3 essentials for a well-run ER observation unit

Hospital leaders must ensure efficiency, standards for inclusion
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More hospitals use observation units to improve patient flow within the emergency department, but there are several factors to consider before creating one at your facility, two physicians write in MedPageToday.

Hospital leaders must determine whether an observation unit aligns with the ED and the organization's respective goals, as well as the amount of space, money and staff it will need, write Michael Silverman, M.D., and Puneet Chopra, M.D., both partners with Emergency Medicine Associates, which provides physician staffing for hospitals. Once they answer those questions, they must consider the following: 

Criteria for inclusion: One misconception about observation units is that they should be the destination for any patient placed under observation status, write Chopra and Silverman. Instead, hospitals must develop patient-specific metrics to determine who goes to the unit. These measures will vary based on patient population but common starting points include: probable discharge in the next 24 hours; lack of diagnostic uncertainty; and stable condition with little risk of clinical deterioration.

Resources/space: Chopra and Silverman recommend against "virtual observation," which places observation patients in any available bed throughout the hospital rather than a dedicated unit. Such a policy, they write, typically results in unnecessarily long stays because completing these patients' care isn't a top priority. An effective observation unit needs physical space of its own, ideally adjacent to the ED, but such space in a hospital is usually occupied. For best results, they said, the unit must be closed and have its own medical and nursing directors, with a staffing ratio of about one nurse per five patients and one tech per 15 nurses.

Efficiency: Hospitals must prioritize the care of observation patients, after ER and intensive care unit patients. Otherwise, the authors write, there will be too many observation unit patients waiting for tests.

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