Observation units

Observation wards have been proposed as a way of reducing the time spent in the main emergency department and providing the patient with more comfortable and appropriate surroundings during their early

investigation and treatment phase (Department of Health, 2003). Four systematic reviews of the literature on observation wards/short stay wards have been found.

In 1989, Krome published a review spanning 15 years and made the following conclusions:

• they were a safe location for initial treatment • patients should have regular observation • care must be time limited

• all patients need a plan and clear objectives to their stay in the short stay ward

• they should be managed by the emergency department • they should not replace inpatient beds.

He did not draw conclusions about the effect on waiting or length of stay.

In 1998, Goodacre examined the use of short-stay units in the UK and undertook a review of the literature. He found that use of these facilities is highly variable and that evidence of clinical value and cost effectiveness compared with other methods of care were lacking.2

In 2003, Cooke et al. concluded that all types of assessment/admission wards seem to have advantages over traditional admission to a general hospital ward, including reducing the number of admissions and length of stay. A successful ward needs proactive management and

organisation, senior staff involvement, and access to diagnostics and is dependent on a clear set of policies in terms of admission and care. Many diagnostic groups benefit from this type of unit, excluding those who will inevitably need longer admission. Vigorous financial studies have yet to be undertaken in the UK. In 2003 Daly et al., found that short stay and observation units have the potential to benefit patients,

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reduce length of stay, improve the efficiency of emergency

departments and improve cost effectiveness. However, the benefits reported were variable.

A further review by Hassan (2003) looked at clinical decision units for patients needing a longer period of investigation than is usual in the emergency department but not requiring full admission to hospital. The study did not quote any evidence of their effect on emergency

department waiting times.

As an extension of emergency department evaluation, an observation unit has also been shown to reduce the workload in the emergency department, thus giving staff better flexibility and improving the flow of patients (Brillman et al., 1995; Cooke et al., 2003). Patients may also benefit from the increased time available for monitoring their clinical condition after emergency department treatment, and as a direct result of this, referral to a specialist team (for example, cardiology) can be made earlier (Hanlon et al., 1997).

Only two studies were found that focused on the effect of

overcrowding on the emergency department. In Kelen et al. (2001) a 14-bed acute care unit was established remote from the main

emergency department. The unit was designed for those patients needing more than four hours’ evaluation. During the first ten weeks 1589 patients were seen, representing 14.5% of the emergency department volume. Approximately a third were classified as post- emergency department management, 20% were admission processing and the rest (nearly half) were for primary evaluation. The number of patients who left without being seen decreased from 10.1% to 5%. The ambulance diversion was a mean of 6.7 hours per 100 patients

immediately before the unit opened and 5.6 hours per 100 patients during the same time in the previous year and decreased to 2.8 after the unit opened (p<0.05). The monthly hours of ambulance diversion decreased by 40% (202 hours to 123 hours, p<0.05).

Bazarian et al. (1996), examined the impact of using a short-stay inpatient medicine unit (to reduce the number of admitted patients held in the emergency department) on the amount of time that patients spend in the emergency department. The mean (± standard deviation [SD]) number of admitted patients per day waiting in the emergency department for more than eight hours for an inpatient bed dropped from 9.6 ±4.2, before instituting the surgical observation unit (SOU), to 2.3 ±2.6. The authors reported that, after implementation of the SOU, there was a significant reduction in the average time spent in the emergency department for ‘treat and release’ patients with chest pain (from 7.3 ±6.0 hours to 5.5 ±4.8 hours per patient; p<0.001) and asthma (from 5.0 ±3.6 hours to 4.2 ±2.9 hours per patient; p<0.05), but not for those with sickle cell crisis or seizure. However, these findings were confounded by an increase in the average number of beds during the study period from 722 to 736.

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Length of stay appears to decrease with the use of observation / short stay wards. In a retrospective analysis of an emergency department observation unit, Williams et al. (2000), found that the average length of stay and number of admissions remained the same for the ten most common diagnostic groups. In the group suitable for admission to the observation ward the average length of stay decreased from 3.97 to 2.59 days in the study period. The number of patients in the suitable groups increased by 19% over the four-year study period but the total bed days fell by 23%. When compared to patients in the same

diagnostic groups in other hospitals in the same town it was discovered that the original length of stay had increased in the other hospitals by 8%. However, it is not possible to conclude that this difference was due to the initiation of a short stay ward.

Saunders and Gentile (1988) studied patients with mild exacerbations of pancreatitis and compared 27 consecutive patients managed through the observation ward with 27 randomly selected patients admitted directly to hospital. The condition of 14 of the observation ward patients improved sufficiently for discharge within 24 hours, with a mean stay of 14.4 hours. The remaining 13 observation ward patients required continuing hospitalisation, with an average length of stay of 7.5 days, which exceeded the average length of stay for patients admitted directly to hospital (5.8 days). There may be bias in the sample in that the observation ward patients had significantly lower serum amylase levels than patients admitted to hospital, suggesting less severe disease. Hadden et al. (1996) also found, in a prospective study of 214 patients, that observation in a general ward resulted in the patient being seen later and having an increased the length of stay in hospital when compared with observation unit stay. Patients also had to wait longer in a ward before being seen by a senior doctor. No studies have been found that show that observation units increase patient length of stay.

Medical admissions may also be avoided by use of observation/short stay wards. Many studies were excluded as they use an analysis that counts an admission to a short stay ward only as having avoided an admission, when in reality it is an admission to a different area of the hospital. A study in Singapore (Lateef and Anantharaman, 2000) demonstrated that by using observation wards it was possible to achieve a 6.4% saving to direct inpatient admissions to the hospital. Ross (2001) showed that if patients were admitted to an observation unit where they had an accelerated process of investigation and care this could be effective in improving inpatient bed availability and each emergency department observation unit bed would keep between one and three patient beds available for other uses.

McDermott et al. (1997) used a prospective RCT in patients with acute asthma who did not meet discharge criteria within three hours of presentation to the emergency departme nt. Patients were randomly allocated to receive ongoing care in either the emergency diagnostic

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and treatment unit or in a hospital ward. Of the 110 patients managed through the emergency diagnostic and treatment unit, 59% were discharged home and 41% were transferred on to a ward. In this study, 45 patients avoiding an inpatient admission.

Brillman and Tandberg (1994) undertook a retrospective comparative cohort analysis of patients with asthma — 834 before the observation ward was opened and 390 after it was opened. They found that use of an observation unit for patients with asthma reduced initial discharge rates from the emergency department and did not change admission rates. A ‘before and after’ study (Gouin et al., 1997) investigating the introduction of a paediatric observation ward noted a reduction in admissions of 31%. The frequency of under 24 hour admissions

decreased from 17% to 10% but with an increased rate of repeat visits to the emergency department within 72 hours (from 3% up to 5%). However, Willert et al. (1985) in a randomised clinical trial of 103

children with asthma, showed no difference between groups in the rate of re-presentation to emergency.

A study in an emergency care tertiary centre with 46 000 annual visits looked at whether there was a cost reduction in providing observation beds to avoid full hospital admission. Only 32% of the admissions could have been treated in an observation ward and the potential savings from inpatient bed closures would only have amounted to 1.68 full-time equivalents because they would have been evenly spread across the hospital. This would not be enough to staff a four-bed observation unit, which would require at least five full-time equivalents (Sinclair and Green, 1998).

The purpose of chest pain assessment units is to rule out myocardial infarction or other serious cardiac pathology and are therefore a specialised type of observation ward or clinical decision unit. Present regimes take six to 12 hours.

In a systematic review of the literature on chest pain units Goodacre (2000) concluded that chest pain assessment unit care is safe and costs are well defined. There is no strong evidence that a chest pain assessment unit will improve outcomes if routine practice is good. Cost savings have been shown when compared with routine care in the United States but may not be reproduced the UK. The studies did not specifically look at the time spent in emergency department or the effects of chest pain assessment units on this time. Eighty per cent of patients seen in chest pain assessment units avoided full hospital admission. In an RCT involving 100 chest pain patients, Gomez et al.

(1996) evaluated the efficacy of their ‘rapid’ protocol, which included a period of observation in a chest pain unit to exclude the diagnosis of myocardial ischaemia. The average length of stay for ‘rapid’ protocol patients was 15.4 ±12.2 hours, which compared favourably with 54.6 ±12.6 hours for patients receiving routine care. As the authors attributed these findings to their protocol, it is not clear what role the

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observation unit played. Subsequently Taylor et al. (2002), have studied a clinical rule-out strategy and found that the median time for discharge was 23 hours. There was no comparative data on ‘routine practice’. A prospective, observational, cohort study by Goodacre et al. (2002) verified the safety of such a system but did not look at the time factors.

In conclusion, it appears that assessment/short stay wards may reduce length of stay in emergency department and possibly in the hospital. However, results are variable and confounded by methodological issues. Studies often look at times in specific hospital areas rather than

patient-focused times in hospital and ‘wasted’ time.