In adults, respiratory disorders are the second most frequent diagnoses treated in emergency department observation units (EDOUs) and account for the most frequent indication for placement of pediatric patients into an EDOU. With appropriate patient selection, chronic obstructive pulmonary disease exacerbations, and community-acquired pneumonia can be managed in the EDOU. EDOU management results in equivalent or better outcomes than inpatient care with decreased length of stay, increased patient satisfaction, lower cost and in some studies decreased mortality. Evidence-based protocols are important to ensure appropriate patients are placed in the EDOU, standardize best practice interventions, and guide disposition decisions.
Key points
- •
Asthma, chronic obstructive pulmonary disease, and community-acquired pneumonia are the second most common category of diseases treated in an emergency department observation unit (EDOU).
- •
EDOU management of respiratory disorders is effective, efficient, safe, and less costly compared with inpatient care.
- •
Risk stratification ensures appropriate patients are placed in the EDOU.
- •
Use of condition-specific rapid diagnostic and treatment protocols and clinical pathways allow for standardizing care using evidence-based best practice.
Respiratory conditions are common complaints seen in the emergency department (ED). After initial ED evaluation, stabilization, and treatment, patients may require further testing or treatment. The ED observation unit (EDOU) offers an alternative disposition to inpatient admission for patients who require short-term monitoring, testing, and/or treatment. By using rapid diagnostic and therapeutic protocols, the vast majority of patients can be safely discharged home within 24 hours (or 2 midnights).
This article focuses on 3 respiratory conditions that are frequently managed in an EDOU: exacerbations of asthma and chronic obstructive pulmonary disease (COPD) and treatment of community-acquired pneumonia (CAP). Other authors discuss additional respiratory conditions such as congestive heart failure and pneumothorax elsewhere within this issue.
Asthma
Jennifer Andrews, a 35-year-old female asthmatic, complains of shortness of breath and wheezing for 2 days. Despite nebulizer therapy and oral corticosteroids in the ED, her peak flow measurement increases to only 200 L/min (personal best 400 L/min). Auscultation reveals persistent diffuse expiratory wheezing. She is placed in the EDOU, where she receives nebulized bronchodilator therapy. After 15 hours, her peak flow increases to 350 L/min and auscultation reveals only rare expiratory wheezing. Ambulatory pulse oximetry on room air is 98%. She is discharged with prescriptions for oral and inhaled corticosteroids. Follow-up with her primary care physician is arranged.
The Global Initiative for Asthma defines asthma as “a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation.” This common disease affects 7.0 million children and 18.7 million adults in the United States. In 2011, asthma accounted for 1.6 million ED visits and 27% (439,000) were hospitalized an average of 3.6 days (1.6 million hospital days). Asthma is one of the most common conditions managed in an observation setting for all ages.
The cost of asthma care in the United States increased to $56 billion in 2007 with the majority of cost owing to the cost of hospitalization ($50 billion). The average annual costs for an asthma-related hospital stay are estimated at $3600 per child and as much as $6600 per adult. Annually, asthma causes adults to miss 14 million days of work and children to miss 10 million days of school.
Evidence for Emergency Department Observation Unit Management of Asthma Exacerbation
The EDOU is ideal for asthma exacerbation care and offers many advantages to traditional admission. Because ED rescue therapy (eg, corticosteroids) may not reach full effect for up to 6 hours, the EDOU allows time for medications to achieve effect and for repeated clinical assessments so that final disposition can be made. This extended period of observation affords time for patient teaching and preventative treatments that may lead to decreased recidivism, admissions, morbidity, and mortality.
Numerous studies since the 1980s have demonstrated that treatment of adult and pediatric asthmatics in an EDOU avoids hospitalization, is cost effective, and is clinically beneficial with reduced morbidity and mortality. Prospective, randomized, clinical trials found greater patient satisfaction and perceived quality of life.
Despite evidence favoring EDOU use for asthma exacerbation, reports demonstrate that EDOUs continue to be underused. This is evidenced by large numbers of both pediatric and adult patients treated as inpatients during short-stay admissions.
Patient Selection
Patient assessment should include determination of risk factors, especially those for fatal or near-fatal asthma ( Box 1 ). Asthma severity can be classified as mild, moderate, or severe based on vital signs and physical examination findings. Scoring systems assess symptom severity and treatment response but do not assess the need for admission. Commonly used scores include the Pediatric Asthma Severity Score, Pulmonary Index Score, Pediatric Respiratory Assessment Measure, and RAD (respiratory rate, accessory muscle use, decreased breath sounds) score. Unfortunately, there is no one, widely accepted and sufficiently validated scoring system.
- •
Prior intubation
- •
Prior admission to the intensive care unit
- •
Frequent emergency department visits (≥3 per year)
- •
Frequent hospitalizations (≥2 per year)
- •
Recent steroid use
- •
Steroid dependence
- •
Significant comorbidities (eg, cardiovascular disease, other chronic lung disease, chronic psychiatric disease, etc)
- •
Limited access to health care
Emergency Department Observation Unit Care of Patients With Asthma Exacerbation
Protocols
The use of condition-specific protocols are a hallmark of EDOU management that provide an excellent opportunity for standardizing care using evidence-based best practice. Use of asthma protocols in the EDOU for adults and children shows numerous clinical and financial advantages compared with routine nonstandardized care ( Box 2 ).
Inclusion criteria
- •
Alert and oriented, acceptable vital signs
- •
Intermediate response to therapy – improving but still wheezing
- •
PEFR (peak flow) 40% to 70% predicted (or personal best) after β 2 agonists
- •
β 2 agonist nebulizers (2 treatments or 10 mg albuterol) + steroids given in ED
- •
Minimum ED treatment time greater than 2 hours
- •
Chest radiography, if done, with no significant acute findings (eg, pneumonia, pneumothorax, congestive heart failure, et.)
Exclusion criteria
- •
Unstable vital signs or clinical condition—severe dyspnea, confusion, drowsiness
- •
Poor response to initial ED treatment
- ○
Persistent use of accessory muscles, RR >40, or excessive effort
- ○
Elevated P co 2 (>50 mm Hg) plus decreased pH (<7.40) if ABG done
- ○
O 2 saturation of less than 92% on room air, unless documented chronic hypoxia
- ○
PEFR of less than 40% predicted or personal best
- ○
- •
Suspicion of acute coronary syndrome, new-onset congestive heart failure, or pneumonia
Potential interventions
- •
Serial treatments with nebulized β 2 agonist and ipratropium
- •
IV magnesium sulfate
- •
Frequent reassessment (every 2–4 hours)
- •
Systemic steroids (PO or IV)
- •
Pulse oximetry and oxygen with cardiac monitoring as needed
Discharge criteria
- •
Home ( Patient to be discharged on steroids , nebulizers , with follow-up and smoking cessation counseling , if relevant )
- ○
Acceptable vital signs: HR <100, RR <20 after ambulation (if able)
- ○
Pulse oximetry ≥95% on room air (or return to baseline)
- ○
Resolution of bronchospasm or return to baseline status
- ○
PEFR greater than 70% predicted (or 70% personal best) if reliable reading
- ○
- •
Admit
- ○
Progressive deterioration in clinical status or vital signs
- ○
Failure to resolve bronchospasm within 15 hours
- ○
Persistent PEFR less than 70% of predicted (if reliable)
- ○
Hypoxic despite therapy, if not chronic state
- ○
Abbreviations: ABG, arterial blood gases; ED, emergency department; HR, heart rate; PEFR, peak expiratory flow rate; RR, respiratory rate.
Patients suitable for the EDOU include those with low or moderate asthma severity who do not improve adequately with initial ED therapy or who cannot be safely discharged home owing to concerns about treatment adherence or follow-up. Patients at very high risk for poor outcomes may benefit from a period of observation regardless of initial response to therapy.
A study by McCarren and colleagues found patients achieving a peak expiratory flow rate of 40% or greater after 3 β-agonist treatments had high probability of EDOU discharge, peak expiratory flow rate from 32% to 40% had intermediate probability whereas rates of 32% or less had a low probability of discharge and therefore are not appropriate for EDOU placement and require inpatient care.
Emergency department observation unit interventions
Patients with asthma exacerbations placed in the EDOU require vital sign monitoring, including measurement of oxygen saturation and frequent clinical reassessments to gauge response to therapy. Pulse oximetry measurement during ambulation may provide information regarding response to treatment and aid in disposition decisions. Many patients being placed in an EDOU for an asthma exacerbation will have received a chest radiograph as part of the workup performed in the ED. Clinical judgment should be exercised to determine which patients require imaging. It should be strongly considered in patients with new-onset wheezing, indicators of pneumonia, and risk of other alternative diagnosis, as well as those patients who are either failing to respond to therapy or are worsening clinically despite therapy.
Patient education is important in the management and prevention of recidivism. Patients and caregivers should receive education regarding asthma medications, proper inhaler and peak flow meter use, smoking cessation if applicable, avoidance of asthma triggers, and treatment plan after EDOU discharge including close follow-up with a primary care provider.
Medical Treatments for Asthma Exacerbation
Short-acting β 2 agonists (SABA) are first-line medications for the treatment of asthma exacerbations. The most commonly used SABA is albuterol sulfate, administered via a nebulizer (‘wet’ form) or a metered dose inhaler with a holding chamber or spacer (‘dry’ form). For patients with nonsevere asthma exacerbations, SABA therapy via metered dose inhaler with a spacer is at least as effective as nebulized therapy and is considered by Global Initiative for Asthma as an efficient and cost-effective delivery method. A metered dose inhaler with a spacer is preferred in children with mild to moderate asthma. Levalbuterol, the nonracemic enantiomer form of albuterol, has not been shown to offer any significant advantages over albuterol. Its use may be considered in patients at risk for tachyarrhythmias or who have previously shown better tolerance to nonracemic enantiomer form of albuterol.
Short-acting anticholinergics, also known as short-acting muscarinic antagonists, such as ipratropium bromide, reduce bronchoconstriction through blockade of the cholinergic receptors. They are a useful adjunct to SABA, but are not effective as monotherapy. The combination of anticholinergics and SABA improves pulmonary function and reduces admission rates. The effectiveness of anticholinergic therapy has only been demonstrated in the acute setting. Continuation of anticholinergic therapy once a patient is hospitalized has not been shown to improve outcomes.
Systemic corticosteroids (CS), another first-line therapy, should be initiated in the ED and continued in the EDOU. CS reduce β 2 agonist therapy requirements and hospital admission rates, prevent relapses, and reduces overall mortality. Oral formulations have similar efficacy to intravenous (IV) and intramuscular routes and is the preferred route of administration in patients who can tolerate oral intake. Intramuscular and IV administration should be reserved for patients who do not tolerate oral intake. Patients placed in the EDOU should have CS therapy continued. The use of dexamethasone as the initial CS used in the ED may make additional doses of CS unnecessary. The data are limited, but there seems to be relatively similar rates of relapse for either single-dose or 2-day dosing dexamethasone as compared with a multiday course of prednisolone or prednisone. Other benefits of this approach are improved palatability, increased compliance, and parental preference.
Antibiotics are not recommended for routine exacerbations of asthma. Even in cases of an infectious cause of asthma exacerbation, viral infections are much more common than bacterial. In cases where there is radiographic evidence of pneumonia or other strong clinical indicators of a bacterial infection, antibiotics would be appropriate.
Patients requiring continued therapy with subcutaneous β 2 -agonists, IV magnesium sulfate, or epinephrine are likely poor candidates for an EDOU protocol and likely require hospital admission Table 1 .
| Medication | Pediatric Dose (≤12 y) | Adult Dose |
|---|---|---|
| Inhaled short-acting β 2 -agonists | ||
| Albuterol Nebulizer solution (0.63, 1.25, 2.5 mg/3 mL and 5.0 mg/mL) | 0.15–0.3 mg/kg up to 5 mg every 2–4 h as needed | 2.5–10 mg every 2–4 h as needed |
| Metered-dose inhaler (90 μg/puff) | 4–8 puffs every 2–4 h inhalation maneuver as needed. Use valve holding chamber; add mask in children <4 y | 4–8 puffs every 20 min up to 4 h, then every 2–4 h as needed |
| Levalbuterol (R-albuterol) | ||
| Nebulizer solution (0.63 mg/3 mL, 1.25 mg/0.5 mL, 1.25 mg/3 mL) | 0.075–0.15 mg/kg up to 5 mg every 2–4 h as needed | 1.25–5 mg every 2–4 h as needed |
| Metered-dose inhaler (45 μg/puff) | See albuterol metered-dose inhaler dosage | See albuterol metered-dose inhaler dosage |
| Systemic (injected) β 2 -agonists | ||
| Epinephrine 1:1000 (1 mg/mL) | 0.01 mg/kg up to 0.3–0.5 mg every 20 min for 3 doses subcutaneous | 0.3–0.5 mg every 20 min for 3 doses subcutaneous |
| Terbutaline (1 mg/mL) | 0.01 mg/kg every 20 min for 3 doses then every 2–6 h as needed subcutaneous | 0.25 mg every 20 min for 3 doses subcutaneous |
| Anticholinergics | ||
| Ipatropium bromide Nebulizer solution (0.25 mg/mL) | 0.25–0.5 mg every 2–4 h as needed | 0.5 mg every 2–4 h as needed |
| Metered-dose inhaler 18 μg/puff) | 4–8 puffs every 2–4 h as needed | 8 puffs every 2–4 h as needed |
| Systemic corticosteroids (Applies to all 3 corticosteroids) | ||
| Prednisone Methylprednisolone Prednisolone | 1–2 mg/kg given in divided dose BID (maximum 60 mg/d) until peak expiratory flow is 70% of predicted or personal best | 40–80 mg/d given once daily or BID in divided dose (maximum 80 mg/d) until peak expiratory flow reaches 70% of predicted or personal best |
| Dexamethasone | 0.6 mg/kg (maximum of 16 mg/d), 1 dose at discharge, and/or second dose the following day | 12–16 mg/d, 1 dose at discharge, and/or second dose the following day |
Disposition
Patients who fail to improve or worsen significantly require admission to an inpatient service. Patients are likely appropriate for discharge when there has been sufficient clinical improvement such that the patient has at most minimal symptoms and there are objective findings such as normal pulse oximetry and peak flow measurements. Patients should be educated about the plan for outpatient therapy, including systemic CS if required. If the patient is being discharged on prednisone the adult dose is 1 mg/kg/d (maximum dose of 60 mg/d) for 5 to 7 days. The pediatric dose of prednisone is 1 to 2 mg/kg/d (maximum dose of 40–60 mg) for 3 to 5 days. The patient should have a supply of a SABA rescue inhaler. Using a stepwise approach, the National Asthma Education and Prevention Program recommends the addition of controller medications in select patients. These may include inhaled corticosteroids and long-acting β 2 -agonists.
Asthma
Jennifer Andrews, a 35-year-old female asthmatic, complains of shortness of breath and wheezing for 2 days. Despite nebulizer therapy and oral corticosteroids in the ED, her peak flow measurement increases to only 200 L/min (personal best 400 L/min). Auscultation reveals persistent diffuse expiratory wheezing. She is placed in the EDOU, where she receives nebulized bronchodilator therapy. After 15 hours, her peak flow increases to 350 L/min and auscultation reveals only rare expiratory wheezing. Ambulatory pulse oximetry on room air is 98%. She is discharged with prescriptions for oral and inhaled corticosteroids. Follow-up with her primary care physician is arranged.
The Global Initiative for Asthma defines asthma as “a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation.” This common disease affects 7.0 million children and 18.7 million adults in the United States. In 2011, asthma accounted for 1.6 million ED visits and 27% (439,000) were hospitalized an average of 3.6 days (1.6 million hospital days). Asthma is one of the most common conditions managed in an observation setting for all ages.
The cost of asthma care in the United States increased to $56 billion in 2007 with the majority of cost owing to the cost of hospitalization ($50 billion). The average annual costs for an asthma-related hospital stay are estimated at $3600 per child and as much as $6600 per adult. Annually, asthma causes adults to miss 14 million days of work and children to miss 10 million days of school.
Evidence for Emergency Department Observation Unit Management of Asthma Exacerbation
The EDOU is ideal for asthma exacerbation care and offers many advantages to traditional admission. Because ED rescue therapy (eg, corticosteroids) may not reach full effect for up to 6 hours, the EDOU allows time for medications to achieve effect and for repeated clinical assessments so that final disposition can be made. This extended period of observation affords time for patient teaching and preventative treatments that may lead to decreased recidivism, admissions, morbidity, and mortality.
Numerous studies since the 1980s have demonstrated that treatment of adult and pediatric asthmatics in an EDOU avoids hospitalization, is cost effective, and is clinically beneficial with reduced morbidity and mortality. Prospective, randomized, clinical trials found greater patient satisfaction and perceived quality of life.
Despite evidence favoring EDOU use for asthma exacerbation, reports demonstrate that EDOUs continue to be underused. This is evidenced by large numbers of both pediatric and adult patients treated as inpatients during short-stay admissions.
Patient Selection
Patient assessment should include determination of risk factors, especially those for fatal or near-fatal asthma ( Box 1 ). Asthma severity can be classified as mild, moderate, or severe based on vital signs and physical examination findings. Scoring systems assess symptom severity and treatment response but do not assess the need for admission. Commonly used scores include the Pediatric Asthma Severity Score, Pulmonary Index Score, Pediatric Respiratory Assessment Measure, and RAD (respiratory rate, accessory muscle use, decreased breath sounds) score. Unfortunately, there is no one, widely accepted and sufficiently validated scoring system.
- •
Prior intubation
- •
Prior admission to the intensive care unit
- •
Frequent emergency department visits (≥3 per year)
- •
Frequent hospitalizations (≥2 per year)
- •
Recent steroid use
- •
Steroid dependence
- •
Significant comorbidities (eg, cardiovascular disease, other chronic lung disease, chronic psychiatric disease, etc)
- •
Limited access to health care
Emergency Department Observation Unit Care of Patients With Asthma Exacerbation
Protocols
The use of condition-specific protocols are a hallmark of EDOU management that provide an excellent opportunity for standardizing care using evidence-based best practice. Use of asthma protocols in the EDOU for adults and children shows numerous clinical and financial advantages compared with routine nonstandardized care ( Box 2 ).
Inclusion criteria
- •
Alert and oriented, acceptable vital signs
- •
Intermediate response to therapy – improving but still wheezing
- •
PEFR (peak flow) 40% to 70% predicted (or personal best) after β 2 agonists
- •
β 2 agonist nebulizers (2 treatments or 10 mg albuterol) + steroids given in ED
- •
Minimum ED treatment time greater than 2 hours
- •
Chest radiography, if done, with no significant acute findings (eg, pneumonia, pneumothorax, congestive heart failure, et.)
Exclusion criteria
- •
Unstable vital signs or clinical condition—severe dyspnea, confusion, drowsiness
- •
Poor response to initial ED treatment
- ○
Persistent use of accessory muscles, RR >40, or excessive effort
- ○
Elevated P co 2 (>50 mm Hg) plus decreased pH (<7.40) if ABG done
- ○
O 2 saturation of less than 92% on room air, unless documented chronic hypoxia
- ○
PEFR of less than 40% predicted or personal best
- ○
- •
Suspicion of acute coronary syndrome, new-onset congestive heart failure, or pneumonia
Potential interventions
- •
Serial treatments with nebulized β 2 agonist and ipratropium
- •
IV magnesium sulfate
- •
Frequent reassessment (every 2–4 hours)
- •
Systemic steroids (PO or IV)
- •
Pulse oximetry and oxygen with cardiac monitoring as needed
Discharge criteria
- •
Home ( Patient to be discharged on steroids , nebulizers , with follow-up and smoking cessation counseling , if relevant )
- ○
Acceptable vital signs: HR <100, RR <20 after ambulation (if able)
- ○
Pulse oximetry ≥95% on room air (or return to baseline)
- ○
Resolution of bronchospasm or return to baseline status
- ○
PEFR greater than 70% predicted (or 70% personal best) if reliable reading
- ○
- •
Admit
- ○
Progressive deterioration in clinical status or vital signs
- ○
Failure to resolve bronchospasm within 15 hours
- ○
Persistent PEFR less than 70% of predicted (if reliable)
- ○
Hypoxic despite therapy, if not chronic state
- ○
Abbreviations: ABG, arterial blood gases; ED, emergency department; HR, heart rate; PEFR, peak expiratory flow rate; RR, respiratory rate.
Patients suitable for the EDOU include those with low or moderate asthma severity who do not improve adequately with initial ED therapy or who cannot be safely discharged home owing to concerns about treatment adherence or follow-up. Patients at very high risk for poor outcomes may benefit from a period of observation regardless of initial response to therapy.
A study by McCarren and colleagues found patients achieving a peak expiratory flow rate of 40% or greater after 3 β-agonist treatments had high probability of EDOU discharge, peak expiratory flow rate from 32% to 40% had intermediate probability whereas rates of 32% or less had a low probability of discharge and therefore are not appropriate for EDOU placement and require inpatient care.
Emergency department observation unit interventions
Patients with asthma exacerbations placed in the EDOU require vital sign monitoring, including measurement of oxygen saturation and frequent clinical reassessments to gauge response to therapy. Pulse oximetry measurement during ambulation may provide information regarding response to treatment and aid in disposition decisions. Many patients being placed in an EDOU for an asthma exacerbation will have received a chest radiograph as part of the workup performed in the ED. Clinical judgment should be exercised to determine which patients require imaging. It should be strongly considered in patients with new-onset wheezing, indicators of pneumonia, and risk of other alternative diagnosis, as well as those patients who are either failing to respond to therapy or are worsening clinically despite therapy.
Patient education is important in the management and prevention of recidivism. Patients and caregivers should receive education regarding asthma medications, proper inhaler and peak flow meter use, smoking cessation if applicable, avoidance of asthma triggers, and treatment plan after EDOU discharge including close follow-up with a primary care provider.
Medical Treatments for Asthma Exacerbation
Short-acting β 2 agonists (SABA) are first-line medications for the treatment of asthma exacerbations. The most commonly used SABA is albuterol sulfate, administered via a nebulizer (‘wet’ form) or a metered dose inhaler with a holding chamber or spacer (‘dry’ form). For patients with nonsevere asthma exacerbations, SABA therapy via metered dose inhaler with a spacer is at least as effective as nebulized therapy and is considered by Global Initiative for Asthma as an efficient and cost-effective delivery method. A metered dose inhaler with a spacer is preferred in children with mild to moderate asthma. Levalbuterol, the nonracemic enantiomer form of albuterol, has not been shown to offer any significant advantages over albuterol. Its use may be considered in patients at risk for tachyarrhythmias or who have previously shown better tolerance to nonracemic enantiomer form of albuterol.
Short-acting anticholinergics, also known as short-acting muscarinic antagonists, such as ipratropium bromide, reduce bronchoconstriction through blockade of the cholinergic receptors. They are a useful adjunct to SABA, but are not effective as monotherapy. The combination of anticholinergics and SABA improves pulmonary function and reduces admission rates. The effectiveness of anticholinergic therapy has only been demonstrated in the acute setting. Continuation of anticholinergic therapy once a patient is hospitalized has not been shown to improve outcomes.
Systemic corticosteroids (CS), another first-line therapy, should be initiated in the ED and continued in the EDOU. CS reduce β 2 agonist therapy requirements and hospital admission rates, prevent relapses, and reduces overall mortality. Oral formulations have similar efficacy to intravenous (IV) and intramuscular routes and is the preferred route of administration in patients who can tolerate oral intake. Intramuscular and IV administration should be reserved for patients who do not tolerate oral intake. Patients placed in the EDOU should have CS therapy continued. The use of dexamethasone as the initial CS used in the ED may make additional doses of CS unnecessary. The data are limited, but there seems to be relatively similar rates of relapse for either single-dose or 2-day dosing dexamethasone as compared with a multiday course of prednisolone or prednisone. Other benefits of this approach are improved palatability, increased compliance, and parental preference.
Antibiotics are not recommended for routine exacerbations of asthma. Even in cases of an infectious cause of asthma exacerbation, viral infections are much more common than bacterial. In cases where there is radiographic evidence of pneumonia or other strong clinical indicators of a bacterial infection, antibiotics would be appropriate.
Patients requiring continued therapy with subcutaneous β 2 -agonists, IV magnesium sulfate, or epinephrine are likely poor candidates for an EDOU protocol and likely require hospital admission Table 1 .
Related posts:
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Care of Neurologic Conditions in an Observation Unit
Care of Infectious Conditions in an Observation Unit
Observation Medicine
Care of Neurologic Conditions in an Observation Unit
Care of Respiratory Conditions in an Observation Unit
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