Emergency Department Observation Units

Authors:

Helen Lu, MD; and Matthew Wheatley, MD, on behalf of the SAEM ED Admin and Clinical Operations Committee.

Overview

Observation care is defined by the Centers for Medicare & Medicaid Services (CMS) as short-term treatment and reassessment provided for a patient to determine the need for admission. This care can be administered within any bed in the hospital. Cohorting observation patients in dedicated areas and managing them with patient care protocols has demonstrated effectiveness in reducing both length of stay and costs. Emergency Department Observation Units (EDOUs) have proven effective in managing patients with a range of conditions, including chest pain, asthma, syncope, atrial fibrillation, transient ischemic attack, and other common complaints. Many EDOUs are staffed with Advanced Practice Providers (APPs) and an emergency department (ED) physician who oversees care.

EDOUs allow providers to decompress the ED by transferring patients who will require less than 24 hours of continuing care out of the ED. Ideally, these are patients with a single low-acuity issue who do not meet admission criteria but cannot be discharged immediately. EDOUs have been shown to reduce ED diversion hours and the number of patients who leave without being seen, decrease hospital admissions and length-of-stays, and preserve inpatient beds for more complex cases.

EDOUs should be customized based on the needs of the individual ED and hospital. EDOU may be placed adjacent to the ED or on a different floor in the hospital depending on space limitations. If necessary, specific beds in the ED may be designated for observation purposes, allowing for “obs in place” in the ED.

While many EDOUs are administered and staffed by the ED, alternative arrangements exist where the units are managed by hospitalists or staffed by a separate group of emergency medicine, internal medicine, or family medicine physicians.

Interested Parties

In establishing or expanding EDOUs, various departments within the hospital play critical roles. Hospital administration, including the chief executive officer, chief nursing officer, and chief medical officer, must endorse and support the implementation of an EDOU despite the initial investment required in staffing. Ideally, this unit should be situated adjacent to the ED to optimize its effectiveness. Nursing administration is essential in providing strong leadership for staffing and education within the EDOU, collaborating closely with the EDOU medical director to ensure adherence to utilization and quality metrics. Hospital medicine/internal medicine departments, particularly hospitalists, are vital partners in refining the criteria for EDOU admission, determining which short-stay inpatients or medicine observation patients could be managed within the unit. Consulting services, such as cardiology and neurology, should prioritize early rounds for EDOU patients to facilitate timely decision-making. Radiology departments need to prioritize imaging for EDOU patients due to the unit's focus on short turnaround times. Ancillary services, including physical therapy, occupational therapy, and social services, can expedite patient disposition through efficient coordination of placement or transportation services. Collaboration among these departments is essential for the successful implementation and operation of an EDOU, ultimately improving ED throughput and patient care.