Observation Unit Helps Prevent ED Diversion : Solutions to overcrowding and ambulance diversion 'crisis' proven to be effective.

In the first year and a half of the unit's operation, Dr. Dick and another emergency physician devoted all their practice to the observation unit, which had a nursing staff separate from the rest of the hospital.

Residents were slated in June 2005 to begin rotations for the first time through the observation unit.

The ED has plans to increase the observation unit to 36 beds or possibly even 48 beds in the near future, he said.

Observation Units: Silver Bullet?

A 10-bed observation unit that has operated for about 9 years in the ED at Brigham and Women's Hospital, Boston, has also had a dramatic effect on the flow of care through the department, said Richard Zane, M.D., vice chair of emergency medicine at Brigham and Women's.

The unit has allowed for not only more “timely and appropriate work-ups in the ED, but also the ability to offload lower-acuity patients from inpatient services. This frees up inpatient capacity for higher-acuity patients,” Dr. Zane said.

“We've been successful in prescreening patients who will not require inpatient work-up after the observation unit. We very much try to avoid having [the observation unit] used as a holding unit until patients get a bed,” he added.

While observation units are potentially beneficial in increasing patient care capacity, “I would view them, not infrequently, as an incomplete solution,” cautioned Randall B. Case, M.D., an emergency physician and a vice president at Siemens Medical Solutions' Healthcare Services Corporation.

“There are other systemic issues within the [hospital] that often are the root-cause issues behind emergency department crowding,” said Dr. Case, who recently chaired ACEP's Emergency Medicine Practice Committee. Last year, the Committee studied the various causes of ED crowding and concluded that “the most common root cause for ED crowding is delayed inpatient cycle time.”

In many cases, “the real reason the ED gets crowded is that the inpatient units manifest some inefficiency, or delay, in discharging their patients,” Dr. Case said. Until those patients' beds are freed up, there is no place for the admitted ED patients to go.

“If this is the case on a regular basis at your institution, then it might be more effective to address the systemic inefficiency directly, rather than relying on observation beds as an inpatient capacity buffer,” Dr. Case explained.

“It's thought in the literature that every observation bed provides you the equivalent of about 2.5 inpatient beds, only because you're pushing patients through the system in an active manner,” Dr. Dick explained.

“I don't think that adding 24 beds in the ED—where you haven't really fixed the boarder problem or the movement of patients through the system per se—would have as big of an impact as an active ongoing observation unit that has a physician on site,” he said.

Even if observation units are just one of the many solutions to ED overcrowding, they are rapidly becoming the standard, Dr. Zane said. The vast number of new emergency departments that are being built or renovated are including observation units, he added.