observation medicine – the inpatient fast...
TRANSCRIPT
4/17/2015
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Observation
Medicine – The
Inpatient Fast
TrackKirk Jensen, MD, MBA, FACEPJody Crane, MD, MBA, FACEP
These presenters have nothing to disclose
April 29, 2015
Cambridge, MA
Session Objectives
After this session, participants will be able to:
Describe the elements of successful observation
strategies
Identify opportunities to improve patient flow in your
hospital through the use of Observation Units and
Clinical Decisions Units
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OBJECTIVES:• Understand the difference between observation
status and observation medicine
• Gain insight into the operational principles and goals
of observation medicine
• Identify opportunities to improve patient flow in
your hospital through the use of Observation Units
and Clinical Decisions Units
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Observation Status
Outpatient designation in which patients are
physically located in the hospital but are
financially treated as if they are outpatients
• Patients may be billed a higher level
from the ED and/or billed hourly by
the hospital
• Reimbursement for services varies
widely based primarily on payer type
• Patients are charged a la carte for
procedures and may be exposed to
more out of pocket expenses
• Presents problems for patients as
there is still a requirement for 3
inpatient days to qualify for CMS
payment for SNF
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2-Midnight Rule
� Designed to establish better
definition around observation
status as hospitals struggle to
comply with recovery audits
� Is hotly debated as it does not
solve many of the current issues
related to the move towards
observation medicine such as:
� Increased patient
responsibility in the form of
co-pays and other costs
� Eligibility requirements for
long term care
reimbursement (Medicare
ACO Waiver)
The future is uncertain
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Observation Medicine
Management of patients with relatively straightforward admission diagnoses
� Admissions mainly for
diagnostic work-ups
� Disease course is relatively
well-defined or knowable
Primary goal-to reduce inpatient length of stay by:
� Streamlining care pathways
� Reducing variation
� Better aligning treatment
capacity with patient demand
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Hospital Settings in Which Observation Services are Provided
Setting Description Characteristics
Type 1 Protocol driven,
observation unit
Highest level of evidence for favorable
outcomes; Care typically directed by ED
Type 2 Discretionary care,
observation unit
Care directed by a variety of specialists;
Unit typically based in ED
Type 3 Protocol driven,
bed in any location
Often called a “virtual observation unit”
Type 4 Discretionary care,
bed in any location
Most common practice; Unstructured care;
Poor alignment of resources with patients’
needs
Ross M. et. al. Protocol Driven Emergency Department Observation Units Offer Savings, Shorter Stay, and Reduced Admissions.
Health Affairs. 32:12: 2149-2156, December 2013.
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Three Study Groups
Emory/Grady*, 2010 Georgia, 2010 US, 2009-10
ED Visits - Number 185,901 4,194,602 133,957,000
Observation Visits
Number 7,199 101,593 1,392,000
Average (hrs) LOS 17.2 27.6 22.3
Visits > 24 hrs 10.4% 44.4.% 29.0%
Visits > 36 hrs .1 24.7 14.9
Visits > 48Hrs .1 7.2 6.9
Visits > 72hrs 0.0 1.6 .9
Rate of inpatient
admission
13.1% 15.8% 23.2%
Ross M. et. al. Protocol Driven Emergency Department Observation Units Offer Savings, Shorter Stay, and Reduced Admissions.
Health Affairs. 32:12: 2149-2156, December 2013
*Emory/Grady - Type 1 Observation Units
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3 Considerations in
Optimizing Your Observation Unit
1. A defined treatment location
2. Matching capacity and demand
3. Standard approach to care
KJ
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Observation Unit LocationType 1 Inpatient Observation Unit
A discrete location with a defined
number of rooms dedicated for
observation patients.
Observation
Better differentiated (would-be
admissions), very clear, algorithmic
workups and well-defined treatment
endpoints.
Examples:
� Chest Pain
� TIA
� COPD
� CHF
In or near the ED
There is a blurred line between
Observation Units and Clinical Decision
Units.
CDU
Shorter stay, managed by ED,
undifferentiated and straightforward
conditions that should go home soon.
Examples:
� Abdominal pain
� Chest pain rule-out
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Matching Capacity and Demand
Involves understanding
Inclusion/Exclusion patient
populations, admission rates, and
LOS
This data will provide the foundation
for occupancy analyses
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Standard approaches to care
Dedicated physician
group overseeing the
unit
Well-defined patient
population with
inclusion/exclusion
criteria
Standardized
diagnostic and
treatment
pathways
for different patient
populations
Standardized
patient flow
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Standard approaches to care:Dedicated Physician Group
• There should be a single physician group
overseeing the unit and admitting to the unit,
a “closed” unit.
• In many fee-for-service cultures, this is very
difficult to accomplish
• This group should be responsible for:
– The admission and disposition of every
patient
– Establishing protocols
– Performance improvement and
accountability
• Consults should be minimized, if not
eliminated
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Standard approaches to careA Well-Defined Patient Population
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15A Well-Defined Patient Population
Clinical Decision Unit
Condition Guidelines
Emory Midtown Hospital
Emory University Hospital
Grady Memorial Hospital(Grady conditions are bulleted)
Index of CDU protocols (GMH italicized)ABDOMINAL INJURY……………………………………………………………3
ABDOMINAL PAIN ………………………………………………………………4
ACUTE HEART FAILURE ……………………………………………………..5
ALLERGIC REACTION …………………………………………………………..6
ASTHMA …………………………………………………………………………….7
ATRIAL FIBRILLATION – ACUTE ONSET…………………….…..…….8
BACK PAIN ………………………………………………………………………….9
CELLULITIS ………………………………………………………………………..10
CHEST INJURY ……………………………………………………………..……11
CHEST PAIN – POSSIBLE ACS ……………………………………….……12
COPD EXACERBATION ……………………………………………………...13
DEEP VEIN THROMBOSIS ………………………………………………….14
DEHYDRATION OR VOMITING ………………………………….………15
DILANTIN TOXICITY …………………………………………………….……16
ELECTROLYTE ABNORMALITY …………………………………………..17
GASTROINTESTINAL BLEED ……………………………………….…..…18
HEADACHE ………………………………………………………………….…..19
HEAD INJURY ……………………………………………………………….…..20
HYPEREMESIS GRAVIDARUM …………………………………..…….…21
HYPERTENSIVE URGENCY…………………………………………….…….22
HYPOGLYCEMIA………………………………………………………..……….23
HYPERGLYCEMIA……………………………………………………………....24
PNEUMONIA…………………………………………………………….…..…25
PYELONEPHRITIS………………………………………………………..…….27
RENAL COLIC…………………………………………………………………....28
SEIZURES…………………………………………………………….…………….29
SOCIAL ADMISSIONS ………………………………………………………..30
SUPRAVENTRICULAR TACHYCARDIA …………..………………...…31
SYNCOPE ……………………………………………………………………….…32
TRANSFUSION OFBLOOD AND BLOOD PRODUCTS…………....33
TRANSIENT ISCHEMIC ATTACK………………………………………....34
VAGINAL BLEEDING………………………………………………………..….35
VERTIGO……………………………………………………………………….…..36
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A Well-Defined Patient Population: Inclusion/Exclusion Examples
ABDOMINAL INJURY (NON-PENETRATING)
INCLUSION CRITERIA
• Cooperative patient with stable vital signs (RR>8
or <24, SBP>100, P>60 or <110)
• No Peritoneal Signs
• Negative initial imaging studies (i.e. CT)
• Pertinent lab results acceptable (e.g., Hbg)
• Surgery consult documented
CDU INTERVENTIONS
• NPO initially, advance per physician
• Repeat Hct q 4-6 hours (if pertinent to patient’s
management)
• Serial abdominal examinations (e.g. q 4 hours)
• If indicated by physician, serial ultrasounds
• Immediate reevaluation of ED physician or
surgeon if patient develops:
- Significant vomiting
- Increasing abdominal pain
- Increased tenderness
- Worsening vital signs:
Decreased BP, increased HR, fever
EXCLUSION CRITERIA
• Uncooperative patient, patients requiring
restraints
• Impending alcohol withdrawal syndrome
• ETOH estimated >200mg/dl at transfer
• Pregnancy >20 weeks
• Abnormal vital signs (above)
• CT scan not done or significant acute abnormality
DISCHARGE CRITERIA
Patient is ambulatory
• Serial abdominal exams essentially negative
• Repeat labs reviewed and stable (Specifically any
Hb drop?)
• Vital signs reviewed and stable
• Patient able to tolerate PO
• Appropriate follow-up established
• Surgery agrees with disposition
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A Well-Defined Patient Population: Diagnostic Exclusion Criteria
General
� Total Care patients
� Symptomatic anemia
� Any patient who requires 1:1 monitoring and/or
restraints (dementia/suicidal)
� Patients with possible airway compromise
� Patients requiring ICU or clear multi-day stay
� >20 week pregnancy with abdominal/pelvic
complaints
� Overdoses requiring cardiac monitoring
� Uncorrected hyperkalemia (K>6) or hypokalemia
(K<2.5)
� Patients needing trauma evaluation or
observation secondary to trauma
� Shock from any source (septic, anaphylactic,
cardiogenic, neurogenic)
Cardiac
� STEMI/NSTEMI
� Rising Indeterminate or positive troponins
� Recent episode of V tach of V fib
� Persistent chest pressure in high risk CAD patient
� Symptomatic 2nd / 3rd degree heart block
Neuro
� Persistent stroke symptoms or onset within 6 hours
� Uncontrollable Seizures
Pulmonary
� Patient in moderate to severe respiratory distress
� PNA with PORT score above 90
� PE that is associated with either hypoxemia and is
either saddle or bilateral burden
� Either spontaneous or traumatic pneumothorax
ID
� Impending sepsis (specifically elderly with
urosepsis)
� Concern for or diagnosis of bacterial meningitis
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A Well-Defined Patient Population: General Exclusions from the CDU
• PATIENTS WITH INCOMPLETE CHART
• HIGH SEVERITY OF ILLNESS
• HIGH INTENSITY OF SERVICE
• PATIENTS FOR WHOM INPATIENT ADMISSION IS CLEARLY
NEEDED
• AGE LESS THAN 15 YEARS OLD
• OBSTETRIC PATIENTS OVER 20 WEEKS PREGNANT
• PATIENTS AT RISK OF SELF HARM
• ANTICIPATED CDU LENGTH OF STAY LESS THAN 4 HOURS
OR OVER 24 HOURS
• PATIENTS WITH (1) AN ACUTE GAIT DISTURBANCE, (2)
“RULE OUT HIP FRACTURE,” OR (3) OVER AGE 65 WITH
BACK PAIN
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Standard Approaches to CareStandardized Diagnostic and Treatment Pathways
� Diagnostic, Treatment, and Medication
components
� Customized for each different condition
� Coordinated with physicians, nurses and
pharmacy
� Minimize or eliminate consults in favor of
diagnostic and treatment pathways
defined by specialty leadership
� Diagnostic, Treatment, and Medication
components
� Customized for each different condition
� Coordinated with physicians, nurses and
pharmacy
� Minimize or eliminate consults in favor of
diagnostic and treatment pathways
defined by specialty leadership
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Observation Protocols by Condition
1. Insulin Drip
2. GI Bleed
3. Renal Colic
4. Abdominal Pain
5. Vertigo
6. Allergic Reaction
7. Headache
8. Back Pain
9. TIA
10. Cellulitis
11. A fib
12. Pneumonia
13. DVT/PE
14. Heart Failure
15. Pyelonephritis
16. Chest Pain
17. Hypertensive Urgency
18. Hypertensive Urgency
19. Asthma
20. Metabolic Dehydration
21. Routine Medications
22. Pain Management
23. Warfarin
24. Potassium Replacement
25. Magnesium Replacement
26. Basal Bolus Insulin
27. Syncope
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Anatomy of the Observation Protocols
Non-Medication Orders
• Prompt for
medication
reconciliation
• Vital Signs
• Activity
• Intake/Output
• Labs
• Diet
• Consults
• Alert physician
if:
• SBP < 110
• HR > 100
• Dizziness
• Chest Pain
Radiology
• Type of test/
plain films
• Indication, as
needed
• Contrast vs. no
contrast
Medications
• Medication name
• Dose
• Strength
• Route (IV, PO, SC, etc.)
• Frequency
• Prompts for standard
orders:
• Potassium
replacement
• Magnesium
replacement
• Routine
medications
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Observation Protocol for Chest Pain- Non-Medication OrdersNon-Medication Orders
1. □ Perform medication
reconciliation
2. □ Cardiac monitoring □ IV Fluid
□ Rate ____ ml/hrx ___ liters then ___ ml/hr
3. □ Vital Signs □ Vital signs every 4 hours
4. □ O2 □ @ 2 L/NC □ Monitor pulse ox: every 4 hours
□ Titrate to keep POX > 93%
5. □ Activity □ Ad Lib □ Bedrest
□ OOB w/assist □ May participate in PT/OT as
tolerated
6. □ Intake and output, every 4
hours
7. □ EKG □ EKG STAT
□ EKG with serial cardiac enzymes and as needed for chest pain
8. □ Insert saline lock
9. □ Labs at ____ □ CBC □ D-dimer
□ Chem 7 □ Lipid panel
□ PT/INR □ BNP
□ CKMB/Troponin @ 6 hours □ Hepatic Panel
□ CKMB/Troponin @ 12 hours □ Lipase
10. □ Diet: □ Regular □ 1800 ADA
□ Clear Liquid □ 2 gram sodium
□ NPO □ Low calorie
□ Puree □ Other
11. □ Consults □ Case Management
□ Cardiology
12. □ Document symptom reassessment every 4 hours
13. □ Contact physician immediately for any of the following (unless otherwise notified by physician):
□ SBP < 100
□ HR > 110
□ Complaints of dizziness
□ Complaints of chest pain
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Observation Protocol for Chest Pain - Radiology Radiology
14. □ CXR Indication: □ PA/Lat
________________ □ Portable
15. □ 2D Echocardiogram, indication:
________________
16. □ Stress test type:
________________
17. □ CT chest angio (r/o PE)
18. □ Venous Doppler:
________________
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Observation Protocol for Chest Pain- Medications Medication Dose Strength Route Frequency19.19.19.19. □ Aspirin: contraindication (Y/N) □ 81 mg□ 325 mg PO Daily20.20.20.20. □ □ Simvastatin OR□ Atirvastatin □ 40 mg□ 80 mg. PO Daily21.21.21.21. □ Metoprolol □ 12.5 mg□ 25 mg□ 50 mg□ Other PO BID: (Hold if HR < 60 and/or SBP < 90)22.22.22.22. □ Clopidogrel □ 300 mg□ 600 mg PO Now23.23.23.23. □ Clopidogrel 75 mg PO Daily24.24.24.24. □ Enoxaparin (Lovenox) 1 mg/kg:____ mg SC □ One time□ Every 12 hours25.25.25.25. □ Nitroglycerin (Nitrostat) 0.4 mg SL For chest pain every five minutes26.26.26.26. □ Nitropaste ½ inch Apply to chest wall For chest pain change every 8 hours (Hold for SBP < 120)27.27.27.27. □ Morphine 2 mg IV Prn every 30 minutes x 2 for unrelieved chest pain28.28.28.28. □ Norvasc (for patients with bradycardia: beta-blocker contraindicated) 5 mg PO Daily29.29.29.29. □ Diltiazem (for cases of afib) 60 mg PO Every 12 hours x 2 doses30.30.30.30. □ Carvedilol (Coreg) 3.125 mg PO Daily31.31.31.31. □ Lisinopril 10 mg PO Daily32.32.32.32. □ Furosemide 20 mg PO Every 12 hours x 2 doses33.33.33.33. □ Losartan 25 mg PO Daily34.34.34.34. □ Digoxin 0.25 mg PO DailyProtocols (Complete Standard Orders):Protocols (Complete Standard Orders):Protocols (Complete Standard Orders):Protocols (Complete Standard Orders):35.35.35.35. □ Potassium replacement36.36.36.36. □ Magnesium replacement37.37.37.37. □ DVT Prophylaxis38.38.38.38. □ Complete routine medication
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Key Contacts
Here
Key Contacts Here
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Examples of Observation Protocols3. How do we select a stress test with imaging?:
Based on the above, here is the breakdown of what is available and where –
Emory University Hospital CDU – 7/2011
• Emory University Hospital CDU Weekdays, 7AM-5PM
o Male any age, or Female >55; no renal failure:
� BMI <30, no known CAD =
• Lexiscan technecium SPECT
• Dobutamine stress echo
• Exercise stress echo – if able to exercise
• Coronary CTA (EUH only)
� BMI > 30, known CAD, or no available SPECT isotopes =
• Lexiscan Rubidium PET – on hold
• Lexiscan technecium SPECT
o Female <55:
• Dobutamine echo
• Exercise Stress echo
• Adenosine MRI
o Severe Asthma / COPD; renal failure:
• Dobutamine echo
• Dobutamine SPECT (rest / stress sestimibi)
• Lexiscan Rubidium PET – on hold
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Evidence Based
Pathways
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JC
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Standard
Approaches to
CareStandard CDU
Patient Flow
Emory University School of Medicine Clinical Decision Unit Manual, 2012
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Summary: Optimizing Your Observation Unit
1. A defined treatment location
2. Matching capacity and demand
3. Standard approaches to care,
including…
� A dedicated physician group overseeing the unit
� Well defined patient population with inclusion/exclusion
criteria
� Standardized diagnostic and treatment pathways for
different patient populations
� Standardized patient flow
KJ© Jensen, Crane,
Nolan