This toolkit was developed and compiled by members of the ACEP Observation Medicine Section and the Emergency Medicine Practice Committee to provide members with resources on how to start emergency department (ED) observation services, billing and reimbursement information and quality improvement tools.

ABC’s of Starting an ED Observation Service

The Healthcare System's Tincture of Time (Must be an ACEP Observation Section member to access)
This textbook was created for the clinician providing observation services. Louis Graff, MD, FACEP is editor and authored some chapters within the text. It delineates the resources needed to manage an observation program, reviews specific patient conditions that can be evaluated and treated in observation beds and reviews how observation services are provided around the world.

Policy: Emergency Department Observation Services
PREP: State of the Art: Observation Units in the Emergency Department
ACEP Policy and Policy Resource and Education Paper (PREP) with observation medicine concepts, conditions suitable for observation, and observation medicine metrics.

The ABC’s of Observation Medicine
This PowerPoint presentation addresses the principles of observation medicine, strategies for starting an observation medicine service, quality metrics, staffing and financial issues.

Recommendations for the Evaluation and Management of Observation Services (permissions required to access)
Developed by the Society of Cardiovascular Patient Care, this Consensus White Paper provides information on setting up an observation unit, business considerations, staffing, and quality metrics. It includes recommendations and guidelines for managing specific cardiovascular conditions in the observation unit.

Development and Maintenance of Key Partnerships in an ED Observation Unit
Recommendations for identifying key stakeholders for participation in the development of an observation unit. Tips on navigating through specialty input on managing specific conditions in an observation unit.

Observation for Infants and Children
Terminology and the scope of use of observation for infants and children are outlined. The literature on location of units, ages of patients managed, and benefits are referenced.

Observation for Geriatric Patients
Admission rates to inpatient services and length of stay for geriatric patients are highlighted.

Open vs. Closed Units
This paper provides an overview of open and closed observation units. Evidence addressing length of stay, use of protocols, patient satisfaction, and impact on boarding among other factors are referenced.

Observation Units as Holding Units
A holding area is defined, and the impact of utilizing an observation unit as a holding area are enumerated.

Sample Condition-Specific Guidelines and Order Sets

• Brigham and Women's Hospital  
• Duke University Medical Center  
• Hospital of Central Connecticut  
• Houston Northwest Medical Center  
• William Beaumont Hospital  
• Highland Hospital  
• Emory HealthCare – Grady Health System

Billing and Documentation Issues

• Documentation Guidelines for Emergency Physicians Providing Observation Services. General CPT requirements  
• Observation Physician Coding FAQs
• Observation Care Payments to Hospitals FAQ
• CMS Claims Processing for facilities See section 290 Outpatient Observation Services
• BWH Provider FAQs for Conversations with Observation Patients

Quality Improvement Tools

• Observation Unit Dashboards  
• Sample Observation Unit Policy and Procedure Manual
  • BWH Policy and Procedures Manual
  • Emory CDU Manual and Protocols
   
• Patient-Facing Materials
  • BWH Patient Welcome Brochure Document
  • CMS resource: Are you a Hospital Inpatient or Outpatient  
  • Rapid Growth in Medicare Hospital Observation Services: What's Going On?

Fellowship and Residency Curriculum

• UTSW OBS Clinical Decision Unit Medicine Elective- Medical Student
• University of Pittsburgh Sample Emergency Medicine Residency Observation Medicine Curriculum
• Emory Observation Medicine Fellowship Curriculum

Additional Resources

• ACEP Observation Medicine Section  
• SAEM Observational Medicine Interest Group