The feasibility of emergency department observation units in the management of mild to moderate hyponatremia.

OBJECTIVE: To describe the feasibility of managing hyponatremia patients under outpatient observation status in an academic medical center, and compare outcomes based on the use of an emergency department observation unit (EDOU). METHODS: This is a retrospective cohort study of emergency department hyponatremic patients managed in four hospitals within a large urban academic medical center over 27 months. All patients had an admit-to-observation order, ICD-10 codes for hyponatremia, and mild (130-135 mmol/L) to moderate (121-129 mmol/L) hyponatremia. Observation settings were divided into two groups: EDOU and Non-Observation Unit (NOU) inpatient beds. Severe hyponatremia (≤120 mmol/L) was excluded. Primary clinical outcomes were inpatient admit rate, length of stay (LOS), total direct cost, the rate of adverse events and 30-day recidivism. RESULTS: 188 patients were managed as an observation patient, with 64 managed in an EDOU setting (age 74.0 yr, 70.3% female) and 124 managed in a NOU setting (age 71.5 yr, 64.5% female). Patient subgroups were similar in terms of presenting complaints, comorbidities, and medication histories. Initial and final sodium levels were similar between settings: EDOU (125.1 to 132.6 mmol/L) vs NOU (123.5 to 132.0 mmol/L). However, outcomes differed by setting for observation to inpatient admit rate (EDOU 28.1% vs NOU 37.9%, adjusted effect 0.70), overall length of stay (EDOU 19.2 h vs NOU 31.9 h; adjusted effect -10.5 h and total direct cost ($1230 vs $1531; adjusted effect -$167). EDOU sodium correction rates were faster (EDOU 0.44 mmol/L/h vs 0.24 mmol/L/h; adjusted effect 0.15 mmol/L/h) and 30-day recidivism rate was similar (EDOU 13% vs NOU 15%). There were no index visit deaths or intensive care unit admissions. CONCLUSION: Management of selected hyponatremia patients under observation status is feasible, with the EDOU setting demonstrating lower admit rates, shorter length of stay, and lower total direct costs with similar clinical outcomes.

The Impact of Virtual Care in an Emergency Department Observation Unit.

STUDY OBJECTIVE(S): We report the impact of telemedicine virtual rounding in emergency department observation units (EDOU) on the effectiveness, safety, and cost relative to traditional observation care. METHODS: In this retrospective diff-in-diff study, we compared observation visit outcomes from 2 EDOUs before (pre) and after (post) full adoption of telemedicine rounding tele-observation (tele-obs) with usual care in control EDOU and care in a hospital bed in an integrated health system without tele-obs. Tele-obs physicians did not work at the control hospital. Outcomes were the length of stay, total direct costs, admission status, and adverse events (ICU and death). Difference-in-differences modeling evaluated outcomes with covariates including age, sex, payer type, and clinical classification software diagnostic category. Data from a system data warehouse and a cost accounting database were used. RESULTS: Of the 20,861 EDOU visits, 15,630 (74.9%) were seen in the preperiod and 6,657 (31.9%) in control EDOU. Of 23,055 non-EDOU inpatient visits assigned to observation status (nonobservation unit), 76% were seen in the preperiod. Adjusted length of stay was not significantly different for tele-obs and control EDOUs (26.4 hours versus 23.5 hours), which remained lower than in hospital settings (37.9 hours). The pre-post diff-in-diff was not significant (P=.78). Inpatient admission status was similar for tele-obs and control EDOUs (20.9% versus 22.4.%) and lower than in hospital settings (30.3%). Prepost odds ratios for inpatient admission and adverse outcomes did not change significantly for all study groups. Adjusted costs increased over time for all settings; however, the prepost median cost change was not significantly different between tele-obs EDOUs and control EDOUs ($162.5 versus $235) and was lower than the change for control hospital settings ($783). Median tele-obs EDOU cost over both periods ($1,541) remained significantly lower than hospital costs ($2,413). CONCLUSION: Using tele-obs to manage observation patients in an ED observation unit was not associated with significant differences in length of stay, admission status, measured adverse events, or total direct cost.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS: A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: This executive summary of the clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS: A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. These guidelines present an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated and shared decision-making with patients is recommended.

The impact of emergency department observation units on a health system.

IMPORTANCE: Protocol driven ED observation units (EDOU) have been shown to improve outcomes for patients and payers, however their impact on an entire health system is unknown. Two thirds of US hospitals do not have such units. OBJECTIVE: To determine the impact of a protocol-driven EDOU on health system length of stay, cost, and resource utilization. METHODS: A retrospective, observational, cross-sectional study of observation patients managed over 25 consecutive months in a four-hospital academic health system. Patients were identified using the "admit to observation" order and limited to adult, emergent / urgent, non-obstetric patients. Data was retrieved from a cost accounting database. The primary study exposure was the setting for observation care which was broken into three discrete groups: EDOUs (n = 3), hospital medicine observation units (HMSOU, n = 2), and a non-observation unit (NOU) bed located anywhere in the hospital. Outcomes included observation-to-inpatient admission rate, length of stay (LoS), total direct cost, and inpatient bed days saved. Unadjusted outcomes were compared, and outcomes were adjusted using multiple study variables. LoS and cost were compared using quantile regressions. Inpatient admit rate was compared using logistic regressions. RESULTS: The sample consisted of 48,145 patients who were 57.4% female, 48% Black, 46% White, median age of 58, with some variation in most common diagnoses and payer groups. The median unadjusted outcomes favored EDOU over NOU settings for admission rate (13.1% vs 37.1%), LoS [17.9 vs 35.6 h), and cost ($1279 vs $2022). The adjusted outcomes favored EDOU over NOU settings for admission rates [12.3% (95% CI 9.7-15.3) vs 26.4% (CI 21.3-32.3)], LoS differences [11.1 h (CI 10.6-11.5 h)] and cost differences [$127.5 (CI $105.4 - $149.5)]. Adjusted differences were similar and favored EDOU over HMSOU settings. For the health system, the total adjusted annualized savings of the EDOUs was 10,399 bed days and $1,329,443 in total direct cost per year. CONCLUSION: Within an academic medical center, EDOUs were associated with improved resource utilization and reduced cost. This represents a significant opportunity for hospitals to improve efficiency and contain costs.

Fast track dialysis: Improving emergency department and hospital throughput for patients requiring hemodialysis.

OBJECTIVE: To describe the impact of a novel communication and triage pathway called fast track dialysis (FTD) on the length of stay (LOS), resource utilization, and charges for unscheduled hemodialysis for end stage renal disease (ESRD) patients presenting to the emergency department (ED). METHODS: Prospective and retrospective cohorts of ESRD patients meeting requirements of routine or urgent hemodialysis at a tertiary academic hospital from September 25th, 2016 to September 25th, 2018 in 1 year cohorts. Two sample t-tests were used to compare most outcomes of the cohorts with a Mann-Whitney U test used for skewed data. Nephrology group outcomes were analyzed by two-way ANOVA and Kruskal-Wallis and chi-square tests. RESULTS: There were 98 encounters in the historical cohort and 143 encounters in the fast track dialysis cohort. FTD had significantly lowered median ED LOS (4.05 h, vs 5.3 h, p < 0.001), median hospital LOS (12.8 h vs 27 h, p < 0.001), time to hemodialysis (4.78 h vs 7.29 h, p < 0.001), and median hospital charges ($26,040 vs $30,747, p < 0.016). The FTD cohort had increased 30 day ED return for each encounter compared to the historical cohort (1.85 visits vs 0.73 visits, p < 0.001), however no significant increase in 1 year ED visits (6.52 visits vs 5.80, p = 0.4589) or 1 year readmissions (5.89 readmissions vs 4.81 readmissions, p = 0.3584). Most nephrology groups had significantly lower time to hemodialysis order placement and time to start hemodialysis. CONCLUSION: A multidisciplinary approach with key stakeholders using a standard pathway can lead to improved efficiency in throughput, reduced charges, and hospital resource utilization for patients needing urgent or routine hemodialysis. A study with a dedicated geographic observation unit for protocolized short stay patients including conditions ranging from low risk chest pain to transient ischemic events that incorporates FTD patients under this protocol should be considered.

Disability After Minor Stroke and Transient Ischemic Attack in the POINT Trial.

Background and Purpose- While combination aspirin and clopidogrel reduces recurrent stroke compared with aspirin alone in patients with transient ischemic attack (TIA) or minor stroke, the effect on disability is uncertain. Methods- The POINT trial (Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke) randomized patients with TIA or minor stroke (National Institutes of Health Stroke Scale score ≤3) within 12 hours of onset to dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel versus aspirin alone. The primary outcome measure was a composite of stroke, myocardial infarction, or vascular death. We performed a post hoc exploratory analysis to examine the effect of treatment on overall disability (defined as modified Rankin Scale score >1) at 90 days, as well as disability ascribed by the local investigator to index or recurrent stroke. We also evaluated predictors of disability. Results- At 90 days, 188 of 1964 (9.6%) of patients enrolled with TIA and 471 of 2586 (18.2%) of those enrolled with stroke were disabled. Overall disability was similar between patients assigned DAPT versus aspirin alone (14.7% versus 14.3%; odds ratio, 0.97 [95% CI, 0.82-1.14]; P=0.69). However, there were numerically fewer patients with disability in conjunction with a primary outcome event in the DAPT arm (3.0% versus 4.0%; odds ratio, 0.73 [95% CI, 0.53-1.01]; P=0.06) and significantly fewer patients in the DAPT arm with disability attributed by the investigators to either the index event or recurrent stroke (5.9% versus 7.4%; odds ratio, 0.78 [95% CI, 0.62-0.99]; P=0.04). Notably, disability attributed to the index event accounted for the majority of this difference (4.5% versus 6.0%; odds ratio, 0.74 [95% CI, 0.57-0.96]; P=0.02). In multivariate analysis, age, subsequent ischemic stroke, serious adverse events, and major bleeding were significantly associated with disability in TIA; for those with stroke, female sex, hypertension, or diabetes mellitus, National Institutes of Health Stroke Scale score, recurrent ischemic stroke, subsequent myocardial infarction, and serious adverse events were associated with disability. Conclusions- In addition to reducing recurrent stroke in patients with acute minor stroke and TIA, DAPT might reduce stroke-related disability. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT00991029.

Tamsulosin does not increase 1-week passage rate of ureteral stones in ED patients.

OBJECTIVE: The objective of the study is to determine if tamsulosin initiated in the emergency department (ED) decreases the time to ureteral stone passage at 1 week or time to pain resolution, compared to placebo. METHODS: We performed a prospective, randomized, double-blinded, placebo-controlled trial of tamsulosin vs placebo in ED patients with ureterolithiasis on computed tomography. Patients were identified and enrolled between April 2007 and February 2009 and were randomized to either 0.4 mg of tamsulosin or placebo for 1 week. We contacted participants using a telephone survey on post-ED visit days 1, 2, 3, and 7. The primary outcome was time to stone passage, with secondary outcomes being maximum pain score and amount of pain medication required. RESULTS: Of the 127 patients enrolled during this study, 15 were lost to follow-up, and 12 required surgical interventions before the 7-day mark, leaving 100 patients for analysis. Of the 100 patients, 53 received tamsulosin and 47 received placebo. There was no difference between groups in percentage of male, mean age, initial serum creatinine, average stone size, stone location, and history of prior stone. The probability that the patient did not pass a stone at 7 days was not different between tamsulosin and placebo, 62.1% (95% confidence interval, 49.1%-75.1%) vs 54.4% (95% confidence interval, 40.3%-68.6%; P = .58). There was no significant difference in the high pain score (P = .12) or hydrocodone/acetaminophen intake (P = .76) between treatment groups at any of the time points. CONCLUSION: This study reveals no difference in the proportion of stone passage or high pain score and pain medication utilization at 7 days between tamsulosin and placebo.

The Impact of "Emergency-only" Hemodialysis on Hospital Cost and Resource Utilization.

INTRODUCTION: Undocumented immigrants are excluded from benefits that help compensate for scheduled outpatient hemodialysis (HD), compelling them to use emergency departments (ED) for HD. Consequently, these patients can receive "emergency-only" HD after presenting to the ED with critical illness due to untimely dialysis. Our objective was to describe the impact of emergency-only HD on hospital cost and resource utilization in a large academic health system that includes public and private hospitals. METHODS: This retrospective observational study of health and accounting records took place at five teaching hospitals (one public, four private) over 24 consecutive months from January 2019 to December 2020. All patients had emergency and/or observation visits, renal failure codes (International Classification of Diseases, 10th Rev, Clinical Modification), emergency HD procedure codes, and an insurance status of "self-pay." Primary outcomes included frequency of visits, total cost, and length of stay (LOS) in the observation unit. Secondary objectives included evaluating the variation in resource use between persons and comparing these metrics between the private and public hospitals. RESULTS: A total of 15,682 emergency-only HD visits were made by 214 unique persons, for an average of 36.6 visits per person per year. The average cost per visit was $1,363, for an annual total cost of $10.7 million. The average LOS was 11.4 hours. This resulted in 89,027 observation-hours annually, or 3,709 observation-days. The public hospital dialyzed more patients compared to the private hospitals, especially due to repeat visits by the same persons. CONCLUSION: Health policies that limit hemodialysis of uninsured patients to the ED are associated with high healthcare costs and a misuse of limited ED and hospital resources.

National Stroke Association recommendations for systems of care for transient ischemic attack.

Transient ischemic attacks (TIAs) are common and portend a high short-term risk of stroke. Evidence-based recommendations for the urgent evaluation and treatment of patients with TIA have been published. However, implementation of these recommendations reliably and consistently will require changes in the systems of care established for TIA. The National Stroke Association convened a multidisciplinary panel of experts to develop recommendations for the essential components of systems of care at hospitals to improve the quality of care provided to patients with TIA. The panel recommends that hospitals establish standardized protocols to assure rapid and complete evaluation and treatment for patients with TIA, with particular attention to urgency and close observation in patients at high risk of stroke.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS: A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

The Changing Role of Chest Pain in the Emergency Department Observation Unit.

BACKGROUND: This study objective was to describe changes in the utilization of a protocol-driven emergency department observation unit (EDOU) for chest pain over time. METHODS: This is a retrospective serial cross-sectional study of data from a clinical data warehouse of a single integrated healthcare system. We estimated long-term trends (2009-2019) in EDOU visits at 4 system hospitals, using monthly proportions as the main outcome, and month of visit as the exposure variable, accounting for age and sex. Rate changes associated with compulsory use of the History, EKG, Age, Risk factors, Troponin (HEART) score in 2016 were analyzed. RESULTS: There were 83,168 EDOU admissions among 1.3 million ED visits during the study interval, with an average admission rate of 5.9% of ED visits. The most common conditions were chest pain (41.2%), transient ischemic attack (7.8%), dehydration (6.3%), syncope (5.8%), and abdominal pain (5.2%). In each hospital, there was a temporal annual decline in the proportion of EDOU visits for chest pain protocols ranging from -7.9% to -2.8%, an average rate of -3.3% per year (95% CI, -4.6% to -2.0%) or a 54% (from 54% to 25%) relative decline in over the 11-year study interval. This decline was significantly steeper in younger middle-aged patients (ages 39-49). The HEART score intervention had a small impact on baseline decline of -3.1% at the 2 intervention hospitals, reducing it by -1.5% (95% CI, -2.2% to -0.8%). CONCLUSIONS: Utilization of the EDOU for chest pain decreased over time, with corresponding increases in other conditions. This decline preceded the introduction of the HEART score.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: This executive summary of the clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS: A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. These guidelines present an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated and shared decision-making with patients is recommended.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS: A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

The recidivism characteristics of an emergency department observation unit.

STUDY OBJECTIVE: We describe the recidivism characteristics of an adult emergency department (ED) observation unit population and determine whether rates differ according to demographic or clinical features. METHODS: This prospective observational cohort study of a protocol-driven ED observation unit reviewed all discharged ED observation unit patients who returned within 14 days of discharge for an unscheduled ED visit or direct inpatient admission to the study hospital, or a proximate affiliated hospital, during 6 consecutive months. Age, sex, initial ED observation unit diagnosis, ED observation unit length of stay, and return visit disposition were determined from hospital databases and confirmed by chart review. All return visits were classified as related or unrelated to the index visit. RESULTS: There were 55,727 ED visits, with 4,348 patients admitted to the ED observation unit, of whom 80.7% (3,509) were discharged. Patients with or without a return visit were similar in terms of age (56.9 years [standard deviation (SD) 19.5 years]), percentage of male patients (40.0%), or initial ED observation unit length of stay (15.0 hours [SD 6.0 hours]). Of discharged ED observation unit patients, 375 (10.8%) had a return visit, of which 277 (7.9%) were related. Of return visits, 86.3% of patients had only 1 return visit, 11.6% had 2, and 2.1% had 3 or more; 4.2% of returns occurred at an affiliated hospital. Time to first return visit was clustered within the first week for related visits, with a mean time to return of 4.5 days (SD 3.9 days). On return visit, 40.2% of patients were treated and discharged from the ED, 36.2% were treated in the ED and admitted, 14.4% were treated in the ED and then the ED observation unit and discharged home, 12.3% were directly admitted to the hospital, and 2.5% were treated in the ED and then the ED observation unit and admitted. Among common conditions, related return visit rates were highest for headache (16.1%), back pain (13.8%), and abdominal pain (12.7%) and lowest for chest pain (3.6%). As a group, therapeutic protocols, and specifically painful conditions, had significantly higher related return visit rates than diagnostic protocols (10.8% versus 5.1%). CONCLUSION: Patients who return after an ED observation unit visit are similar to patients who do not return in terms of age, sex, or initial length of stay. However, ED observation unit recidivism rates do differ according to observation category, with painful conditions showing the highest recidivism rates.

Financial Viability of Emergency Department Observation Unit Billing Models.

BACKGROUND: Outpatients receive observation services to determine the need for inpatient admission. These services are usually provided without the use of condition-specific protocols and in an unstructured manner, scattered throughout a hospital in areas typically designated for inpatient care. Emergency department observation units (EDOUs) use protocolized care to offer an efficient alternative with shorter lengths of stay, lower costs, and higher patient satisfaction. EDOU growth is limited by existing policy barriers that prevent a "two-service" model of separate professional billing for both emergency and observation services. The majority of EDOUs use the "one-service" model, where a single composite professional fee is billed for both emergency and observation services. The financial implications of these models are not well understood. METHODS: We created a Monte Carlo simulation by building a model that reflects current clinical practice in the United States and uses inputs gathered from the most recently available peer-reviewed literature, national survey, and payer data. Using this simulation, we modeled annual staffing costs and payments for professional services under two common models of care in an EDOU. We also modeled cash flows over a continuous range of daily EDOU patient encounters to illustrate the dynamic relationship between costs and revenue over various staffing levels. RESULTS: We estimate the mean (±SD) annual net cash flow to be a net loss of $315,382 (±$89,635) in the one-service model and a net profit of $37,569 (±$359,583) in the two-service model. The two-service model is financially sustainable at daily billable encounters above 20, while in the one-service model, costs exceed revenue regardless of encounter count. Physician cost per hour and daily patient encounters had the most significant impact on model estimates. CONCLUSIONS: In the one-service model, EDOU staffing costs exceed payments at all levels of patient encounters, making a hospital subsidy necessary to create a financially sustainable practice. Professional groups seeking to staff and bill for both emergency and observation services are seldom able to do so due to EDOU size limitations and the regulatory hurdles that require setting up a separate professional group for each service. Policymakers and health care leaders should encourage universal adoption of EDOUs by removing restrictions and allowing the two-service model to be the standard billing option. These findings may inform planning and policy regarding observation services.

Chest pain center accreditation is associated with better performance of centers for Medicare and Medicaid services core measures for acute myocardial infarction.

The aim of this study was determine whether hospitals accredited by the Society of Chest Pain Centers hospitals (accredited chest pain centers [ACPCs]) are associated with better performance regarding Centers for Medicare and Medicaid Services core measures for acute myocardial infarction (AMI) than nonaccredited hospitals. The study was a retrospective, observational cohort study of hospitals reporting Centers for Medicare and Medicaid Services core measures for AMI from January 1, 2005, to December 31, 2005, on the basis of the presence or absence of Society of Chest Pain Centers accreditation. Data were obtained from the Web sites of the Centers for Medicare and Medicaid Services (Hospital Compare), Society of Chest Pain Centers listings, and the American Hospital Directory. Groups were compared in terms of demographics and mean percentage compliance with all 8 AMI core measures. Student's t test, chi-square analysis, and logistic regression were used to analyze bivariate relations. Multivariate logistic regression models used a propensity-score adjustment factor. Of the 4,197 hospitals that reported core measures for AMI, 178 (4%) were accredited and 4,019 (96%) were not. ACPCs had been accredited for an average of 12 months and were larger (378 vs 204 beds), more often teaching hospitals (52% vs 30%), and more often urban (95% vs 69%) (all p <0.0001). There were 395,250 patients with AMIs, of whom 55,418 (14%) presented to ACPCs and 339,832 (86%) presented to nonaccredited hospitals. There was significantly greater compliance with all 8 AMI core measures at ACPCs (p <0.0001), except for lytic therapy <30 minutes after arrival (p = 0.04), for which unadjusted performance was the same. In conclusion, ACPCs were associated with better compliance with Centers for Medicare and Medicaid Services core measures and saw a greater proportion of patients with AMIs.

An emergency department diagnostic protocol for patients with transient ischemic attack: a randomized controlled trial.

STUDY OBJECTIVE: To determine whether transient ischemic attack patients treated with an accelerated diagnostic protocol in an emergency department (ED) observation unit will experience shorter lengths of stay, lower costs, and comparable clinical outcomes relative to patients with traditional inpatient admission. METHODS: A prospective randomized study of ED transient ischemic attack patients with a normal head computed tomography scan, ECG, and laboratory test results and no known embolic source. Patients were randomized to an inpatient bed or to accelerated diagnostic protocol care. Both groups had orders for serial clinical examinations, a neurology consultation, carotid Doppler tests, echocardiography, and cardiac monitoring. Accelerated diagnostic protocol patients with positive testing results were admitted. Study outcomes were length of stay, 90-day total direct cost, recidivism, and clinical outcome. RESULTS: One hundred forty-nine transient ischemic attack patients were randomized to the accelerated diagnostic protocol (75) or admission (74), with both groups similar in age, percentage of male patients, and stroke risk factors. Accelerated diagnostic protocol patient median length of stay was lower (25.6 hours [interquartile range 21.9 to 28.7 hours] versus 61.2 hours [interquartile range 41.6 to 92.2 hours]), and their 90-day costs were less ($890 [interquartile range $768 to 1,510] versus $1,547 [interquartile range $1,091 to 2,473]). Fifteen percent of accelerated diagnostic protocol patients were admitted, with all positive clinical outcomes occurring while patients were in the observation unit. More accelerated diagnostic protocol patients received carotid imaging (97% versus 91%) and in less time (median 13.0 hours versus 25.2 hours), and more received echocardiography (97% versus 73%) in less time (median 19.1 versus 43.0 hours). Both groups had comparable rates of related return visits (12% each), subsequent strokes (3 versus 2), and major clinical event (4 each). CONCLUSION: A diagnostic protocol for transient ischemic attack using an accelerated diagnostic protocol is more efficient and less costly than traditional inpatient admission and demonstrated clinical outcomes comparable to those of traditional inpatient admission.

The diagnostic accuracy of 64-slice computed tomography coronary angiography compared with stress nuclear imaging in emergency department low-risk chest pain patients.

STUDY OBJECTIVE: We compared the accuracy of multidetector computed tomography (CT) coronary angiography with stress nuclear imaging for the detection of an acute coronary syndrome or 30-day major adverse cardiac events in low-risk chest pain patients. METHODS: This was a prospective study of the diagnostic accuracy of myocardial perfusion imaging and multidetector CT in low-risk chest pain patients. The target condition was an acute coronary syndrome (confirmed >70% coronary stenosis on coronary artery catheterization) or major adverse cardiac events within 30 days. Patients were low risk by Reilly/Goldman criteria and had negative serial ECGs and cardiac markers. All had both rest/stress sestamibi nuclear imaging and multidetector CT. Patients with abnormal stress nuclear imaging results (reversible perfusion defects) or multidetector CT results (stenosis >50% or calcium score >400) were considered for cardiac catheterization, and those with discordant results had a greater than 30-day reevaluation (including ECG) by a cardiologist. All were followed up for evidence of major adverse cardiac events within 30 days by review of hospital records and structured telephone interview. Primary outcomes were the accuracy of multidetector CT and myocardial perfusion imaging for the detection of an acute coronary syndrome and 30-day major adverse cardiac events. RESULTS: Of the 92 patients, 7 (8%) were excluded because of uninterpretable multidetector CT scans. Of the remaining 85 study patients (49+/-11 years, 53% men), 7 (8%) were found to have the target condition, with all having significant coronary stenosis (88%+/-9%) and none having myocardial infarction or major adverse cardiac events during 30 days. Stress nuclear imaging results were negative in 72 (85%) patients, and multidetector CT results were negative in 73 (86%) patients. The sensitivity of stress nuclear imaging was 71% (95% confidence interval [CI] 36% to 92%), and multidetector CT was 86% (95% CI 49% to 97%), and the specificity was 90% (95% CI 81% to 95%) and 92% (95% CI 84% to 96%), respectively. The negative predictive value of stress nuclear imaging and multidetector CT was 97% (95% CI 90% to 99%) and 99% (95% CI 93% to 100%), respectively, and the positive predictive value was 38% (95% CI 18% to 64%) and 50% (95% CI 25% to 75%), respectively. CONCLUSION: The accuracy of multidetector CT is at least as good as that of stress nuclear imaging for the detection and exclusion of an acute coronary syndrome in low-risk chest pain patients.

History, Principles, and Policies of Observation Medicine.

The history of observation medicine has paralleled the rise of emergency medicine over the past 50 years to meet the needs of patients, emergency departments, hospitals, and the US health care system. Just as emergency departments are the safety net of the health system, observation units are the safety net of emergency departments. The growth of observation medicine has been driven by innovations in health care, an ongoing shift of patients from inpatient to outpatient settings, and changes in health policy. These units have been shown to provide better outcomes than traditional care for selected patients.