Intro to Observation Medicine
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- Harry Rose
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2 Philip A. Lewalski, M.D., F.A.C.E.P. Director of Observation Services Assistant Professor Department of Emergency Medicine Wayne State University School of Medicine Detroit Receiving Hospital
3 Unique Perspective Will always be an ER Doc, but New insight into the world upstairs ED Observation Units (EDOU) increasing rapidly >35% w/ dedicated EDOU, 66% of academic programs >50% administered by E.D. & growing 10% required rotation/25% electives Quasi floor experience-leads to better knowledge and decisions Type 1 Units 23% - 38% decreased LOS 17% - 44% decreased admit rate Lower rates of missed MI s (4.5% vs 0.4%) billion savings/year (27-42%) Better outcomes/satisfaction/resource utilization Cost generally not greater to patient (denied admit expensive!) Watch unnecessary meds 30 day re-admits/aco s
4
5 Goal: LOS >8 hrs but <24 (15?) (>8hrs in 1 calendar day) Open versus Closed (3T vs CDU) Provider Staffing Physician/MLP Protocols Order Sets Typical Workload H&P (FH) Progress Note Discharge Summary Accurate Times
6 Nursing buy in to rapid turn around Nurses very happy to have physicians readily available Nursing now integrated between 3T,CDU and the E.D. Resource Commitment from Hospital (gaming the system) Transport Radiology Ancillary Tests Expedited test results and consults
7 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Chest pain/cardiac Asthma/respiratory Gastrointestinal/abdominal General ailments/medical Dehydration Syncopy/near/syncopy Psychiatric/social/services Congestive heart failure Head injuries Kidney problems Orthopedic injury (fractures) Transient ischemic attacks/strokes Back pain/back injury Trauma Blood transfusions Vertigo/ENT problems Deep vein thrombosis
8 ED Model: Original Harper CDU Abd. Pain, AICD, Allergic Rx, Anemia, Asthma, A fibrillation, Cellulitis, Chest Pain, CHF, COPD, DVT, Dehydration, Dilantin toxicity., Electrolyte Abnormalities, GI Bleed, Headache, Hyperemesis, Hyperglycemia, Hypertensive Urgency, Hypoglycemia, Missed Dialysis, PEG tube replacement, PID, Pharyngitis/Peri-tonsillar Abscess, Pneumonia, Pyelonephritis, Renal Colic, Seizures, SVT, Syncope, TIA, Vertigo
9 Everything Model: DRH 3T (and now CDU) Previous 32 diagnoses, plus everything else that doesn t meet Interqual/Admit criteria & many potential 30 day readmits; plus social issues (DRH) (Thank God for internists in 3T) E.D. physicians bring trauma experience and ER Mentality to the table 2 nd & 3 rd year elective opportunity
10 CDU ,211 Patients 16 Beds/Staffing Discharges: 18 hrs 28 Upgrades: 16 hrs 47 Upgrade Rate: 25.9% LOS>24hrs 20% LOS>48hrs 1% % of all Observation Patients: 95%
11 3T ,997 Patients 24++beds/Staffing Discharges: 23 hrs 47 * Upgrades: 24hrs * Upgrade Rate: 23.4% LOS>24hrs 38.3% LOS>48hrs 5.5% * Despite huge social admit issues
12 Consult the Wiki
13 ASTHMA Condition-Specific Guidelines Transfer Criteria Intermediate response to therapy in ED Acceptable VS PEFR (peak flow) 40 70% predicted (or personal best) after nebulized treatments Nebulized treatments plus steroids given in ED Unremarkable chest x-ray ED management for 2 hours
14 Exclusion Criteria Unstable VS (RR > 40) Poor response to initial ED therapy o Impending respiratory fatigue persistent accessory muscle use, poor air exchange o Depressed mental status o O2 Sat < 92% on RA (unless chronic hypoxia) o PEFR < 40% predicted or personal best o Elevated pco2 > 50, decreased ph < 7.30 (if ABG done) Suspicion of ACS or ECG changes (if done) Abnormal chest x-ray pneumonia, new onset CHF Toxic theophylline level Bronchospasm due to epiglottitis, aspiration, or foreign body
15 More and more like the floor Things I ve learned Timely ED Dictations Sign Out Critical Orders on Boarded Patients Diabetic PEER Cases Everyone s Busy! (But not necessarily on time ) Medication Reconciliation/Medication Lists!!
16 Things I ve learned Careful what you tell patients Leads to unrealistic expectations Social Work/Case Managers more blunt than us! And many times do not have what the patient wants/demands Don t be a Triage Doctor (my pet peeve) Can t always have diagnosis, but try not to be too robotic
17 And now the bad news: Tenet/DMC new direction Mid November?? Observation Admission Orders and Cancellations Still important for the time being Or-check the wiki or call the observation physician
18 Tales from the Dark Side-CDU
19 Tales from the Dark Side-CDU
20 Tales from the Dark Side-CDU
21 Tales from the Dark Side-CDU
22 Tales from the Dark Side-CDU
23 The Future Observation Units are a high growth area Elective still?? Follow Up s/lectures from 3T yes ED safety net of Health Care EDOU safety net of ED Dissection..x 2
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