Observation Medicine: Providing Safe and Cost-Effective Care Beyond the Emergency Department

Christopher W. Baugh, MD, MBA, FACEP, Editor

R. Gentry Wilkerson, MD, FACEP, Editor

Observation units fill a ubiquitous need by providing a setting of care for patients not clearly requiring an inpatient admission to receive additional diagnostic workup or therapeutic intervention beyond the scope of a typical Emergency Department visit. Care for the patient with chest pain in whom the initial evaluation did not reveal a diagnosis and sufficient concern remained for myocardial infarction or ischemia was one of the earliest examples of observation care and remains the most common complaint encountered there today. More than three decades ago, chest pain units emerged to provide the right setting to continue care for these patients, reducing both avoidable admissions and inappropriate discharges. Since that time, the conditions routinely managed during an observation stay have multiplied, and continue to evolve as progressive clinicians search for novel conditions amenable to care in the observation setting. Patients with conditions previously cared for routinely in an inpatient setting now rarely need this level of care. Inpatient admission for hyperemesis gravidarum, migraine, asthma, transient ischemic attack, syncope, and many other similar conditions is becoming increasingly rare. Providers working with access to an observation unit can hardly imagine practicing without one.

This shift in care to observation units resulted from many trends, including payer policy changes, advances in diagnostics and treatments, improved understanding of pathophysiology, Emergency Department and inpatient crowding, and the pioneering work of early adopters, thought leaders, and mentors who have created and disseminated best practices for safe and efficient observation care. We are grateful for these individuals, many of whom have contributed to this special issue of Emergency Medicine Clinics of North America . They have led the way to demonstrate that an observation stay can reduce hospital length of stay and thus cost, while also improving patient satisfaction and protocol compliance without compromising quality and safety.

Observation care is more relevant today than ever before. Looking forward, we expect the use of observation care to continue to expand. In order to create value, this care needs to be delivered by providers who embrace the best practices of a dedicated unit and condition-specific protocols to guide patient care. Many questions remain about how to optimize care, and as our tools and understanding change over time, new opportunities will emerge for further investigation into how to provide optimal care. For example, the introduction of highly sensitive troponin assays in the United States will fundamentally change the Emergency Department evaluation of patients presenting with chest pain and the role that observation care plays in this population.

In addition, as new conditions are explored for observation care, they need to be studied to establish criteria for patient selection, evidence-based interventions, and specific criteria for safe discharge. Such deliberate plans will enable further shifts of eligible patients out of inpatient beds, avoiding unnecessary admissions while still providing patient-centered care. Payer policy will surely continue to evolve, incentivizing lower costs while still demanding high-quality outcomes. In such an environment, a well-run observation unit shines as a valuable asset for hospitals with sufficient Emergency Department visit volume to operate one.

We hope you find this compilation a comprehensive representation of the most current and enlightened thinking on the topic of observation medicine. We have organized this issue to give a general understanding of observation medicine and observation units followed by a series of articles that focus on specific diagnoses and organ systems. We want to inspire readers to establish or improve observation units in their own hospitals and intend this issue to serve as a valuable resource for that purpose.

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