RAMS Observation Medicine Roadmap

OBSERVATION MEDICINE Observation Medicine encompasses the skills and knowledge needed to appropriately identify and provide active patient care beyond initial ED care.

MED STUDENT (MS3/4)

JUNIOR RESIDENT

background

Senior RESIDENT

Resources

AUTHORS: Margarita E. Pena, MD; Maria Aini, MD; Mary M. Fitzgerald MD; and Pawan Suri, MD Welcome to the Observation Medicine Roadmap, your definitive step-by-step guide on how to succeed in Observation Medicine at every training level. Don’t know where to start? Click on “Background” or select your training level above. A full list of fellowships, conferences, and podcasts can be found in “Resources.”

For pearls of wisdom from faculty and residents in the trenches, click on “Insider Advice.”

FELLOW

insider Advice

1 - SENIOR MEDICAL STUDENT Planning 3rd/4th Years • F ind out if the ED you are doing your Emergency Medicine rotation(s) has an ED observation unit (EDOU) and ask to shadow an Observation provider or if there are opportunities to also see patients that are in the EDOU. The program you rotate at may provide you with the opportunity to spend some of your scheduled shifts in the EDOU. • C onsider setting up a rotation at an EDOU. This would be a 4thyear elective rotation. You can find one by searching for hospitals with both an Emergency Medicine residency and an EDOU. Rotations are typically 4 weeks.

• S uggested readings- see PGY-1 readings in the Observation Medicine Reading List as these give a good overview of Observation Medicine.

2 - JUNIOR RESIDENT Recognizing disposition • A s a new intern, one of the most important tasks you will face is recognizing the disposition for the patient early on in their ED course. Ideally, you will be training at a facility that has an OU, and in particular, an OU managed by emergency physicians. For the first year of residency, the focus should be on becoming familiar with the different protocols and determining which patients are suitable for the OU versus an inpatient admission using inclusion and exclusion criteria found in the protocols.

OU protocols and plans • U pon admitting patients to the OU, you may be expected to place orders and select protocols for their short hospital stay with the ultimate goal being to have the patient evaluated and ready for discharge within 23 hours. Following up on that patient’s OU course after discharge is particularly important for learning. Did the patient’s OU course follow your proposed protocol, or were changes made by the OU physician and specialist?

OU Experience • A fter some experience in the ED, it may be beneficial to explore shifts in the OU. This is typically started in the second year of residency. Some residency programs incorporate longitudinal OU shifts over the entire course of residency, while others have dedicated months of OU shifts.

OU Mentors • I f you are interested in OU medicine, another goal during intern year should be to establish a mentor in the field. Reach out to the OU director at your hospital and explain your interest, offer to become involved with research projects, and attend any OU administrative meetings.

3 - SENIOR RESIDENT Emphasis on time in OU • B y the beginning of your second year, you should feel comfortable stratifying which patients are suited for OU management.

During your second and third year, the focus is on arriving at correct and timely disposition for OU patients. Also important is the ability to recognize when a patient is unstable for discharge from the OU and should be considered for inpatient admission.

Administrative Involvement • Th e goal should be to become familiar with overall management of an OU. You should have some understanding of Observation coding and billing, how to create new OU protocols, optimal staffing, quality issues and metrics of an OU. Attending OU administration meetings or going to an Observation Medicine conference also would be available if you have a particular interest in OU after graduation.

4 - FELLOWSHIP Introduction

• F or EM graduates who want to pursue a career in Observation Medicine, a one-year OM fellowship will provide administrative and leadership skills necessary for a future Observation Unit Directorship role.

• The fellow often functions as an assistant EDOU director, working under the direct guidance of the medical director. They lead an interdisciplinary team to achieve length of stay targets via expedited patient care. The OU team encompasses case managers, advanced practice providers (APPs), nurses, social workers, physicians, and consultants. The fellow will participate in Performance Improvement activities specific to observation unit operations. The observation fellowship will focus on developing new evidence-based pathways that expand the scope of the Unit and improve efficient throughput.

Clinical Operations

• E D and EDOU clinical operations leadership teams will provide mentorship to the fellow. The fellowship will include training and experience in project management and health analytics pertaining to observation and ED care. Fellows will gain the knowledge and experience necessary to create a business proposal for the development and scaling of observational services, and create sustainable unit staffing models that optimize resource utilization.

Education and Training

• Th e fellow shall work clinically in the Observation Unit as well as the Emergency Department • At the conclusion of training, the fellow will be a content expert in all aspects of observation care. This role requires building successful relationships with other departments across the institution. The Observation Medicine Fellow will attend national training conferences in observation medicine as well as participate and present at monthly fellowship didactic sessions. The fellow will play a central role in educating residents, APPs, faculty and staff on clinical pathways, patient selection, performance improvement, and clinical issues relevant to observation medicine.

Elective Time

• Th e fellow will be encouraged to develop a unique niche within observation medicine. This may include research, transitions of care from an observation setting, health policy, and telehealth. The Fellow will be paired with an appropriate mentor during this elective time.

Professional Development

• Th e Fellow will be required to participate in a research project pertaining to Observation Medicine.

• The Fellow may be sponsored by the Department to attend an Observation Medicine conference.

• The Fellow may be sponsored to attend academic meeting (SAEM/ACEP, etc) to present their research and participate in the Observation Medicine Interest Groups.

5 - BACKGROUND Observation Medicine encompasses the skills and knowledge needed to appropriately identify and provide active patient care beyond initial ED care for patients who are not well enough to be discharged from the ED but not ill/injured enough to require a full admission in an inpatient setting.

The History of Observation Medicine Historically, there were only two disposition options for emergency physicians - admit or discharge. This left emergency physicians with sometimes difficult disposition decisions for patients too sick to discharge but not necessarily requiring a full inpatient hospitalization. Recently, a third disposition option has emerged, placement in an observation unit. Observation units allow for further diagnostic and therapeutic interventions beyond the initial ED care, and frequent reassessments to evaluate disease progression along a time continuum. The average observation unit stay is 15 hours, after which it is determined if a patient can be safely discharged home or whether the patient requires further evaluation and treatment in an inpatient setting. Guidelines regarding observation versus inpatient care are often dictated by The Center for Medicare and Medicaid Services [CMS]. Multiple factors have led to an increased use of observation care and subsequently an increase in the number of observation units including: ED and hospital overcrowding, resource overutilization, payer audits, payment denials, and medical innovations shifting care to outpatient settings. It is estimated that 12-25% of ED patients admitted to the hospital may qualify for an observation unit stay instead.

Emergency medicine has long recognized the importance of observation care and has established itself as the leader in the science and practice of observation medicine. The American College of Emergency Physicians first issued Observation Medicine practice guidelines in 1988 and the Observation Medicine section was established in 2001.

Why is Observation Medicine an Important Skill Set for the Emergency Physician?

One of the most important skills of an Emergency Medicine physician is determining an appropriate and safe disposition. Since diseases progress over time, an observation unit allows the emergency physician to witness diseases improving or worsening beyond the 4-6 hour period of an ED stay and the effect of treatments. Moreover, the OU allows for the appropriate time to apply an evidence based clinical model for safer dispositions to home. This makes the physician a better prognosticator of disease and helps to improve disposition decision-making.

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Observation medicine is also an area for emergency physicians to broaden their value to their hospital and increase their general employability. OUs run by emergency physicians improve patient outcomes and decrease health care spending, and thus are desired assets for every hospital system. Multiple changes in health care have led to increasing numbers of observation units opening in hospitals, especially in larger academic institutions. It is likely that a graduating emergency physician will be employed in a hospital with an observation unit and Observation Medicine knowledge and skills will be expected. On a more practical note, the lifestyle of an OU physician can be more predictable than the lifestyle of the ED physician who works only in the emergency department.

Depending on the hospital, the hours tend to more resemble typical business hours. As well, it provides an interesting mix between acute ED management and post-acute traditional but short-term hospital ward management.

Why are Emergency Physicians ideally suited to management of an Observation Unit?

When patients are placed in the OU from the ED, the plan of care has often already been put in motion by the initial ED physician.

Hand-off of patient care to a like-minded physician allows for a more seamless and symmetric transition. Further, because emergency physicians are trained and practice in a disposition-driven manner, the short-term management of patients with the goal of determining ultimate dispositions is inherent to how emergency physicians are trained and work. Several studies comparing ED OU care to inpatient care for common conditions such as asthma, chest pain, syncope, atrial fibrillation and TIA found OU care has lower levels of diagnostic uncertainly, lower costs, shorter lengths of stay, improved patient outcomes and improved clinical outcomes.

Additionally, OU stays are associated with reductions in health care costs to society.

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6 - RESOURCES Professional Organizations

Conferences

• S ociety of Academic Emergency Medicine (SAEM) Observation Medicine Interest Group • A merican College of Emergency Physicians (ACEP) Observation Medicine Section

• C enter for Emergency Medical Education Observation Care • W orld Congress Observation Management Summit Sponsor: The American Board of Quality Assurance and Utilization Review Physicians, Inc.

Observation Medicine Fellowships*

On-line Resources

• E MRA Fellowship Guide, 2nd Edition Observation Medicine • E mory University School of Medicine Atlanta, GA – Director: Michael A. Ross, MD • J ohn Hopkins Medicine Baltimore, MD – Director: Peter Hill, MSc, MD • Th omas Jefferson University Philadelphia, PA – Director: Maria Aini, MD • U niversity of Colorado School of Medicine Aurora, CO – Director: Jennifer Wiler, MD, MBA • U niversity of North Carolina Chapel Hill, NC – Director: Ahbi Mehrotra, MD, MBA * Length of fellowship varies, is from 1- 2 years. Some are administrative fellowships with Observation Medicine included in the curriculum.

Conferences • M ichigan ACEP Observation Medicine: Science & Solutions Conference

(Note: There are other observation medicine conferences but this is the only ACEP sponsored conference, includes an Observation innovation, quality & research poster session, and gives CME credit)

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• A CEP Observation Medicine Section. Observation Medicine Toolkit • O bservation Medicine Protocols • P odcast of Observation Medicine Topics: POBScast

Textbooks

• G raff LG. Observation Medicine. 1993, Boston: Andover Medical Publishers, Inc. • M ace SE (editor): Observation Medicine: Principles and Protocols, 2017, Cambridge UK. Cambridge University Press.

• B augh CW, Graff L. Observation Medicine and Clinical Decision Units. In Walls R, Hockberger R, Gausche-Hill M, eds.Rosen’s EmergencyMedicine: Concepts And Clinical Practice, Philadelphia, PA:Elsevier; 2018.

• P eacock Wf. Short Stay Management Of Heart Failure.

Philadelphia, Pa: Lippincott Williams & Wilkins; 2006.

• P eacock Wf, Cannon Cp. Short Stay Management of Chest Pain. New York, Ny: Humana; 2009.

• P eacock Wf. Short Stay Management of Acute Heart Failure.

New York, Ny: Humana; 2012.

Journal Issue Dedicated to Observation Medicine

• R eilly BM, Evans AT, Schaider JJ, Das K, Calvin JE, Moran LA, et al. Impact of a clinical decision rule on hospital triage of patients with suspected acute cardiac ischemia in the • E mergency Medicine Clinics of North America, August 2017, emergency department. JAMA 2002;288:342-50. volume 35, number 3 • K eller T, Zeller T, Peetz D, Tzikas S, Roth A, Czyz E, et al.

Sensitive troponin I assay in early diagnosis of acute myocardial Articles suggested for students/residents: infarction. N Engl J Med 2009;361:868-77. (as per suggestions in Wheatley M, Baugh C, Osborne A, et al.

• R eichlin T, Hocholzer W, Bassetti S, Steur S, Stelzig C, Hartwiger A model longitudinal observation medicine curriculum for an S, et al. Early diagnosis of myocardial infarction with sensitive emergency medicine residency. 2016; 2394):482-492) cardiac troponin assays. N Engl J Med 2009;361:858-67.

• A msterdam EA, Kirk JD, Bluemke DA, Diercks D, Farkouh Medical Students/PGY1: ME, Garvey JL. Testing of low-risk patients presenting to • R oss MA, Aurora T, Graff L, Suri P, O’Malley R, Ojo A, et al. the emergency department with chest pain: a scientific State of the Art: Emergency Department Observation Units. statement from the American Heart Association. Circulation CritPathwCardiol 2012;11:128-38.

2010;122:1756-76.

• W iler, JL, Ross MA, Ginde AA. National study of emergency • E l-Hayek G, Benjo A, Utresky S, Al-Mallah M, Cohen department observation services. Acad Emerg Med R, Bamira D, et al. Meta-analysis of coronary computed 2011;18:959-65. tomography angiography versus standard of care strategy for • G raff, LG. Observation MEDICINE The Healthcare System’s the evaluation of low risk chest pain: are randomized controlled Tincture of Time. (online textbook) trials and cohort studies showing the same evidence? Int J • E mory Clinical Decision Unit Manual Emory University Cardiol 2014;177:238-45.

School of Medicine, Department of Emergency Medicine: CDU • R ydman RJ, Isola ML, Roberts RR, Zalenski RJ, McDermott Manual. Ross MA, Wheatley M, Leach G, O’Malley R, Osborne MF, Murphy DG, et al. Emergency Department Observation A. electronic media, Macintosh i-Book. 2012.

Unit versus hospital inpatient care for a chronic asthmatic population: a randomized trial of health status outcome and PGY2 cost. Med Care 1998 36:599-609.

Chest Pain: • R aff GL, Chinnaivan KM, Cury RC, Garcia MT, Hecht HS, • H ess EP, Brison RJ, Perry JJ, Calder LA, Hollander JE, et al. SCCT guidelines on the use of coronary Thiruganasambandamoorthy V, Agarwal D, et al. Development computed tomographic angiography for patients presenting with of a clinical prediction rule for 30-day cardiac events in acute chest pain to the emergency department: a report of the emergency department patients with chest pain and possible Society of Cardiovascular Computed Tomography Guidelines acute coronary syndrome. Ann Emerg Med 2012;59:115-25 e1.

Committee. J Cardiovasc Comput Tomogr 2014;8:254-71.

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Asthma: • M cDermott MF, Murphy DG, Zalenski RJ, Rydman RJ, McCarren M, Marder D, et al. A comparison between emergency diagnostic and treatment unit and inpatient care in the management of acute asthma. Arch Intern Med 1997 157: 2055-62.

Transient ischemic attack: • R oss MA, Compton S, Medado P, Fitzgerald M, Kilanowski P, O’Neil BJ. An Emergency Department Diagnostic Protocol for Patients With Transient Ischemic Attack: A Randomized Controlled Trial. Ann Emerg Med 2007;50:109-19.

• N ahab F, Leach G, Kingston C, Mir O, Abramson J, Hilton S, et al. Impact of an Emergency Department Observation Unit Transient Ischemic Attack Protocol on Length of Stay and Cost. J Stroke Cerebrovasc Dis. 2012;21:673-8.

• R oss M, Nahab F. Management of transient ischemia attacks in the twenty-first century. Emerg Med Clin North Am 2009;27: 51-69, viii.

Atrial Fibrillation: • D ecker WW, Smars PA, Vaidyanathan L, Gayal DG, Boie ET, Stead LG, et al. A prospective, randomized trial of an emergency department observation unit for acute onset atrial fibrillation. Ann Emerg Med 2008;52(4): 322-8.

Syncope: • S un BC, McCreath H, Liang L, Bohan S, Baugh C, Ragsdale L, et al. Randomized Clinical Trial of an Emergency Department Observation Syncope Protocol Versus Routine Inpatient Admission. Ann Emerg Med 2014;64:167-75.

• S hen WK, Decker WW, Smars PA, Goyal DG, Walker AE, Hodge DO, et al. Syncope Evaluation in the Emergency Department Study (SEEDS): a multidisciplinary approach to syncope management. Circulation 2004;110: 3636-45.

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Congestive Heart Failure: • C ollins SP, Pang PS, Fonarow GC, Yancy CW, Bonow RO, Gheorghiade M. Is hospital admission for heart failure really necessary: the role of the emergency department and observation unit in preventing hospitalization and rehospitalization. J Am Coll Cardiol • P eacock WF, Fonarow GC, Ander DS, Maisel A, Hollander JE, Januzzi JL, et al. Society of Chest Pain Centers Recommendations for the evaluation and management of the observation stay acute heart failure patient: a report from the Society of Chest Pain Centers Acute Heart Failure Committee.

CritPathwCardiol. 2008;7:83-6.

• C ollins SP, Lindsell CJ, Naftilan AJ, Peacock WF, Diercks D, Hiestand B, et al. Low-risk acute heart failure patients: external validation of the Society of Chest Pain Center’s recommendations. CritPathwCardiol. 2009;8:99-103.

Pediatrics: • C onners GP, Melzer SM, Betts JM, Chitkara MB, Jewell JA, Lye PS, et al. Pediatric observation units. Pediatrics 2012;130:172-9.

• M acy ML, Kim CS, Sasson C, Lozon MM, Davis MM. Pediatric observation units in the United States: A systematic review. J Hosp Med 2010;5:172-82.

Geriatrics: • C aterino JM, Hoover EM, Moseley MG. Effect of advanced age and vital signs on admission from an ED observation unit.

Am J Emerg Med 2012 • R oss MA, Compton S, Richardson D, Jones R, Nittis T, Wilson. The use and effectiveness of an emergency department observation unit for elderly patients. Ann Emerg Med 2003;41: 668-77.

PGY3/4 Health Policy: • A CEP Policy: Emergency department observation services.

Ann Emerg Med 2008;51:686.

• C MS Hospital Payment (2010): Medicare Claims Processing Manual, Chapter 4 - Part B Hospital (Including Inpatient Hospital Part B and OPPS). Section 290 Outpatient Observation Services. http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/clm104c04.pdf.

Accessed April 27, 2015.

• A MA (2015). Evaluation and Management (E/M) Service Guidelines. Current Procedural Terminology 2015, Professional Edition. A. J. Abraham M, Anderson C, et al. Chicago, Ill, AMA. Financial Issues: • B augh CW, Bohan JS. Estimating observation unit profitability with options modeling. Acad Emerg Med 2008;15:445-52.

• B augh CW, Venkatesh AK, Bohan JS. Emergency department observation units: A clinical and financial benefit for hospitals.

Health Care Manage Rev 2011;36:28-37.

• H ostetler B, Leikin JB, Timmons JA, Hanashiro PK, Kissane K. Patterns of use of an emergency department-based observation unit. Am J Ther. 2002;9:499-502.

• R oss MA, Hemphill RR, Abramson J, Schwab K, Clark C. The recidivism characteristics of an emergency department observation unit. Ann Emerg Med 2010;56:34-41.

• L eykum LK, Huerta V, Mortensen E. Implementation of a hospitalist-run observation unit and impact on length of stay (LOS): a brief report. J Hosp Med 2010;5(9): E2-5.

National Policy Issues: • R oss MA, Hockenberry JM, Mutter R, Barrett M, Wheatley M, Pitts SR. Protocol-Driven Emergency Department Observation Units Offer Savings, Shorter Stays, And Reduced Admissions.

Health Affairs 2013;32:2149-56.

• V entatesh AK, Suter LG. Observation “services” and observation “care” – one word can mean a world of difference.

Health Serv Res 2014;49:1083-7.

• F eng Z, Wright B, Mor V. Sharp rise in medicare enrollees being held in hospitals for observation raises concerns about causes and consequences. Health Aff 2012;31:1251-9.

• B augh CW, Venkatesh AK, Hilton JA, Samuel PA, Schuur JD, Bohan JS. Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year.

Health Aff 2012;31:2314-23.

Unit Management: • P eacock F, Beckley P, Clark C, Disch M, Hewins K, Hunn D, et al. Recommendations for the evaluation and management of observation services: a consensus white paper: the society of cardiovascular patient care. Crit Pathw Cardiol 2014;13:136-98.

Web-based Resources • R oss MA, Aurora T, Graff L, Suri P, O’Malley R, Ojo A, et al.

• w ww.obsprotocols.org - wiki site with sample protocols State of the Art: Emergency Department Observation Units.

• w ww.acep.org/observationsection/ - ACEP observation CritPathwCardiol. 2012;11:128-38. medicine section with an online textbook and sample protocols

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Important Aspects of Observation Medicine and Often Cited References and/or of Historical Importance Characteristics and Number of Observation Units In The United States • M ace SE, Graff L, Mikhail M, Ross M. A National Survey of Observation Units in the United States. Amer J Emerg Med, 2003;21(7): 529-533.

• M ace SE, Shah J. Observation Medicine in Emergency Medicine Residency Programs. Acad Emerg Med, 2002;9(2): 169-171.

• V enkatesh AK, Geisler BP, Gibson Chamber JJ, et al. Use of observation care in US emergency departments, 2001 to 2008.

PLoS One 2011; 6(9), e24326.

• W iler LJL, Ross MA, Ginde AA. National study of emergency department observation services. Acad Emerg Med 2011; 18(9):959-965.

Education And Curriculum • P ena ME. Training and education - medical students/fellows.

In: Mace SE (ed): Observation Medicine: Principles and Protocols, 2017, Cambridge UK. Cambridge University Press, chapter 15, pp. 68-69.

• S uri P. Training and Education – residents. In Observation Medicine In: Mace SE (ed): Observation Medicine: Principles and Protocols, 2017, Cambridge UK. Cambridge University Press, chapter 14, pp. 66-67.

• P ena ME. Training and education - medical students/fellows.

In: Mace SE (ed): Observation Medicine: Principles and Protocols, 2017, Cambridge UK. Cambridge University Press, chapter 15, pp. 68-69.

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• W heatley M, Baugh C, Osborne A, et al. A model longitudinal observation medicine curriculum for an emergency medicine residency. 2016; 2394):482-492.

Protocol-Driven Observation Unit vs. Observation Status • R oss MA, Hockenberry JM, Mutter R, et al. Protocol-driven emergency department observation units offer savings, shorter stays, and reduced admissions. Health Affairs 2013; 32(12):2149-2156.

• S heehy AM, Graf B, Gangireddy S, et al. Hospitalized but not admitted: characteristics of patients with “observation status” at an academic medical center. JAMA Intern Med (Note: This article is based on an observation unit that does not have dedicated observation units or dedicated protocols) Financial Benefits of Observation Units • B augh CW, Bohan JS. Estimating observation unit profitability with options modeling. Acad Emerg Med 2008; 15:445-452.

• B augh CW, Suri P, Caspers CG, et al. Financial viability of emergency department observation unit billing models. Acad Emerg Med 2018; 26(1):31-40.

• B augh CW, Venkatesh AK, Bohan JS. Emergency department observation units: a clinical and financial benefit for hospitals.

Health Care Management Review 2011: 36(11)28-37.

• B augh CW, Vebkatesh JA, Hilton PA, et al. Making greater use of dedicated hospital observation units could save 3.1 billion a year. Health Affairs 2012; 31(10):2314 DOI: 10.1377/ hlthaff.2011.0926

Economic Impact of Observation for Patients (includes the Controversy over “Cost of Observation Care”) • O ’Connor R, Mace SE. Observation Medicine is not the same as observation status. In: Mace SE (ed): Observation Medicine: Principles and Protocols, 2017, Cambridge UK. Cambridge University Press, prologue, pp.

• W right S. Office of Inspector General. Memorandum report: hospitals’ use of observation stays and short inpatient stays for Medicare beneficiaries. Washington, DC: U.S. Department of Health and Human Services, July 2013 (https://oig.hhs.gov/oei/ reports/oei-02-12-00040.pdf).Accessed July 26, 2019) Editorials: • B augh CW, Schur JD. Observation care – high-value care or cost-shifting loophole? N Engl J Med 2013; 369(4); 302-305. July 25, 2013. (Correction to table available at https://search.proquest. com/printviewfile?accountid=50452) Accessed July 26, 2019) • N udelman J, Rubin M. Observation care. N Engl J Med369(15):15):1474- 1475. (October 10, 2013) Extended or Complex Observation • P uetz CT. Extended observation services. In: Mace SE (ed): Observation Medicine: Principles and Protocols, 2017, Cambridge UK. Cambridge University Press, chapter 17, pp.

• G ilmore LC, Nicks BA. Extended and complex observation. In: Mace SE (ed): Observation Medicine: Principles and Protocols, 2017, Cambridge UK. Cambridge University Press, chapter 16, pp.

Patient Satisfaction, Press Ganey, Quality Improvement • C handra A, Sieck S, Hocker M, et al. An observation unit may help improve an institution’s Press Ganey satisfaction score.

Crit Pathw Cardiology: A Journal of Evidence-Based Medicine 2011; 10(2):104-106.

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• M ace SE. Continuous Quality Improvement for the Observation Unit. J Healthcare Quality 2004; 26(1): 29-36.

• M ace SE. Resuscitations in an Observation Unit. J Quality Clinical Practice 1999; 19(3): 155-164.

• M ace SE, Thallner ET. Metrics and performance improvement: patient quality, safety, and experience for the observation unit. . In: Mace SE (ed): Observation Medicine: Principles and Protocols, 2017, Cambridge UK. Cambridge University Press, chap 9, pp.

• R ydman RJ, Roberts RR, Albrecht GL, et al. Patient satisfaction with an emergency department asthma observation unit. Acad Emerg Med 1999; 6(3):178-1183.

• R ydman RJ, Zalenski RJ, Roberts RR, et al. patient satisfaction with an emergency department chest pain observation unit.

Ann Emerg Med 1997; 29(1)109-115.

Hospital Reimbursement • G ranovsky MA. Physician coding and reimbursement. In: Mace SE (ed): Observation Medicine: Principles and Protocols, 2017, Cambridge UK. Cambridge University Press, chapter 62, pp.

348-354.

• G ranovsky MA, Shaeffer CE. Physician coding and reimbursement. In: Mace SE (ed): Observation Medicine: Principles and Protocols, 2017, Cambridge UK. Cambridge University Press, chapter 63, pp. 355-362.

• G ranovsky M. Physician Observation Billing. Available at https://www.mcep.org/wp-content/uploads/2018/10/18Granovsky-Phys-and-Facility-Obs-ReimbFinal.pdf.

• G ranovsky MA, Mckenzie DA. 2019 Reimbursement Update and national trends. February 24, 2019. Available at https://www.acep.org/rc/education/reimbursement-schedule/

7 - INSIDER ADVICE Michael A. Ross, MD “The defining feature of observation care is management to determine the need for inpatient admission. The specialty that is best at that is Emergency Medicine. Like Emergency Medicine, Observation is a service that is defined by time. A protocol driven ED observation unit is a win- win for the patient, provider, payer, and hospital. That doesn’t happen very often in medicine.”

Sharon E. Mace, MD “Observation Medicine, like Emergency Medicine, has responded to the challenges facing the healthcare system with innovative solutions. Observation Medicine has established itself as an integral part of emergency medical care and has the ability to foster creative “cutting edge” answers to the problems confronting our patients and the healthcare in the future.”

Chris M. Baugh MD, MBA “Observation units are increasingly commonplace in hospitals throughout the country and represent a tremendous opportunity for emergency physicians to prevent avoidable inpatient admissions, safely send more patients home and build strong collaborations with other services that improve the care of all patients.”

Matthew A. Wheatley, MD “Observation Medicine is the only area within Emergency Medicine where we get to see the results of our own practice. How precise are our diagnoses and treatments? How do patients progress through their disease process? It is also an area that can greatly impact ED throughput. EM graduates will need to know how to manage patients in this setting once they finish training.”

Brian Hiestand “Observation is not a place in the hospital, or a particular bed. It is an action, a state of being. We instinctively recognize that some patients just need some time to declare themselves. Observation Medicine is simply the formalization of that heuristic.”

Anwar Osborne, MD “Unlike in huge inpatient wards, in observation units, we, effectively, can turn on a dime based on the latest evidence.”

Maria Aini, MD “Observation Medicine serves as not only the safety net for Emergency Medicine but is also our health system’s ‘tincture of time’ and is becoming the cutting edge of acute healthcare.”

Margarita E. Pena, MD “Knowledge and practice of Observation Medicine is essential for all emergency physicians. As ED observation units continue to open around the country, Observation Medicine experts will be needed as well as leaders in Observation Medicine.”