Does your ED have an observation unit, and what's its purpose?

I was just talking with our ED director about this very issue, and my question to him was, "Why not discharge these patients with instructions to return in the AM for further testing."

Basically, the response I received was directed to the revenue lost for those patients who go home feeling well, and decide they don't want to come back in the morning.

Basically, the response I received was directed to the revenue lost for those patients who go home feeling well, and decide they don't want to come back in the morning.

Not to mention, to our docs anyways, fear of potential lawsuit over having someone go home, have an MI or other adverse outcome. It's insane how many (in my opinion) unecessary tests are run simply because the docs are scared to death of lawsuits. Nearly everyone with chest pain is admitted for observation, and everyone from frequent fliers with their migrains to the chronic vomiters gets a full lab workup (including frequent LPs on these chronic migraine sufferers) even though they were in our ED the day before last. It's getting rediculous. Ever since one of the docs who previously worked there got sued for not doing a c-spine xry on an mvc pt before taking him off the backboard (sad really, pt had a fx and is now a quad) the docs are terrified, and will order everything just to make sure. No one trusts themselves and their clinical decisions anymore. Sad, sad, sad what the lawsuit industry has brought our medical profession to.

Edit: Please don't mistake what I'm saying - the doctor who was sued needed to be sued. Radiology called him 3 times to confirm that he did NOT want a C-spine while pt was backboarded, and when pt went back to radiology after being taken off the board, one tech went out on a limb and took the c-spine anyways. Because he was off the board, the fx was difficult to see, and didn't get caught until the pt was sent over to a nearby trauma hospital where they called irate that the pt was off the backboard. When the doc ordered the pt off the board, three nurses refused to take him off, so the doc grabbed the charge nurse who also refused. Doc got red in the face and said fine, I'll take him off if you won't, and I will have you fired. Due to this doc's known manner of rough handling of pts, the nurse decided to do it, hoping to minimize the amount of moving to the pt, but stated in front of the family "you see this, the doctor is ordering me, I don't think this is a good idea, and I don't want to do it" By the time the fx was found, the spinal cord had been damaged for too long and the damage was irreversable. The doctor's rationale for taking the pt off the board??? "He was complaining that the board was hurting his back." Needless to say, all the nurses were spending hours of documentation that night, to make sure to cover their a$$es so that the full brunt of whatever might happen would fall on this incompetent ER doc. And it came back to bit the doc in the a$$. Two weeks later, he was gone without a word - fired on the spot when they found out what the pts outcome was.

2nd Edit: Sorry for hijacking this thread into a new direction, I started off replying about how so many people get placed in obs. for no good reason because of fear of lawsuits, and then I got on a venting rant... so sorry guys!

here in columbia, sc our ed calls our observation unit the clinical decision unit (cdu). in short, this "wing" of our ed admits patients who are not "discharge home" material, nor necessitating hospital admission. we admit those with low probability cardiac chest pain, asthma exacerbation, simple abd pain, metabolic derangement, and the ever-growing psych holds.

my question is simple:

for those who are admitted with chest pain, have negative ecgs and negative serial cardiac enzymes, would it be profitable to keep these patients within the department when performing nuclear stress testing? what i mean by this is one er physician observes the stress test in the dept. while a nuclear tech injects with the radioactive isotope. then, the patient is sent to nuclear medicine for their necessary scans.

again, profitable?

reimbursable?

safe?

our jurisdiction?

carotid

supplying oxygen-rich blood to millions of brains globally

if it wasnt reimbursable, trust me they wouldnt do it.

we have 10 beds in our obs unit. however we dont do stress tests they get sent over to cardiology for that. and are seen by cardio prior to dc.

Here in the UK things are slightly different, we also have CDU's, jokingly refered to as the confused doctor unit, or the can't decide unit. Due to the need in the UK for the patient to spend no more than 4 hours in the department from time of admission to discharge, patients are sent to the CDU where they are no longer 'techinically' in A+E and can await blood results, tests etc or be observed.

That is one of the down sides of the UK system of 4 hour waits, there are just some patients who you need to hold onto for more than four hours but arn't going to send to the ward or admit them.

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All patients stabilise eventually

We have an observation unit, but it works a little differently.

Our ED docs don't usually admit the patient. An attending or hospitalist will. Then it is up to the cardiologist to be there during a stress test.

At most, our docs will write "holding" orders for any patient going to any unit or floor until the hospitalist or attending to write the official orders.

Once a pt has been "admitted" even before they have a bed they are out of our ED doc's jurisdiction unless the pt develops an emergency situation. If they need pain med and the admitting MD didn't write an order for it, the ED doc will sneak an order in.

We have a CDU, it is notoriously abused, despite "guidelines" that were drawn up to avoid inappropriate admissions.

The 4 hour targets mean it is used to "avoid breaches" ie more than 4 hours in A&E just because a ward hasn't been allocated or the speciality hasn't finished their clerking. That's the most common use and means the CDU nurses (there are only two, one senior nurse, one junior or healthcare assist.) spend their time transferring to wards minutes after "admission".

Medical staff try to make us hold on to patients who they think might go home in the morning, usually we ignore them, since that is inappropriate and try to get a ward and move them anyhow.

Head injuries for neuro's is ok, I accept that... drunks to sober up are all too common, people awaiting psych reviews, they take forever! I think the most appropriate is the elderly fall who has to be assessed in the morning for mobility and home support.

We aren't allowed to have under 16's or unstable psych patients and, although psych sometimes ignored, we are not supposed to have ACS patients pre-troponin levels admitted.

The last hospital I worked at had a Clinical Evaluation Unit, which was initally going to be just for stress testing and chest pain... well, apparently we did not have as many as the studies had indicated we would so then we began to admit people who could be "turned" within 24 hours...head injury obs, chest pains, trauma that could have gone home but the patient was especially whiney, questionable abdominal pains...drunks, diabetics, severe asthma...

It was actually more like med surg than anything. The biggest problem came with patients who should have been admitted, but no one wanted them on their service...

It did seem to work pretty well, except that they required the ED nurses to work there, and being that it was more med surg than ED it quickly became a place that everyone hated to be assigned to....