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by Annabella V Salvador-Kelly and Nancy S Kwon and Matthew Wheatley and Type I and Type II and Type III and Type IV and Patient Evaluation and In general, patients with ongoing neurologic symptoms are not candidates for the OU These patients meet criteria for inpatient care, and often require extensive nursing care and consultation Although there are exceptions, most patients with new fixed neurologic finding have had a stroke or other insult and benefit from care on a stroke unit New inability to ambulate Altered mental status New neurologic findings (persistent) Patients receiving inpatient-type procedures, such as renal or liver biopsy Post-operative recovery Patients who meet inpatient criteria Geriatric patients represent an increasing population that presents to the ED Out of 136 million ED visits per year, more than 20 million are patients who are age 65 years and older5 Elderly patients who present to the ED often use more resources because they typically have complicated medical histories, are on multiple medications, and require more social services57 They are more likely to have depression, falls, and functional and cognitive impairment58,59 Cognitive impairment, such as dementia and delirium, accounts for up to 40% of geriatric patients59-61 These age-associated problems are often unappreciated by emergency physicians due to time constraints and lack of education62 The ED is often an infeasible place to perform such assessments because of the need to rapidly assess and treat patients An OU can be an appropriate setting to perform a more comprehensive geriatric screening assessment In one study by Foo et al, performing the geriatric screening identified serious unmet needs in more than 10% of patients in their study group63 The inability to identify their needs puts them at greater risk for premature discharge, adverse events, and readmission63 Geriatric assessments focus on investigating the patient’s medical, functional, and social status and can include fall risk, mobility and ability to perform activities of daily living, visual acuity, hearing assessment, and nutritional and swallowing evaluation63 Geriatric patients often are admitted to the hospital when the diagnosis is unclear or further monitoring is needed, but they can be more vulnerable to complications from hospitalization such as nosocomial infections, decubitus ulcers, deep vein thrombosis, functional decline, and other adverse outcomes18,64,65 OUs can be utilized to monitor and further evaluate the geriatric patient who presents with unclear presentations63,66,67 In one study by Ross et al, the most common diagnoses in elderly patients placed in an OU were chest pain (24%), dehydration (117%), syncope (65%), back pain (46%), and chronic obstructive pulmonary disease (38%)67 Compared to younger patients, the LOS and admission rate for these geriatric patients was higher67 OUs that provide this level of care for elders often have extensive resources, especially social work and care management In addition, an emergency pharmacist can be of great help in this setting, as many of these patients are on multiple medications Conditions in older adults to consider for exclusion to the OU include: likely need for placement in a skilled nursing or rehabilitation facility, failure to thrive, exacerbation of chronic problems, inability to ambulate, altered mental status, and a projected LOS of greater than 24 hours66 CMS requires a 3-day hospital stay prior to placement68 For Medicare beneficiaries, copayments are significantly higher for outpatient services, and placing geriatric patients in the OU may cause financial hardship68,69 The number of pediatric OUs in the nation is not reported on a national basis, but the literature and healthcare reform supports their increased utilization70 Limited data show that pediatric OUs exist in almost 39% of free-standing children’s hospitals, 39% of hospitals with separate pediatric wards, and approximately 4% of hospitals without pediatric wards71-73 Pediatric OUs are emerging as an alternative site of care for children with selected diagnoses Previous data have shown that pediatric patients often are hospitalized for brief durations74-76 Nearly one-third of pediatric admissions are hospitalized for 1 night or less76,77 ED visits for patients younger than 15 years account for close to 25 million visits per year, and for patients between 15-24 years, account for more than 22 million visits per year5 For these reasons, pediatric OUs are an ideal setting for monitoring serial physical examinations, awaiting consultations, and administering short courses of treatment78 The most frequent pediatric OU diagnoses include abdominal pain, allergic reactions, asthma, bronchiolitis, croup, dehydration, gastroenteritis, minor trauma such as head trauma, and toxic ingestions70,79 Children with painful vaso-occlusive sickle cell crisis may be admitted to the OU Macy et al attempted to summarize the literature on standard outcome measures for pediatric OUs79 The study found that the metrics for pediatric OUs are not clearly defined and are variable in the current literature79 These metrics included LOS, admission rates, return visit rates, and costs79 Prior data show that less than 25% of pediatric OU patients are converted to inpatient status79,80 The admission rate may vary depending upon the diagnosis Admission rates reportedly range from as low as 5% for croup and head injury, to approximately 50% for respiratory diseases such as asthma, pneumonia, and bronchiolitis2,70,75,79,81-83 Although the return visit rate is inconsistently defined, the rates range from 001% to 5%, with return time frames ranging from 48 hours to 1 month84-92 The OU presents a golden opportunity to educate patients on their disease processes and on preventive medicine Patients who can especially benefit include vulnerable patient populations such as the elderly, patients with poor access to healthcare and limited health literacy, and those with multiple risk factors for disease56,60 In a pilot demonstration project by Silverman et al, the OU was utilized to identify patients with previously undiagnosed dysglycemia using a HbA1C, initiate treatment and referrals, and educate patients about their disease56 As an extension of this project, diabetes champions were also identified and trained to become diabetes educators Limited literature exists regarding utilization of the OU to educate patients There is opportunity to expand education for diseases and high-risk behaviors that pose significant morbidity and mortality Some of these areas include education on smoking cessation, alcohol dependence, and chronic diseases such diabetes, hypertension, heart disease, and stroke 56,93-95 Such educational interventions can lead not only to improved knowledge, but also to increased satisfaction with their care96 OUs play a critical role in the care of selected patients presenting to the emergency department The most efficient OU is a Type 1 unit located in the ED OUs have many benefits, including improvement of patient care, management of hospital and ED overcrowding, increased patient satisfaction, decreased LOS, and cost effectiveness20 Observation medicine has become a specialized area of emergency medicine As OUs expand, observation medicine should become a required part of the emergency medicine curriculum The training for observation medicine is currently variable, although some data suggest that trainees view education in this area as a positive experience34,97 1 Medicare Benefit Policy Manual CMS, 2014 Accessed April 23, 2015, at http://wwwcmsgov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c06pdf 2 Silvestri A, McDaniel-Yakscoe N, O’Neill K, et al Observation medicine: The expanded role of the nurse practitioner in a pediatric emergency department extended care unit Pediatr Emerg Care 2005 and 21:199-202 3 ACEP State of the Art: Observation Units in the Emergency Department and May 2011 4 Medicare Processing Manual CMS, 2015 Accessed June 2, 2015, at http://wwwcmsgov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c04pdf 5 National Hospital Ambulatory Medical Care Survey 2011 Accessed July 30, 2015, at http://wwwCDCgov/NCHS/data/ahcd/nhamcs_emergency/2011_ed_web_tablespdf 6 Tang N, Stein J, Hsia RY, et al Trends and characteristics of US emergency department visits, 1997-2007 JAMA 2010 and 304:664-70 7 Pitts SR, Pines JM, Handrigan MT, et al National trends in emergency department occupancy, 2001 to 2008: Effect of inpatient admissions versus emergency department practice intensity Ann Emerg Med 2012 and 60:679-86 e3 8 Kellermann AL Crisis in the emergency department N Engl J Med 2006 and 355:1300-1303 9 Taylor J Don’t bring me your tired, your poor: The crowded state of America’s emergency departments Issue Brief George Wash Univ Natl Health Policy Forum 2006:1-24 10 Kocher KE, Meurer WJ, Fazel R, et al National trends in 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Medicine Practice Guidelines: Clinical characteristics and utilization of biochemical markers in acute coronary syndromes Circulation 2007 and 115:e356-375 44 Than M, Cullen L, Aldous S, et al 2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: The ADAPT trial J Am Coll Cardiol 2012 and 59:2091-2098 45 Reichlin T, Hochholzer W, Bassetti S, et al Early diagnosis of myocardial infarction with sensitive cardiac troponin assays N Engl J Med 2009 and 361:858-867 46 Jneid H, Anderson JL, Wright RS, et al 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/Non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines Circulation 2012 and 126:875-910 47 Meyer MC, Mooney RP, Sekera AK A critical pathway for patients with acute chest pain and low risk for short-term adverse cardiac events: Role of outpatient stress testing Ann Emerg Med 2006 and 47:427-435 48 Hackam DG, Kapral MK, Wang JT, et al Most stroke patients do not get a warning: A population-based cohort study Neurology 2009 and 73:1074-1076 49 Rothwell PM, Warlow CP Timing of TIAs preceding stroke: Time window for prevention is very short Neurology 2005 and 64:817-820 50 Roger VL, Go AS, Lloyd-Jones DM, et al Heart disease and stroke statistics — 2012 update: A report from the American Heart Association Circulation 2012 and 125:e2-e220 51 Nahab F, Leach G, Kingston C, et al Impact of an emergency department observation unit transient ischemic attack protocol on length of stay and cost J Stroke Cerebrovasc Dis 2012 and 21:673-678 52 Amarenco P, Goldstein LB, Szarek M, et al Effects of intense low-density lipoprotein cholesterol reduction in patients with stroke or transient ischemic attack: the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial Stroke 2007 and 38:3198-3204 53 Amarenco P, Bogousslavsky J, Callahan A, 3rd, et al High-dose atorvastatin after stroke or transient ischemic attack N Engl J Med 2006 and 355:549-559 54 Sirimarco G, Deplanque D, Lavallee PC, et al Atherogenic dyslipidemia in patients with transient ischemic attack Stroke 2011 and 42:2131-2137 55 Amarenco P, Labreuche J Lipid management in the prevention of stroke: Review and updated meta-analysis of statins for stroke prevention Lancet Neurol 2009 and 8:453-463 56 Silverman RA, Schleicher MG, Valente CJ, et al Prevalence of undiagnosed dysglycemia in an emergency department observation unit Diabetes Metab Res Rev 2015 57 Wilber ST, Gerson LW, Terrell KM, et al Geriatric emergency medicine and the 2006 Institute of Medicine reports from the Committee on the Future of Emergency Care in the US health system Acad Emerg Med 2006 and 13:1345-1351 58 Samaras N, Chevalley T, Samaras D, Gold G Older patients in the emergency department: A review Ann Emerg Med 2010 and 56:261-269 59 Hwang U, Shah MN, Han JH, et al Transforming emergency care for older adults Health Aff (Millwood) 2013 and 32:2116-2121 60 Hustey FM, Meldon SW, Smith MD, et al The effect of mental status screening on the care of elderly emergency department patients Ann Emerg Med 2003 and 41:678-684 61 Carpenter CR, Bassett ER, Fischer GM, et al Four sensitive screening tools to detect cognitive dysfunction in geriatric emergency department patients: Brief Alzheimer’s Screen, Short Blessed Test, Ottawa 3DY, and the caregiver-completed AD8 Acad Emerg Med 2011 and 18:374-384 62 Biese KJ, Roberts E, LaMantia M, et al Effect of a geriatric curriculum on emergency medicine resident attitudes, knowledge, and decision-making Acad Emerg Med 2011 and 18 Suppl 2:S92-S96 63 Foo CL, Siu VW, Tan TL, et al Geriatric assessment and intervention in an emergency department observation unit reduced re-attendance and hospitalisation rates Australas J 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Emergency Medicine Reports, ISSN 0746-2506, 04/2016, Volume 37, Issue 8
Authors Annabella V. Salvador-Kelly, MD, FACEP, Associate Medical Director, Long Island Jewish Medical Center; Attending Physician, Department of Emergency... 
Medicine | Heart failure | Pediatrics | Medical imaging | Nuclear magnetic resonance--NMR | Physicians | Emergency services | Emergency medical care | Patient satisfaction | Asthma | Geriatrics
Journal Article
Annals of Emergency Medicine, ISSN 0196-0644, 2006, Volume 48, Issue 4, pp. e417 - e426
Journal Article
Journal of Emergency Nursing, ISSN 0099-1767, 2006, Volume 32, Issue 5, pp. 370 - 381
Journal Article
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