History of Observation Medicine

Observation medicine encompasses the skills and knowledge needed to appropriately identify and provide active patient care beyond initial emergency department (ED) care for patients who are not well enough to be discharged from the ED but not ill/injured enough to require a full admission in an inpatient setting.

History of Observation Medicine

Historically, there were only two disposition options for emergency physicians - admit or discharge. This left emergency physicians with sometimes difficult disposition decisions for patients too sick to discharge but not necessarily requiring a full inpatient hospitalization. Recently, a third disposition option has emerged, placement in an observation unit (OU). Observation units allow for further diagnostic and therapeutic interventions beyond the initial ED care, and frequent reassessments to evaluate disease progression along a time continuum. The average OU stay is 15 hours, after which it is determined if a patient can be safely discharged home or whether the patient requires further evaluation and treatment in an inpatient setting. Guidelines regarding observation versus inpatient care are often dictated by The Center for Medicare and Medicaid Services (CMS). Multiple factors have led to an increased use of observation care and subsequently an increase in the number of OUs including: ED and hospital overcrowding, resource overutilization, payer audits, payment denials, and medical innovations shifting care to outpatient settings. It is estimated that 12-25% of ED patients admitted to the hospital may qualify for an OU stay instead. Emergency medicine (EM) has long recognized the importance of observation care and has established itself as the leader in the science and practice of observation medicine (OM). The American College of Emergency Physicians (ACEP) first issued OM practice guidelines in 1988 and the OM section was established in 2001.

Why Observation Medicine is an Important Skillset for Emergency Physicians

One of the most important skills of an EM physician is determining an appropriate and safe disposition. Since diseases progress over time, an OU allows the emergency physician to witness diseases improving or worsening beyond the 4-6 hour period of an ED stay and the effect of treatments. Moreover, the OU allows for the appropriate time to apply an evidence-based clinical model for safer dispositions to home. This makes the physician a better prognosticator of disease and helps to improve disposition decision-making. Observation medicine is also an area for emergency physicians to broaden their value to their hospital and increase their general employability. OUs run by emergency physicians improve patient outcomes and decrease health care spending, and thus are desired assets for every hospital system. Multiple changes in health care have led to increasing numbers of OUs opening in hospitals, especially in larger academic institutions. It is likely that a graduating emergency physician will be employed in a hospital with an OU and OM knowledge and skills will be expected. On a more practical note, the lifestyle of an OU physician can be more predictable than the lifestyle of the ED physician who works only in the emergency department. Depending on the hospital, the hours tend to more resemble typical business hours. As well, it provides an interesting mix between acute ED management and post-acute traditional but short-term hospital ward management.

Why Emergency Physicians are Ideally Suited to Manage Observation Units

When patients are placed in the OU from the ED, the plan of care has often already been put in motion by the initial ED physician. Hand-off of patient care to a like-minded physician allows for a more seamless and symmetric transition. Further, because emergency physicians are trained and practice in a disposition-driven manner, the short-term management of patients with the goal of determining ultimate dispositions is inherent to how emergency physicians are trained and work. Several studies comparing EDOU care to inpatient care for common conditions such as asthma, chest pain, syncope, atrial fibrillation, and transient ischemic attack (TIA) found OU care has lower levels of diagnostic uncertainly, lower costs, shorter lengths of stay, improved patient outcomes, and improved clinical outcomes. Additionally, OU stays are associated with reductions in health care costs to society.