This conference was a great investment of time. (I would include a link to the event so you could see who presented and the topics, but WRG has taken down the link and does not seem to list any past events.) Without exception, the speakers were knowledgeable and informative, conveying lots of good details and experience. This was the fifth year that WRG has produced this conference and a large number of attendees and presenters have participated in the event over the years. The continuity from repeat participation resulted in interesting observations and lessons-learned, based on changes over time.
Regardless of the motivation driving observation unit creation in a hospital, every hospital has observation patients. Because of their undeniable presence among your patient population, they cannot be avoided. Certainly improved management of observation patients has the potential to improve patient flow. But regardless of this potential, observation patients must be managed properly to ensure good outcomes – both clinically for the patient, and financially for the hospital. Recent reimbursement changes have increased the potential for negative financial outcomes with observation patients. A consensus among presenters was that observation patients managed in a dedicated obs unit were significantly better managed than observation patients placed in on-service care units throughout the hospital. Another key learning was that appropriate case management staffing levels are essential (and easily justified if you dig for the data) to avoid loosing your shirt with observation patients.
The practice of emergency medicine, for physicians and nurses, has changed over the past 10 years. The role of observation medicine has grown considerably – many ER docs and nurses still find observation medicine boring and look to swap assignments with others in triage or more acute care areas – but there is a growing acceptance and understanding of the observation role. At the same time, a growing number of hospitals are committed to getting observation right.
It struck me that the level of care delivered (not patient status) in most observation units is very similar to variable acuity units. Obs units tend to have a higher nurse to patient ratio than med surg, but less than the ratio in the ED. These specialized units also include patient monitoring capabilities and the observation of some pretty complex therapies like chemotherapy. Many of the same management and implementation challenges exist for both obs and variable acuity units – staffing skill mix, admissions requirements, and policies and procedures that are unique in the hospital. Many hospitals feel they lack the patient volumes to clearly justify dedicated obs units, despite patient flow problems. Why not create a unit that provides both observation care and variable acuity nursing?
Another topic that came up at the conference was the discharge lounge. The group reported, “I've never heard of a discharge lounge that worked.” And yet, the reasons described for past failures seemed, to this observer, to be implementation failures rather than an indictment of the concept itself. Creating new types of care delivery units of any kind in hospitals is hard – hence the value of a conference on observation units.
I also noticed at this conference a keen interest in other institution's policies, procedures, templates and guidelines – particularly as it relates to implementing a new policy or procedure at the requesting hospital. This is also a common request on the listservs that I subscribe to, the NPSF and biomed listservs. The delivery of health care is incredibly complex and highly variable from provider to provider. Other institutions' protocols, order sheets, policies and procedures are an interesting read, but their value is directly related to how closely your hospital's operations and environment (including providers and patient population) match those of the other hospital's – an unlikely coincidence in my experience.
There is no substitute for good needs assessment, planning, execution and ongoing active management; there is no “instant” observation unit kit to which a hospital can just add staff and a few hundred square feet to create an effective and profitable observation unit that will run itself. To me this is healthcare's greatest frustration and attraction – it's not easy playing Sherlock Holmes and helping solve Important Problems in the delivery of care, but it is what makes getting up the morning worthwhile.
Oh, by the way, you can buy a CD of all the presentations (except the pre-conference workshops like mine – those were charged for separately) from this conference. Go to this page, and select conference “HW707-01/22/2007 Optimizing Observation Pa, $150.00” from the drop down.