Untapped Potential for Emergency Department Observation Unit Use: A National Hospital Ambulatory Medical Care Survey (NHAMCS) Study.

INTRODUCTION: Millions of people present to the emergency department (ED) with chest pain annually. Accurate and timely risk stratification is important to identify potentially life-threatening conditions such as acute coronary syndrome (ACS). An ED-based observation unit can be used to rapidly evaluate patients and reduce ED crowding, but the practice is not universal. We estimated the number of current hospital admissions in the United States (US) eligible for ED-based observation services for patients with symptoms of ACS. METHODS: In this cross-sectional analysis we used data from the 2011-2015 National Hospital Ambulatory Medical Care Survey (NHAMCS). Visits were included if patients presented with symptoms of ACS (eg, chest pain, dyspnea), had an electrocardiogram (ECG) and cardiac markers, and were admitted to the hospital. We excluded patients with any of the following: discharge diagnosis of myocardial infarction; cardiac arrest; congestive heart failure, or unstable angina; admission to an intensive care unit; hospital length of stay > 2 days; alteplase administration, central venous catheter insertion, cardiopulmonary resuscitation or endotracheal intubation; or admission after an initial ED observation stay. We extracted data on sociodemographics, hospital characteristics, triage level, disposition from the ED, and year of ED extracted from the NHAMCS. Descriptive statistics were performed using sampling weights to produce national estimates of ED visits. We provide medians with interquartile ranges for continuous variables and percentages with 95% confidence intervals for categorical variables. RESULTS: During 2011-2015 there were an estimated 675,883,000 ED visits in the US. Of these, 14,353,000 patients with symptoms of ACS and an ED order for an ECG or cardiac markers were admitted to the hospital. We identified 1,883,000 visits that were amenable to ED observation services, where 987,000 (52.4%) were male patients, and 1,318,000 (70%) were White. Further-more, 739,000 (39.2%) and 234,000 (12.4%) were paid for by Medicare and Medicaid, respectively. The majority (45.1%) of observation-amenable hospitalizations were in the Southern US. CONCLUSION: Emergency department-based observation unit services for suspected ACS appear to be underused. Over half of potentially observation-amenable admissions were paid for by Medicare and Medicaid. Implementation of ED-based observation units would especially benefit hospitals and patients in the American South.

Profesionales de grado medio como parte del equipomédico de atención a las emergencias en EE. UU funciones, responsabilidades y directrices futuras / Midlevel providers as part of US emergency health care teams: roles, responsibilities,and future directions

El concepto de formar a profesionales no médicos en cuidados sanitarios se originó a mediados de los años 60, cuando hubo una escasez prevista de médicos de atención primaria (AP) y pretendía cubrir dicha escasez. Desde entonces, sus funciones, responsabilidades y autonomía se han desarrollado en diversas direcciones. El objetivo original era que estos profesionales de grado medio (PGM) proporcionasen atención a los pacientes menos graves y trabajaran bajo la supervisión de un médico, pero en los últimos años muchos están trabajando con una relativa autonomía, al atender a un número creciente de pacientes con enfermedad aguda y asumir responsabilidades más allá del cuidado directo del paciente. La literatura disponible muestra que la calidad de la atención proporcionada por los PGM es comparable a la de los médicos. Tienen potencial para cubrir importantes áreas de la atención como la comunicación con el paciente, el control del cumplimiento de las directrices en los cuidados y otros aspectos como la educación y la investigación. Son necesarios estudios actualizados para garantizar la homogenización y normalización en su formación, para definir el alcance y la práctica clínica de la atención que deben prestar y sobre la preocupación de los urgenciólogo por la amenaza profesional que puedan representar (AU)

The concept of training nonphysical health care providers originated in the mid-1960s, when a shortage of primary care physicians was projected. The original intent was to compensate for shortages of primary care physicians. Since then the roles, responsibilities, and autonomy of practice of midlevel providers (MLPs) have evolved in a number of directions. The goal was initially to have the MLP provide care in less acute medical events and work under the supervision of a physician, but many have begun to work with relative autonomy in recent years, caring for increasing numbers of acutely ill patients and taking on responsibilities outside of direct patient care. The literature shows that MLPs offer quality of the care that is comparable to physicians’ care. They have the potential to fill important roles in areas such as patient communication, monitoring of compliance with care guidelines and transitions in care, and in education and research. Current issues are the need to ensure standardization of training, define the scope of MLP care and practice, and address concerns about professional threat to specialist in emergency medicine (AU)

An observation unit may help improve an institution's Press Ganey satisfaction score.

BACKGROUND: : Hospitals measure patient satisfaction through Press Ganey (PG) surveys. The impact of an emergency department observation unit (EDOU) on patient satisfaction has not been reported to date. We hypothesize that an EDOU has a positive impact on patient satisfaction results as measured by PG surveys. METHODS: : This is a retrospective observational analysis of PG scores collected for 8 quarters before the opening of a 13-bed EDOU in January 2002 and compared with 6 quarters post-EDOU opening, starting April 1, 2003, at a tertiary care, academic, urban hospital. The facility, physician staffing, nursing, and wait times all remained the same during this period. Mean values and a 95% confidence interval (CI) are reported and statistical significance is calculated using a t test. Significance is defined as a P < 0.05. RESULTS: : The mean overall PG scores pre-EDOU was 75.2 (95% CI: 74.2-76.2) and post-EDOU was 80.2 (95% CI: 78.9-82.6), which is statistically significant (P = 0.00005). Of 9 scoring categories, 9 increased post-EDOU. Other than the category for physician scores, all other mean values were higher for the EDOU in the subcategories. CONCLUSION: : The introduction of an observation unit appears to be associated with a statistical improvement in patient satisfaction scores as reported by PG, in the setting of same facility, physician staffing, and nursing staffing.