Watch and Earn

The Hospitalist. 2008 April;2008(04):

April 1, 2008 | The Hospitalist

And that offers another advantage: the possibility of doing more patient education.

She points to the example of a unit dedicated to treating heart failure patients.

“You can take advantage of the fact that at this moment, the patient can clearly see cause and effect and maybe you’ll have a chance at getting some behavior changes,” Trupp says. “It’s the case of having put their hand in the fire and feeling and having learned it’s hot; they’ll learn not to do it again. They might learn that the symptoms that landed them in the ED came from excess salt load due to eating Chinese food or chips and salsa.”

Ultimately, for certain conditions, observation units can provide better care. Studies have shown that in the three months following a visit to the hospital, heart failure patients are far less likely to return if they’ve been seen in the observation unit rather than being treated as inpatients.

And if that weren’t enough of an inducement to administrators to create observation units, Dr. Peacock offers one other: The units can do more than pay for themselves.

“We are in an urban environment, and our patient population is not well insured,” he says. “There are years when the ED loses money. The observation unit never loses money. In fact, it’s saved us a few times. That was a pleasant surprise.” TH

Linda Carroll is a medical writer based in New Jersey.

UCLA’s Example

Although there had been talk of creating an observation unit at UCLA for years, it wasn’t until December 2006 that the unit became a reality.

“There were a lot of challenges to getting the infrastructure in place,” says Jason Napolitano MD, medical director of the observation unit at the University of California at Los Angeles Medical Center. “It took a lot of time and momentum to get the right pieces in place.”

First and foremost, Dr. Napolitano says, you need to get the right people involved. For UCLA, that also meant having a dedicated staff. “Some observation units use staff from other departments,” he explains. “We wanted the unit to be its own entity. So we interviewed and hired a staff that would work only in the observation unit. We wanted a staff that would become expert in the conditions treated in the unit so patients would be treated efficiently and accurately.”

And it wasn’t just physicians and nurses who needed to be hired. The reimbursement for observation units can be tricky, Dr. Napolitano says. And the bills are generated and submitted differently than those from other areas of the hospital, he adds.

“There’s a fine line to walk and there are many rules and regulations,” he explains. “You need to have good support staff to do the billing and to do case reviews to make sure you’re getting reimbursed for the care you’re providing. We needed to have the right staff in place before we could open the unit.”

At UCLA, Dr. Napolitano and his colleagues came up with order sets that laid out every aspect of care, from algorithms that determine whether a patient should be sent to the observation unit to lists of drugs determined to be optimal for treating the various medical conditions seen in the unit. “We took a long time to research the best drugs,” Dr. Napolitano says.

One advantage to the order sets: They help standardize decisions as to which patients will end up in the observation unit. “For example, a patient with asthma will be sent to the observation unit or to intensive care depending on the severity of his attack,”

Dr. Napolitano says.

The order sets make the process more automated and more objective.

In the case of the hypothetical asthma patient, tests of pulmonary function are used to determine where the patient ends up. “We have specific peak flow cut points,” Dr. Napolitano says.

With a dedicated staff for the UCLA observation unit, the end result is a team of healthcare providers who work together like a well-oiled machine.

Some people have suggested that the approach used at UCLA may be too automated, too impersonal. “It’s a matter of opinion whether this is damaging to the ‘art’ of medicine,” Dr. Napolitano says. “But there’s still a lot of leeway for physicians and nurses to connect with patients, asking how they feel and in counseling and educating them.”

Besides, Flitcraft says, this standardization “allows everyone—including patients— know what the outcomes are. It lets patients know what we are looking for and how long they can expect to be in the hospital.”

In the end, all the planning paid off: The unit is running almost to capacity six days a week.—LC