The Recidivism Characteristics of an Emergency Department Observation Unit

doi:10.1016/j.annemergmed.2010.02.012

Annals of Emergency Medicine

Volume 56, Issue 1, July 2010, Pages 34-41

https://doi.org/10.1016/j.annemergmed.2010.02.012 Get rights and content

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.

Introduction

It is estimated that 31% of US emergency departments (EDs) either have or are planning an observation unit, and 81% of emergency medicine residencies have or are planning an ED observation unit.1, 2 These units manage ED patients beyond their initial ED visit to determine their need for inpatient admission. For most patients, this serves as an alternative to either inpatient admission or management under “observation status” in an inpatient bed. These units are often managed by emergency physicians using protocol-driven care.1, 3, 4, 5 Several studies of care in the ED observation unit have demonstrated improved health care outcomes for adults and children, such as lower costs, decreased length of stay, improved hospital resource utilization, improved patient satisfaction, and better diagnostic performance.4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 A measure commonly used to assess ED observation unit performance is hospital return visit rate, or recidivism.6, 12, 21 If patients are efficiently managed yet prematurely discharged, only to return and be admitted, then the efficiency benefit is less meaningful. Recidivism rates of other groups, such as ED patients and Medicare Fee-for-Service inpatients, have been studied.22, 23, 24 However, recidivism rates for ED observation unit patients have been studied only for selected patient groups, and the recidivism characteristics of an ED observation unit have not been reported to our knowledge.4, 6, 25 The purpose of this study is to describe the recidivism rates of patients discharged from an ED observation unit that manages several conditions and to examine whether rates differ according to patient demographics or clinical subgroups.

Section snippets

Selection of Participants and Data Collection

This prospective observational cohort study took place during a 6-month period (January 1 to June 30, 2002) in the ED observation unit of a high-volume suburban teaching hospital. We chose to sample a 6-month period on the assumption that it would allow us to capture at least 50 index visits for our 10 most common ED observation unit conditions during 14 days. With an estimated 10% return rate, this method would lead to reviewing at least 5 return visits, the minimum number we believed would be

Results

During 6 months there were 55,727 ED visits, with 4,348 (7.8% of ED census) patients admitted to the ED observation unit and 80.7% (3,509) being discharged from the ED observation unit (Figure 1). These 3,509 ED observation unit discharge visits (made by 3,369 unique patients) formed the population of index visits for our study. Descriptive statistics for these index visits were as follows: mean age 56.9 years (SD 19.5 years), 40% men, and mean length of stay 15.0 hours (SD 6.0).

Of the 3,509

Limitations

This study has several inherent limitations. First, it represents the experience of a single institution with a specific type of ED observation unit, one that is managed by emergency physicians and protocol driven. It is not clear how these results might apply to other observation settings. As such, these findings should be validated in other ED observation unit settings. We did not examine return visits of admitted ED observation unit patients, because the focus was whether discharged ED

Discussion

We found that 7.9% of patients discharged from a protocol-driven ED observation returned within 14 days for symptoms related to their index visit, and 46% of these patients were subsequently admitted. Most returns were for related conditions and were clustered within the first week after discharge, suggesting that a 7-day audit may capture the majority of related returns. Unrelated returns were less common and did not show the same temporal pattern that related revisits did. With the exception

References (37)

S.E. Mace et al.
A national survey of observation units in the United States
Am J Emerg Med
(2003)
J. Brillman et al.
Management of observation unitsAmerican College of Emergency Physicians
Ann Emerg Med
(1995)
M.A. Ross et al.
The use and effectiveness of an emergency department observation unit for elderly patients
Ann Emerg Med
(2003)
E. Martinez et al.
The observation unit: a new interface between inpatient and outpatient care
Am J Med
(2001)
M.A. Ross et al.
An emergency department diagnostic protocol for patients with transient ischemic attack: a randomized controlled trial
Ann Emerg Med
(2007)
M.A. Gomez et al.
An emergency department-based protocol for rapidly ruling out myocardial ischemia reduces hospital time and expense: results of a randomized study (ROMIO)
J Am Coll Cardiol
(1996)
R.J. Rydman et al.
Patient satisfaction with an emergency department chest pain observation unit
Ann Emerg Med
(1997)
L. Graff et al.
Probability of appendicitis before and after observation
Ann Emerg Med
(1991)
L.G. Graff et al.
Impact on the care of the emergency department chest pain patient from the Chest Pain Evaluation Registry (CHEPER) study
Am J Cardiol
(1997)
R. Maag et al.
Improving chest pain evaluation within a multihospital network by the use of emergency department observation units
Jt Comm J Qual Improv
(1997)

S.E. Mace

Pediatric observation medicine

Emerg Med Clin North Am

(2001)

K.D. Keith et al.

Emergency department revisits

Ann Emerg Med

(1989)

S. Cardin et al.

Intervention to decrease emergency department crowding: does it have an effect on return visits and hospital readmissions?

Ann Emerg Med

(2003)

M.A. Ross et al.

Maximizing use of the emergency department observation unit: a novel hybrid design

Ann Emerg Med

(2001)

M.A. Ross et al.

Principles of observation medicine

Emerg Med Clin North Am

(2001)

F. Aminzadeh et al.

Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions

Ann Emerg Med

(2002)

J.S. Bohan

Extended emergency care for painful conditions

Emerg Med Clin North Am

(2001)

S.E. Mace et al.

Observation medicine in emergency medicine residency programs

Acad Emerg Med

(2002)

Cited by (40)

The feasibility of emergency department observation units in the management of mild to moderate hyponatremia
2024, American Journal of Emergency Medicine
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).
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.
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.
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
2023, Annals of Emergency Medicine
Citation Excerpt :
A 30-day recidivism data was not available for this study and was not included. Prior studies have shown that 30-day recidivism rates among EDOU patients are comparable to or superior to patients managed in an inpatient setting.17,18 Patient and provider satisfaction and experience were not studied but have been reported in similar settings.18-20
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.
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.
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).
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.
The impact of emergency department observation units on a health system
2021, American Journal of Emergency Medicine
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.
To determine the impact of a protocol-driven EDOU on health system length of stay, cost, and resource utilization.
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.
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.
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.
Beyond observation: Protocols and capabilities of an Emergency Department Observation Unit
2019, American Journal of Emergency Medicine
Citation Excerpt :
A 30 day return rate of 16.8% is better than that reported for overall ED patients at other academic emergency departments (22–23%) [18,19]. We did not locate any studies that reported 72-hour return rates for Obs Units, however, Ross et al. studied 14-day return rates for an Obs Unit and observed that many return visits occurred within the first 3 days following discharge [16]. Previously reported 72-hour return rates for the entire ED population range between 1 and 15% depending on the hospital and patient population, which is consistent with our return rate of 5.3% for observation unit patients and comparable to our non-Observation ED patient population (6.2%) [20,21].
Emergency Department Observation Units (Obs Units) provide a setting and a mechanism for further care of Emergency Department (ED) patients. Our hospital has a protocol-driven, type 1, complex 20 bed Obs Unit with 36 different protocols. We wanted to understand how the different protocols performed and what types of care were provided.
This was an IRB-approved, retrospective chart review study. A random 10% of ED patient charts with a “transfer to observation” order were selected monthly from October 2015 through June 2017. This database was designed to identify high and low functioning protocols based on length of stays (LOS) and admission rates.
Over 20 months, a total of 984 patients qualified for the study. The average age was 49.5 ± 17.2 years, 57.3% were women, and 32.3% were non-Caucasian. The admission rate was 23.5% with an average LOS in observation of 13.7 h [95% CI 13.3–14.1]. Thirty day return rate was 16.8% with 5.3% of the patients returning to the ED within the first 72 h. Thirty six different protocols were used, with the most common being chest pain (13.9%) and general (13.2%). Almost 70% received a consultation from another service, and 7.2% required a procedure while in observation. Procedures included fluoroscopic-guided lumbar punctures, endoscopies, dental extractions, and catheter replacements (nephrostomy, gastrostomy, and biliary tubes).
An Obs Unit can care for a wide variety of patients who require multiple consultations, procedures, and care coordination while maintaining an acceptable length of stay and admission rate.
Management of dyspepsia—The role of the ED Observation unit to optimize patient outcomes
2018, American Journal of Emergency Medicine
Dyspepsia is a common complaint that can confer significant burden on one's quality of life and may also be associated with serious underlying conditions. The objective of this study was to determine if patients admitted to the emergency department observation unit (EDOU) for severe or persistent dyspepsia would have cost effective management in terms of investigations performed, length and cost of hospital stay. The secondary objective was to determine if any patient characteristics could predict a need for admission to the inpatient unit.
Retrospective chart reviews of patients admitted to the EDOU under the Dyspepsia protocol between January 2008 and August 2014 were conducted. Baseline demographics, investigations performed, outcomes related to EDOU stay, admission and 30-day re-presentation outcomes were recorded.
A total of 1304 patients were included. Median length of stay was 1 day. Cumulative bed-saved days were 38 per month. Two hundred eighteen (16.7%) patients required admission to the inpatient service for further management, while 533 (40.9%) and 313 (24.0%) patients underwent esophagogastroduodenoscopy and hepatobiliary ultrasonography, respectively. No major adverse events were attributed to the EDOU admissions or delays in treatment. No significant clinically relevant factors were associated with a need for admission from the EDOU to the inpatient unit. Median cost of the EDOU admission was approximately one-third that of a similar admission to the inpatient unit.
The EDOU is an appropriate setting to facilitate investigations and treatment of patients with dyspepsia with considerable bed-saved days.
Additional Conditions Amenable to Observation Care
2017, Emergency Medicine Clinics of North America
Citation Excerpt :
Vaso-occlusive crises requiring care beyond the initial ED visit are likely to require greater than 15 to 18 hours recommended for EDOU cases. In addition, painful conditions most frequently require hospital admission from the EDOU or lead to ED recidivism.28 Meeting with stakeholders from internal medicine and hematology is essential before undertaking an EDOU protocol.

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: Please see page 35 for the Editor's Capsule Summary of this article.

: Provide feedback on this article at the journal's Web site, www.annemergmed.com.

: Supervising editor: Donald M. Yealy, MD

: Author contributions: MAR and KS conceived and designed the study and were involved in data collection and validation. CC obtained institutional review board approval. MAR, RRH, JA, KS, and CC were involved in data analysis and article preparation. All authors were involved in final article revisions. MR takes responsibility for the paper as a whole.

: Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.

: Publication date: Available online March 29, 2010.

: Reprints not available from the authors.

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Health policy and clinical practice/original researchThe Recidivism Characteristics of an Emergency Department Observation Unit

Study objective

Methods

Results

Conclusion

Introduction

Section snippets

Selection of Participants and Data Collection

Results

Limitations

Discussion

Am J Emerg Med

Ann Emerg Med

Ann Emerg Med

Am J Med

Ann Emerg Med

J Am Coll Cardiol

Ann Emerg Med

Ann Emerg Med

Am J Cardiol

Jt Comm J Qual Improv

Emerg Med Clin North Am

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Emerg Med Clin North Am

Ann Emerg Med

Emerg Med Clin North Am

Observation medicine in emergency medicine residency programs

Acad Emerg Med

Health policy and clinical practice/original research
The Recidivism Characteristics of an Emergency Department Observation Unit