Where: University Hospital, a 604-bed public teaching hospital affiliated with the University of Texas Health Science Center at San Antonio.
The issue: Reducing length of stay among patients admitted for observation.
Clinicians at University Hospital had noticed that many observation patients at their hospital were not being admitted or discharged within 24 hours. “These observation patients tended to stay much longer, sometimes up to a week in observation status,” said Wen Pao, RN, nurse manager.
Because the observation patients were treated on the same wards, and by the same physicians, as admitted patients, turning them around as fast as possible wasn't always the highest priority. “When observation patients are admitted to non-observation areas, they often are the most stable patients, so for teams that are taking care of sicker patients, it is easy to put these patients on the back burner,” said Luci K. Leykum, FACP, associate professor of hospital medicine.
Other hospitals had dealt with this problem by creating observation-only units as adjuncts to emergency departments, but administrators and hospitalists at University Hospital decided to try a different system. In August 2005, they opened the Clinical Decision Unit for observation patients, staffed by the existing hospitalist service. “The idea was if they were all taken care of in the same place, with the same processes, that the care would be more efficient,” said Dr. Leykum.
How it works
The unit began with 10 beds, although it has since expanded to 26. It is staffed by a hospitalist and a physician assistant who work together in 12-hour shifts to provide 24/7 coverage. Coverage of the unit is a rotating responsibility for University Hospital's hospitalists, who also provide some general housestaff supervision when working nights in the observation units.
“There are times of day when we tend to admit the observation patients. For example, in the afternoon we are frequently admitting several from clinics, or the change of ED shift in the morning is also often a busier time,” said Dr. Leykum.
Whenever they come in, the observation patients—and the need to figure out their care quickly—are now the center of clinicians' attention. “Even the nurses say, ‘These are observation patients. They either need to be admitted or they need to go home,’” explained Ms. Pao. “OK, this patient's been here 20 hours already. What is the plan, what do we need to do?”
The plan seems to have worked, based on results published in the November/December 2010 Journal of Hospital Medicine. In the year after the unit was implemented, length of stay for the most common observation status diagnoses dropped from 2.4 days to 2.2 days. Statistically significant decreases occurred in stays for cellulitis (from 2.4 days to 1.9 days) and asthma (2.2 days to 1.2 days).
However, the length of patient stays for chest pain, pyelonephritis and syncope did not appear to be affected, a finding that could be attributed to already existing programs to deal with some of those patients quickly, according to Dr. Leykum. “We had already put some things in place around chest pain,” she said.
Since the study's publication, the observation unit staff has continued to streamline their processes (with a focus on smoother handoffs) and bring length of stay down even more. “We're now seeing an even bigger spread between the length of stay of patients who are admitted to the observation unit versus a few that get admitted to the regular floors because of bed-capacity issues. There's a day of difference,” said Dr. Leykum.
Bed capacity has been one of the biggest challenges facing the unit. Particularly at the start, other units have had their eye on any vacant observation beds. “The hospital is full. The ED has patients that need to come up. They see two observation beds. They want to put general medical/general surgical patients there, but we know that there's going to be another observation patient who comes through the door in the next hour or so,” said Dr. Leykum.
The solution has been reiteration by hospital leadership about the value of the unit, and more firmness by the hospitalists staffing the unit itself. “Oftentimes, they would call us and say, ‘Oh, is it OK if we can use a bed?’ and people would say OK. They didn't want people waiting in the ED either. We kind of had to police ourselves a bit,” said Dr. Leykum.
There have also been challenges for nurses and patients on the unit, noted Ms. Pao. “The nurses are so used to taking care of the patients the same way. There are certain things that don't need to be done for these patients.”
And for their part, patients are often confused by observation status. Thinking that they've been admitted to the hospital, they are surprised when they are rapidly treated and sent home. “It's a constant education of the patients,” said Dr. Leykum.
Less education may be needed when the observation unit moves into a planned new hospital building. The new unit will have 36 observation beds and be adjacent to the emergency department. The change in structure may also lead to a change in staffing, according to Dr. Leykum.
“What we're trying to do now is figure what's the role of hospital medicine versus what's the role of emergency medicine in caring for observation patients,” she said. “To me, there are two subsets: patients who are remaining in observation status because we don't know what's going on and we need some more time to figure it out, versus patients where we know what's going on and we need to keep them here to observe our treatment and see the impact. Maybe that latter group of patients comes to us in hospital medicine and the former group of patients is cared for by the emergency department.”
The development of the unit turned out to be well-timed, as observation status soon after became a focus of attention for payers, Dr. Leykum noted. “There's so much more scrutiny about patients' status when they're finished with their emergency care and there's so much more scrutiny of one-day length of stay and potential non-reimbursement. I think hospitals need to be on top of this particular issue.”
Her hospital found that the increased documentation was best dealt with by hospitalists seeing observation patients around the clock. “We really do need the physician presence for the hospital to get maximally reimbursed,” she said.
Words of wisdom
Dr. Leykum offered some final advice for hospitalists making the case for an observation unit to administrators: “These patients are already taking up beds, so by cohorting, you're really not asking for more beds, you're just trying to flex your beds in different ways.”