Anwar Osborne

Favorable Bed Utilization and Readmission Rates for Emergency Department Observation Unit Heart Failure Patients

OBJECTIVES The objective was to compare readmission rates and hospital bed-days between acute decompensated heart failure (AHF) patients admitted or discharged following accelerated treatment protocol (ATP)-driven care in an emergency department observation unit (OU). METHODS This was a retrospective cohort study conducted at two urban university-affiliated hospitals. A total of 358 selected AHF patients received treatment on an ATP in the OU between October 1, 2007, and June 30, 2011. The comparison of interest was admission or discharge following OU treatment. The outcome of interest was readmission within 30 and 90 days of hospital discharge following care in the OU. We also examined resource use (inpatient, inpatient plus outpatient-days) between the admitted and discharged groups. Time to readmission analysis was performed with Cox proportional hazards regression. RESULTS Discharged and admitted patients were similar with respect to age, race, sex, ED length of stay (LOS), and OU LOS. Patients admitted from the OU had a higher median B-type natriuretic peptide (BNP; 1,063 pg/mL [interquartile range {IQR} = 552 to 2,067 pg/mL] vs. 708 pg/mL [IQR = 254 to 1,683 pg/mL]; p = 0.002) and blood urea nitrogen (BUN; 19 mg/dL [IQR = 14 to 26 mg/dL] vs. 17 mg/dL [IQR = 13 to 23 mg/dL]) than those discharged (p = 0.04) and a lower median ejection fraction (EF; 22.5% [15% to 43%] vs. 35% [IQR 20% to 55%]; p = 0.002). In models controlling for age, race, sex, clinical site, BNP, BUN, creatinine, and EF, the 30-day readmission rate (13.8% in the study population as a whole) was not significantly different between the patients discharged or admitted following OU care (hazard ratio [HR] = 0.99; 95% confidence interval [CI] = 0.47 to 2.10). The readmission rates were also not significantly different at 90 days (HR = 1.07; 95% CI = 0.65 to 1.77). Within 30 days of discharge from the OU, patients spent a median of 1.7 days (IQR = 0.0 to 5.1 days) as inpatients, compared to 3.5 days (IQR = 2.3 to 5.8 days) among patients admitted from the OU (p < 0.0001). Among readmitted patients, the total median inpatient time was not significantly different between the comparison groups at both 30 and 90 days of follow-up. CONCLUSIONS Selected acute heart failure (HF) patients managed by a rapid treatment protocol in the OU demonstrated favorable hospital use, with discharged patients using fewer bed-days and demonstrating readmission rates that were not higher than admitted patients.

Characteristics of hospital observation services: a society of cardiovascular patient care survey.

INTRODUCTION Little is known about the setting in which observation services are provided, or how observation patients are managed in settings such as accredited cardiovascular patient care centers. OBJECTIVE To describe the characteristics of observation services in accredited Cardiovascular Patient Care hospitals, or those seeking accreditation. METHODS This is a cross-sectional survey of hospitals either accredited by the Society of Cardiovascular Patient Care, or considering accreditation in 2010. The survey was a web-based free service linked to an e-mail sent to Cardiovascular Patient Care coordinators at the respective institutions. The survey included 17 questions which focused on hospital characteristics and observation services, specifically management, settings, staffing, utilization, and performance data. RESULTS Of the 789 accredited hospitals, 91 hospitals (11.5%) responded to the survey. Responding hospitals had a median of 250 inpatient beds (interquartile range [IQR] 277), 32.5 emergency department (ED) beds or hall spots, with an average annual ED census of 41,660 (IQR 30,149). These hospitals had an average of 8 (IQR 9) observation unit beds whose median length of stay (LOS) was 19 hours (IQR 8.1), with a discharge rate of 89.1% (IQR 15). There was an average of 1 observation bed to 3.8 ED beds. Observation units were most commonly administered by emergency medicine (48.5%), but staffed by a broad spectrum of specialties. Nonemergency medicine units had longer LOSs, which were not significant. Most common conditions were chest pain and abdominal pain. CONCLUSIONS Accredited chest pain centers have observation units whose LOSs and discharge rates are comparable to prior studies with utilization patterns that may serve as benchmarks for similar hospitals.

Ability of triage decision rules for rapid electrocardiogram to identify patients with suspected ST-elevation myocardial infarction.

BACKGROUND : The American College of Cardiology/American Heart Association guidelines for ST-elevation myocardial infarction state that an electrocardiogram (ECG) should be performed on patients with suspected acute coronary syndrome upon presentation to the emergency department (ED) within 10 minutes. OBJECTIVE : To determine how previously published clinical criteria for obtaining an ECG at ED triage perform in a population of patients receiving emergency cardiac catheterization for suspected myocardial infarction. This rule was originally derived by Graff to identify clinical criteria for obtaining an ECG at triage to rapidly identify patients with acute myocardial infarction. The Graff rule was developed in a setting where lytic therapy was the primary reperfusion strategy. A modification proposed by Glickman adds several more criteria in an effort to capture additional patients. We hypothesized that the Graff rule would identify most patients for whom the cardiac catheterization laboratory (CCL) was activated and that the Glickman rule would capture the remaining patients. METHODS : Three trained physician reviewers retrospectively applied the Graff decision rule to 430 consecutive patients from a database of emergency CCL activations by ED physicians. The Graff rule recommends that patients between the ages of 30 and 49 years received a rapid ECG if they complained of chest pain and those aged 50 years or older received a rapid ECG when they complained of chest pain, shortness of breath, palpitations, weakness, or syncope. The newly developed Glickman rule, which included nausea and vomiting in patients over the age of 80 years, was applied to the patients where the Graff rule was negative. The triage note or earliest medical contact documentation was used to determine whether the patients complaints would have resulted in a rapid ECG by the decision rule. Each case was reviewed for acute myocardial infarction as defined by high-grade stenosis on the subsequent emergent cardiac catheterization. A single data collection Microsoft Excel spreadsheet was used, and descriptive statistics were performed in Excel and Stata. RESULTS : Of the 430 CCL activations, 415 (97%; 95% confidence interval, 95%-99%) were identified by the Graff rule. Of the 12 patients who were not identified by the rule, only 2 more were identified by the Glickman criteria. Among patients with confirmed ST-elevation myocardial infarction (79% of CCL activations), the Graff rule was 98% sensitive (95% confidence interval, 96%-99%). CONCLUSIONS : The Graff ECG triage rule identified almost all patients for whom the CCL was activated. Modification of the rule as proposed by Glickman added very little to the rules sensitivity, while increasing the number of ECGs required at triage.

The feasibility of Rubidium-82 positron emission tomography stress testing in low-risk chest pain protocol patients.

OBJECTIVE To evaluate the feasibility of dipyridamole-induced reversible ischemia on myocardial perfusion positron emission tomography (PET) imaging using Rubidium-82 (Rb-82 PET) to predict the presence of acute coronary syndrome (ACS) in emergency department (ED) chest pain patients at low risk who were admitted to an observation unit. METHODS Retrospective cross-sectional study of electronic medical records after computerized record retrieval. We matched all ED chest pain visits to a database of all scans read by cardiology between January 1, 2004 and January 1, 2006. A PET scan was performed at the ED physicians discretion after a negative observation unit workup, including serial cardiac biomarkers and ECGs. Data were collected on a standardized abstraction instrument. RESULTS There were 7,691 ED visits for chest pain. Among these patients, 1177 had an Rb-82 PET. Fifty four (4.6%) of these patients had an abnormal or probably abnormal scan. Of these, 28 had catheter-proven significant coronary disease, requiring either revascularization or intensive medical management; 22 patients had ACS by clinical assessment but did not undergo catheterization. Four had no coronary artery disease on catheterization. CONCLUSION In a low-risk chest pain population, cardiac PET imaging had true-positive cardiac catheterization rates which were comparable to prior studies of SPECT sestimibi imaging and coronary CTA imaging. With the rapid dissemination of PET technology, and superior performance compared to current imaging methods, myocardial perfusion PET is a feasible alternative to traditional provocative testing in an ED observation unit.

There's Another Observation Unit?: A Case Series Survey of Second Level Observation Units.

OBJECTIVES Observation units are dedicated areas in the hospital to deliver care to patients in observation status-those too risky to be immediately discharged following an emergency department evaluation but also clearly not in need of an inpatient admission. Observation units have been commonplace for several decades but in recent years some hospitals have begun to operate an additional observation unit with a distinct care delivery model and patient population. METHODS We conducted a survey between June 2014 and December 2014 to determine the prevalence and key operational characteristics of second level observation units in the US. We accessed the list serve of a large specialty organization to reach leaders likely to be directly operating or aware of the presence of a second level unit in their hospital. RESULTS We received 28 responses (response rate of approximately 10%). We found 8 second level OUs, with respondents able to provide detailed data for 6 of them. All were established within the past 5 years. CONCLUSIONS Second level observation units are still relatively uncommon but are emerging as an extension of hospital-based observation services as an additional resource to cohort observation patients into a dedicated unit. These units share some similarities with traditional OUs, such as the nursing ratio of approximately 4:1 and the preponderance of chest pain pathways; however, they also differ in important ways around key metrics, such as length of stay, attending staffing coverage, and rate of subsequent inpatient admission. Additional study is needed both to fully characterize these units and their potential benefits.

A Model Longitudinal Observation Medicine Curriculum for an Emergency Medicine Residency

The role of observation services for emergency department patients has increased in recent years. Driven by changing health care practices and evolving payer policies, many hospitals in the United States currently have or are developing an observation unit (OU) and emergency physicians are most often expected to manage patients in this setting. Yet, few residency programs dedicate a portion of their clinical curriculum to observation medicine. This knowledge set should be integrated into the core training curriculum of emergency physicians. Presented here is a model observation medicine longitudinal training curriculum, which can be integrated into an emergency medicine (EM) residency. It was developed by a consensus of content experts representing the observation medicine interest group and observation medicine section, respectively, from EMs two major specialty societies: the Society for Academic Emergency Medicine (SAEM) and the American College of Emergency Physicians (ACEP). The curriculum consists of didactic, clinical, and self-directed elements. It is longitudinal, with learning objectives for each year of training, focusing initially on the basic principles of observation medicine and appropriate observation patient selection; moving to the management of various observation appropriate conditions; and then incorporating further concepts of OU management, billing, and administration. This curriculum is flexible and designed to be used in both academic and community EM training programs within the United States. Additionally, scholarly opportunities, such as elective rotations and fellowship training, are explored.

A Comprehensive Acute Coronary Syndrome Algorithm for Centers With Percutaneous Coronary Intervention Capability

A comprehensive acute coronary syndrome (ACS) protocol was developed to improve the quality of care for patients admitted with definite or probable ACS. These protocols were constructed to streamline the practice for diverse clinicians who care for ACS patients across a variety of clinical settings. They are applicable in the emergency department, the cardiac catheterization laboratory, and the inpatient settings for hospitals with primary percutaneous coronary intervention capability. These protocols standardized the care by selecting the best therapy for each clinical scenario based on available established guidelines to insure the safest and highest value (quality/cost) medical care.