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Welcome to Part Two of our series on managing observation units; if you missed Part One, you can find it here.
Whether an observation unit is managed by the emergency medicine (EM) program, or the hospital medicine (HM) program depends on the goals and unique circumstances of each site.
The EM program primarily manages a small subset of observation patients, while hospitalists nationwide admit a wide range of patients into observation status daily. As leaders in both emergency and hospital medicine, we focus on developing innovative Short Stay Unit (SSU) models, contrasting with traditional Clinical Decision Units (CDU) or Medical Decision Units (MDU) managed by the EM.
Each approach has its unique advantages and potential challenges:
EM Program Management
Focus:
EM-managed observation units typically focus on conditions seen in emergency settings like chest pain, asthma, or transient ischemic attacks.
Advantages:
These units can facilitate more efficient use of emergency department (ED) resources, reducing overcrowding and potentially decreasing wait times for other patients. The ED staff is typically skilled in rapid diagnosis and stabilization of acute conditions, and test results and treatment are prompt.
Challenges:
ED staff may have less experience in managing complex chronic conditions or coordinating long-term care plans, which can be more relevant in some observation cases. Additionally, observation patients in the ED take space, time, and resources from the more acute patients in the emergency department.
HM Program Management
Focus:
Hospitalists are physicians who specialize in the general medical care of hospitalized patients. Their management of observation units can involve a broader range of conditions, including more complex cases that may require a transition to inpatient status.
Advantages:
Hospitalists have expertise in managing a wide variety of medical conditions and are adept at care coordination and transition of care to outpatient settings; This can lead to more comprehensive care planning and potentially better outcomes for patients who have complex needs. Skilled hospital medicine advanced practice providers (HM APPs), under physician supervision and following established guidelines, can effectively admit and manage the care of these patients as well.
Challenges:
There might be a delay in initiating observation care as patients need to be transferred from the emergency department to the Hospitalist-managed unit, potentially leading to longer wait times and a slower response to acute issues. It’s important to have observation criteria that clearly distinguish observation patients from inpatient patients, ensuring timely and appropriate patient care.
Making the Decision
The decision of whether the emergency or hospital medicine program should manage the observation unit depends on several factors including:
- hospital size
- patient population
- available nursing resources
- available HM resources
- available EM
- and the specific health needs of the community it serves.
Some hospitals may even opt for a hybrid model, where both EM and HM clinicians play roles in the observation unit. The goal is always to provide the most efficient and effective care to meet patient needs while utilizing hospital resources judiciously.