OPERATIONS MANAGEMENT COMMITTEE
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ith the ongoing emphasis on reducing health care costs in the United States and in reducing emergency department wait times and crowding, observation medicine has become an increasingly important field to help address these issues. Observation units have been shown to help decrease overall health care costs, reduce unnecessary admissions and overall length of stay, and help improve emergency department patient flow. Unfortunately, there has not always been a consensus on how to best define observation medicine and what the specific role emergency physicians (EP) should hold in providing this care. While there has been over decade of literature supporting the role of EPs in providing and supervising observation medicine, as well as EPs possessing the mental models of care delivery that are consistent with the sort of cognitive and operational skills required for observation medicine, there remains debate as to whether emergency medicine is best suited to deliver such observation care.1 Presently, many of us in emergency medicine lead observation units and programs which seem to blur the lines between observation and inpatient status. This is often done in academic centers, and is done intentionally, driven by a
Observation medicine is emergency medicine, it is best practiced in a protocol driven fashion, and ultimately you are likely already doing it.” desire to expand our knowledge, to innovate and simply to prove “what’s possible” in the field of observation medicine. While this is important to the advancement of the field, it only further blurs the lines of the central role of observation medicine. It is not uncommon we are asked by medical directors and administrators in
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COMMON SENSE MARCH/APRIL 2022
Observation Medicine – It’s Common Sense Anthony R. Rosania, MD MHA FAAEM Akiva Dym, MD
smaller institutions how observation medicine can be of help to them and their stakeholders. To answer this, we need to step back from the large, complex, observation unit and look at the fundamentals of observation medicine. As outlined by Ross and Granovsky in 2017, a few basic principles govern observation medicine: focused goals, limited duration and intensity of care, and appropriate setting and staffing. We propose a similar model: focusing on the guardrails that keep the care focused and cost effective.2 These guardrails, or principles, are appropriate patient selection, protocol driven care, and defined endpoints for discharge and admission. When adherent to these basic principles, observation medicine is approachable, easily implemented, and highly scalable. In this article, we aim to discuss the basis as to why many believe that observation medicine belongs within the purview of emergency medicine, as well as discuss how to best initiate and implement small scale observation within the emergency department without significant demand for additional space or personnel. Lastly, we will briefly discuss some of the financial aspects which are unique to observation medicine.
Observation Medicine Is Emergency Medicine Before beginning a discussion as to why observation medicine is part and parcel to the specialty of emergency medicine, it is important to draw a distinction between the practice of observation medicine and the hospital status of “observation.” While the two should be closely linked, it is quite often they are not. There are many patients with poorly defined endpoints and high intensity of service who end up on observation status when the principles outlined above are not followed. The principled practice of observation medicine is best defined by CMS Medicare Benefit Policy Manual: Observation care is a well-defined set of specific, clinically appropriate services, which include
ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge.3
Observation medicine is not really a shortening of inpatient medicine/stays but rather a lengthening of what previously had been normal emergency department visits. Central to this definition of observation is the last statement which states “to make a decision concerning their admission or discharge.” Is this not a central concept within emergency medicine? Determining patient need for admission or discharge within observation is an extension of triage and disposition, simply over a longer period of time. The CMS Manual goes on to define that time as usually less than 24 hours. Thus, observation medicine is not really a shortening of inpatient medicine/stays but rather a lengthening of what previously had been normal emergency department visits. As our in-patient admission criteria have changed, so too has the amount of time required to determine if a patient needs to be admitted grown longer. However, this does not change the fact that this determination of disposition is fundamentally related to the concepts of triage and disposition which is at the core of emergency medicine.
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