Observation Medicine in the Journals

In this new series, we will look at articles and abstracts both inside and beyond the emergency medicine journals related to observation medicine. While these may not change care, I hope to provide information on pertinent topics you may have otherwise missed.

On tap in this issue:

• Frailty and Sociodemographic Factors Leading to Admissions from ED Observation Units (EDOU)
• Cardiology Consultation and Provocative Testing
• Short Message Services (SMS) Messaging of Pediatric Results and Length of Stay
• Chest Pain Outcomes and Utilization Related to Disposition
• Mild Traumatic Intracerebral Hemorrhage (ICH) and Observation

Impact of Frailty and Sociodemographic Factors on Hospital Admission from an EDOU

One of the most common metrics of EDOU performance is the percentage of EDOU patients subsequently admitted. Acceptable levels typically are quoted around 15-20%. Identifying patients early in the observation period who will require admission is important for maintaining flow and throughput in the EDOU. This article identifies frailty (measured by the Katz Index of Independence in Activities of Daily Living), dependence on disability insurance, and lower levels of education as risk factors predicting EDOU disposition to an inpatient admission and suggests they may be considered in screening for EDOU dispositions.

Cardiology Consultation Reduces Provocative Testing Rates in an EDOU

I have often heard the discussion that calling consultants leads to more testing and subsequent longer lengths of stay. This article looks at on observation unit where two models were attempted. In the first setting, emergency physicians determined the testing orders in the subsequent setting, cardiologists determined the testing orders in the EDOU. Their findings indicate they were more likely to accept moderate risk patients with cardiologist involvement. Additionally, cardiologists ordered fewer stress tests and coronary CTs in the hospital setting without an increase in adverse outcomes for a 30-day follow-up period. The take away is, when developing observation protocols, do not hesitate to involve the appropriate consultative services to expedite and improve care.

Does Abnormal Laboratory Results Notification with the SMS Shorten Length of Stay in the Pediatric EDOU?

Data and re-evaluation are the drivers of EDOU decision making. The rapidly evolving technology landscape in medicine is creating opportunities on many fronts for improving care. Having data pushed to the clinician, as opposed to requiring the clinician to seek results, is a topic of ongoing research. This study looked at SMS notification or text messaging of abnormal results as a driver of throughput. Among all patients, SMS messaging of abnormal results did not decrease the length of stay; however, among those patients who were admitted, there was a significant decrease in length of stay between the control and study (SMS notification) groups.

It is important to note two items. This study took place outside the United States, and it appears that their definition of a pediatric observation unit may be the emergency department. Despite that, it may provide valuable information regarding pushed results on patient care. Second, while not explicitly mentioned, the lack of difference in the overall pediatric population may be related to the fact that normal results were not sent via SMS, and those with normal results could have been more likely to be discharged.

Observation Status or Inpatient Admission: Impact of Patient Disposition on Outcomes and Utilization Among Emergency Department Patients with Chest Pain

Short inpatient stays are often compared with observation stays in utilization. Interestingly, in this study even when the groups were statistically matched, short inpatient stay patients were more likely to undergo both catheterization and stenting than their counterparts in observation. They do note they excluded patients diagnosed with acute myocardial infarction (AMI) on the index visit. They also exclude admissions beyond short inpatient stays. The incidence of subsequent 30-day AMI was similar in the two groups. The take away here would be that more care does not necessarily mean better outcomes.

Identifying Patients with Mild Traumatic ICH at Low Risk of Decompensation Who are Safe for ED Observation

Care of traumatic ICH varies depending on severity, but can include admissions, ICU stays, and transfers. The authors examined a subset of patients who could be managed in the observation setting. The study looked at consecutive patients with traumatic ICH. Of the patients observed, those with minor isolated subarachnoid hemorrhage had very low rates of deterioration in their EDOU.

It is important to coordinate any observation of ICH patients with all involved services to avoid delays in care if deterioration occurs. Strict inclusion and exclusion criteria are advisable in these patients, and further study is needed. Additionally, care coordination and transition of care must be considered as even in mild traumatic brain injury, ongoing cognitive deficits may be life altering.

References

1. Zdradzinski MJ, Phelan MP, Mace SE. Impact of frailty and sociodemographic factors on hospital admission from an emergency department observation unit. Am J Med Qual. 2017 May/Jun;32(3):299-306.
2. Madsen T, Smyres C, Wood T, et al. Cardiology consultation reduces provocative testing rates in an ED observation unit. Am J Emerg Med. 2017 Jan;35(1):25-8.
3. Bucak IH, Almis H. Does abnormal laboratory results notification with the short message service shorten length of stay in the pediatric emergency department observation unit? Telemed J E Health. 2017 Jul;23(7):539-43.
4. Bellolio MF, Sangaralingham LR, Schilz SR, et al. Observation status or inpatient admission: impact of disposition on outcomes and utilization among emergency department patients with chest pain. Acad Emerg Med. 2017 Feb;24(2):152-60.
5. Pruitt P, Penn J, Peak D, et al. Identifying patients with mild traumatic intracranial hemorrhage at low risk of decompensation who are safe for ED observation. Am J Emerg Med. 2017 Feb;35(2):255-9.

Robert M. Bramante, MD, FACEP
Good Samaritan Hospital Medical Center