of clinical presentation. This additional cost for equipment and supplies must be justified by better outcomes. Enhancing the quality of care remains an important component in the decision process to have an observation unit. It is important to compare the quality of care provided in the observation unit with that provided in the ED or the hospital ward. While several studies have shown that quality of care is equal to inpatient care. there are none that show superiority. Quality comparisons for observation units versus earlyrelease home are moot because these patients are by definition not ready to be released home in the judgment of the clinician. The purpose of the observation umt is to observe and treat patients who do not meet criteria for release home. Observation units are not an alternative for patients who clearly need hospitalization. Significant problems with ED overcrowding are placing observation units at risk of intrahospital dumping of patients who need inpatient care. In these cases, hospital costs and diagnosis-related groups are

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the reasons for the use of ED-based observation units, not superior quality of care. Staffing such units remains a dilemma. Experience with ED-based fast-track systems demonstrates that flexible staffing must be used because of the unpredictable n a t u r e of El) volume. Observation unit staffing is also vulnerable to this problem. It means that a dedicated staff separate from the in-house or ED staff is essential in house or on call to staff the observation unit. This staff adds additional cost to the facility. The clinical needs of ongoing monitoring, recurrent physical assessment, and r e c o r d keeping are required from a staff comfortable with the full range of ED problems. These duties run the risk of being second-line duties for the ED staff and third-line duties for the inpatient staff. The observation unit patient is not really admitted to the hospital and not really an ED patient. The minimal dedicated staff consists of a single nurse. If the unit is fully used seven days a week, 24 hours per day, then four full-time equivalents are required. The minimum cost of a registered nurse in Washington, DC, is about $30,000 per year. F o r the unit this would be $150,000 p e r year plus benefits. This is a low estimate because use of agency staffing means a higher cost of $60,000 p e r nurse. This is a considerable staffing expense for a unit that brings in little additional revenue. Dedicated clerical staff, additional nurses, and dedicated physicians would make costs even more expensive. Risk management remains a serious concern for observation units. Some argue that observation units reduce physician liability risk by increasing the time for clinical decision making. I argue it does nothing to improve b a d decision making. Miscommunication between physician and patient remains a significant problem with ED litigation. Observation units leave the patient and his or her family in admission limbo. The patient may develop the impression that the physician does not know what is going on, or that the patient has not yet met some essential test of severity of illness to deserve to be admitted. This may impair the physician/ patient relationship. Loss of continuity for patients who are turned over to another emergency physician, difficult diagnostic cases, and difficult dispositions are patient categories that increase liability potential. Unfortunately, these are the very patients placed in observation units. The purpose of observation units is to allow for prolonged therapy and observation prior to decision making - - ie, delay decision making. To be cost effective and clinically relevant, observation units must demonstrate a high degree of selectivity. This means there should be a low hospital admission rate from observation units. Review of studies on observation units show acute care hospital admission rates from 12% to 56%. 52-58 Observation units with high hospital admission rates indicate that many patients should have been admitted to the hospital. Observation units with low hospital admission rates can be interpreted as poor decision making - - ie, many of these patients should have been released earlier to home observation. This is especially true of patients who

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require only observation and minimal therapy. It therefore appears that only small groups of patients may benefit from observation units. In summary, it is clear that observation unifs are an unattractive option for emergency medicine. They have organizational problems such as staffing difficulties, potential increased liability, minimal patient benefit, and delays in decision malting.

Questions Question: I ' m from a 1,100-bed hospital, and we have an observation unit established as result of Dr Tom Lee's studies on chest pain evaluation. We've h a d good success primarily for chest pain patients but also for a variety of other types of patients. Our chief success has been shorter stays and avoidance of unnecessary admissions. W h a t I want to hear from some of the panelists is the patient's perception of quality of care in an ED observation unit. I believe that our chief success with this p r o g r a m has been that patients perceive that they are getting better care. They have a shorter stay. W e ' r e a s u b u r b a n area with busy people who d o n ' t want to miss work. They worry about their chest pains. Has anyone studied the patient's perceptions of the quality of care?

Pro Side: Dr Gibler There have been people who have looked at the patient's perception of care during a myocardial infarction. We all think admitting a patient has no societal costs, but this is wrong. You take a young executive, perhaps a vice president of a four-person entrepreneurial group, who comes in with a low-risk history of chest pain. The physician believes it is low risk but recommends admission. This potentially makes him "damaged goods" when he tells the president of his company that the physician thinks he has h e a r t disease. A short period of observation can avoid hospitalization of many of these patients and avoid mislabeling as infirm. An additional advantage to a systematic ED observation unit evaluation is that it may be better than the in-hospital evaluation. At the University of Cincinnati, if someone is admitted at 1:00 AM and judged to be low risk by the resident and attending internal medicine staff, then they are discharged first thing in the morning when the second negative CK-MB comes back, and the patient is determined clinically to be at low risk. These low-risk patients don't go through a s t a n d a r d 24-hour evaluation with subsequent provocative testing. W h e t h e r admitted to the hospital or an observation unit, the patient's perception is favorable when there is a s t a n d a r d ized p r o c e d u r e to evaluate the low-risk patient. Question: Are there patient groups for whom payment by t h i r d - p a r t y payors is likely to be disapproved if admitted to the hospital bed but not if admitted to the observation unit? Do observation units increase your reimbursement for certain short-stay patients, decrease your reimbursement, or is it unchanged?

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Con Side: Dr M a t h e w s To my best knowledge, there are no insurers that pay for an ED observation unit specifically. Within the hospital observation unit, the reimbursement pattern is a little different. I'm talking about Medicare, which influences the private payors. You do have a reimbursement pattern although less in many cases. [ just spoke the other day with the president of Blue Cross/Blue Shield of Illinois, which is the provider for Medicare in Illinois. He stated that the administrators like observation admissions because the criteria being applied a r e n ' t really stringent as in hospital admissions. Observation units are a good way to handle the issue of the social admission - - eg, the Medicare patient with a broken shoulder at 3:00 AM. I think if you have that big a problem with admissions to the hospital, then the solutions lie in the hospital. I think we are being back-doored again. If the surgery or medicine services c a n ' t do their work-up in the ED or hospital, then I believe it is their problem and not ours. For emergency medicine this is a dead stone loser. There is no reimbursement in this at all. I d o n ' t believe even state reimbursement exists. From some of the HMOs you might be able to get some reimbursement because it is cheaper for them. At least in Illinois, I d o n ' t think anyone is getring anything for these patients.

Pro Side: Dr Graff The ED observation unit is not a loser. Our observation beds produce 11% of our ED revenue. We charge an additional fee equal to the hospital room rate. We're reimbursed with no problem. In Connecticut, where there are a lot of insurance companies, they like this idea. Our hospital's contract with the HMO ConniCare requires an ED observation program to avoid hospital admission on many patients in 30 diagnostic syndromes - - eg, abdominal pain, syncope, or chest pain. Health care costs are lowered by more selective hospital admission. Twenty-three-hour bed observation is viewed as similar to ED observation bed. They are both cost reimbursed and not covered by Prospective payment. They both arose since prospective payment began in October 1983. Yet the 23-hour bed is r u n by the utilization nurse without a change in the physician behavior. The goal of the program is to avoid payment denial. I n contrast, the goal of the observation unit program is to avoid hospital admission. Many patients with low probability of serious disease will not need hospital admission after short-term observation. Many patients with an emergency condition needing treatment will not need hospitalization after a few more hours of treatment. The 20% of patients admitted after observation do not show that observation units fail. The 80% of patients sent home after observation show what we are doing right. We d o n ' t consider reimbursement in our admission decisions. If someone has criteria to be admitted to the hospital, then they are admitted. It i s n o t just the poor who are observed. We are in fact reimbursed for the services offered.

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These funds are used to get more nurses and more physicians. We offer services at the same level of care as on the hospital floor.

Pro Side: Dr Leikin I ' m a physician reviewer for the Illinois Peer Review Organization. It would be a good idea for more emergency physicians to speak with other physician reviewers (internists or surgeons) who examine these short-term admissions. Communication was a problem at the University of Illinois. The cases I have reviewed in the last four years have shown many cases in which the physician reviewer believes that the patient's care could have been provided in a less intensive setting. This is the most common reason for denial. If the patient is admitted to an ED observation unit or an observational program, then the physician reviewers look at this and conclude that an attempt has been made to place the patient in a lesser-care setting. I n most cases, the patient's care will be reimbursed.

Con Side: Dr W e i n s t o c k In New York, observation units are not recognized. But clearly in all these reimbursement issues, who collects the money? It goes to the hospital. Does it come back to the cost center that is really providing the service? No, it gets diluted. Patients who undergo observation and then end up admitted to the hospital fall into the all-payors system. The diagnosis-related group is charged for the whole service and there is no credit to the ED. It gets lost up there. Then the administrator turns around and points out that the El) is losing funds. Question: Who has authority to admit or release from the ED observation units, especially in a teaching institution? Do the house staff from medicine or pediatrics have the responsibility? Is it the in-hospital resident's responsibility or does the emergency physician decide if a patient can be released?

Pro Side: Dr Gibler We're currently developing an observation unit at University of Cincinnati. We had one at Vanderbih and staffed it with attending emergency physicians and residents. The emergency physician was responsible for the supervision of these residents. The unit r a n very smoothly. Question: There is the possibility that patients in ED observation units could be available for research protocols. Could the panelists address this?

Pro Side: Dr Leikin Observation can be a teaching tool. To see migration of abdominal pain during a shift will tell a lot more than reading a textbook. Many chelation studies are presently being done on the hospital floor. If toxicology is in the emergency medicine purview, then this research should be in the emergency medicine domain whether in the department or observation unit. Many patients have problems in areas of emergency physicians' expertise that need only short-term management: toxicology, wilderness medicine, hyperbaric

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medicine, environmental emergencies, etc. Because hospitals d o n ' t allow you to care for admitted patients as an emergency physician, I believe the observation unit is one area in which emergency physicians should evaluate these patients with research protocols where appropriate. Question: I notice you all refer to observation units, yet observation medicine has been used from time to time. I think it is a long distance between the two, at least in the setting I work in at Yale. I think the term observation medicine is almost something to be scoffed at. We have difficulty selling emergency medicine as a specialty, and I can just imagine my dean having fun with the term observation medicine. My question is to go back to this length-of-stay issue. If the hospital beds are full it doesn't matter, but it seems that observation medicine does offer a real opportunity in decreasing the length of stay in the ED for those departments that are quite busy. Has anyone measured that, and do you believe that is true?

Con Side: Dr M a t h e w s I ' m not arguing against all observation units. I ' m arguing against this being in the domain of emergency medicine. I believe there is a need to get some patients out of your ED. I d o n ' t believe anyone here would disagree with me. Shuffling them around the corner, u n d e r the direct care of the ED, doesn't even add beds to your department, which may be the critical issue. It doesn't improve your admission routine so patients d o n ' t wait six, eight, or ten hours for a bed. It doesn't work for HMOs, which are telling you to wait four or six hours for transfer of a patient from your hospital to their hospital. What I ' m arguing against is ED observation units. I d o n ' t see that they have any major advantage in the ED or our specialty because they d o n ' t help us get rid of our problems. If we're going to provide the same level of care as for patients in the coronary care unit, then we have an obligation to see that patient very often. If so, what is going to happen to the other 20 or 30 patients for whom the physician is responsible? What is going to happen when the physician is physically in the observation unit and not in the ED? I think it is a great idea to get the patient out of the ED quicldy, away from your purview. But we are not cardiologists. We d o n ' t have the credentials of cardiologists. With ED observation units we are making some decisions after six to ten hours that from a medical legal aspect may give us trouble. We make decisions on who with chest pain needs to be admitted, but we do not provide the definitive care as the cardiologist. ED observation units may work in some places beautifully either because of the payor mix or because of medical staff support. But as a general rule the concept is a disaster, in inner-city hospitals particularly. Patients who no one else wants end up in the observation unit for indefinite periods.

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SUMMARY Pro Side: Dr Graff What we are dealing with is not a physical unit but in reality a concept. We are not emergency room doctors - - we are emergency physician specialists. We deal with emergency medicine in all its aspects; we d o n ' t deal with a room. Whether you have an observation unit or an observation policy, what is important is the concept of how to deal with a certain type of patient. The overcrowding issue may actually help us. Rather than us putting our head into a hole saying we c a n ' t deal with this type of patient - - ie, we d o n ' t deal with continuing care - - we should provide ongoing care for a certain type of patient, a patient who is appropriate for an observation unit. We shouldn't deal with a patient who is appropriate for admission to the hospital, who has 20 or 30 medicines, and who~needs intensive services. We are going to manage patients who have a limited intensity of service that we define as manageable for our nurses, a level of service similar to that on the medicine floors. This saves the bed upstairs for patients who are "train wrecks" with very high service needs that would consume our staff's energies. At the same time, we are offering to society a way of dealing with the health care crisis. The latest Health Care Financing Administration statistics show that more than 12.4% of our nation's gross national product is for health care. This is up from 11.6% of the gross national product from last year despite cost-containment studies and efforts. Our specialty should have input into solutions being developed for these problems. With observation units we are part of the safety net for the population, managing many common emergencies that otherwise would have needed hospital admission. We are part of the solution trying to deal with health care policy.

Con Side: Dr Benjamin I believe that observation units offer no unique service to our patients. Organizational problems in r u n n i n g these units are formidable. There is lack of adequate reimbursement. There are significant staffing problems and costs; there are additional equipment and supply costs. The logistics of those problems prohibit us from supporting the proposition. We believe ED observation units are an expansion service beyond the capabilities of emergency medicine and that there is no improvement in quality of care beyond the existing emergency services. Because of these concerns, we do not support observation units.

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23. Desai MH, Rutan RL, Herndon DN: Managing smoke inhalation injuries. Postgrad Med1989;86:69-76.

53. Israel RS, Lowenstein SR, Marx JA, et ah Management of acute pyelonephritis in an emergency department observation unit. Ann EmergMed 1991;20:253.

24. Heimbaeh DM, Waeckerle JF: Inhalation injuries. Ann EmergMed 1988;17:1316-1320.

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25. Cohen MA, Guzzardi LJ: Inhalation of products of combustion. Ann EmergMed 1983;12:628-632. 26. Fein AM: Toxic gas inhalation. EmergMed 1989;87:53-59. 27. Demling RH: Smoke inhalation injury. PostgradIVied1987:82:63-68. 28. Kinsella J, et ah Increased airways reactivity after smoke inhalation. Lancet 1991;337:595-97. 29. Esch VH, Dyer RF: Polyvinyl chloride toxicity in fires. JAMA 1976;235:393-397. 30. Hartzell 6 E, Packham SC, Switzer WG: Toxic products from fires. Am Ind Hyg AssocJ 1983;44:248-255. 31. Jones J, Krohmer J: Injurythrough inhalation: Cyanide poisoning in fire victims. JEM$1990;12:36-39. 32. Guzzardi L: Toxic products of combustion. TopicsEmergMed1985;7:45-51.

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56. Conrad L, Markovchick KV, Mitchiner J, et ah The role of an emergency department observation unit in the management of trauma patients. J EmergMed 1985;2:325. 57. Henneman DL, Marx JA, Cantrill SC, et ah The use of an emergency department observation unit in the management of abdominal tra urea. Ann EmergMed 1989;18:647. 58. Ammons MA, Moore EE, Rosen P: Role of the observation unit in the management of thoracic trauma. J EmergMeal1986;4:279.

Address for reprints: Louis Graft, MD, FACP, FACEP, New Britain General Hospital, 100 Grand Street, New Britain, Connecticut 06050.

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