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ER Observation Unit Reduces Length of Stay 8 Hours

Analysis  |  By Christopher Cheney  
   May 03, 2018

For emergency room patients, a Maryland hospital's new observation unit has lowered length of stay and reduced admission of patients to inpatient care.

A new observation unit at Carroll Hospital in Westminster, Maryland, designed to treat patients for stays less than 48 hours has reduced its length of stay by more than eight hours and lowered the rate of patients transferring to inpatient care from 33.9% to 12.3%.

In 2016, the observation unit was given a wing in the 168-bed hospital. Three factors contributed to the unit's development: a well-designed set of inclusion and exclusion admissions criteria, dedicated staffing, and a tight working relationship with ancillary services.

"We didn't want to randomly select people for observation status; we wanted to have evidence-based criteria. We established the criteria based on certain diseases and certain conditions that we knew were typically short stays," says Kim Baker, PA-C, director of hospitalist and ICU services.

In August 2016, gaining the designation as a closed unit helped ensure that patients were appropriately placed in the observation unit. "Once we closed the unit and put the inclusion and exclusion criteria in place, we decreased our inpatient conversion rate from about 33% before we closed the unit to around 12%," Baker says.

Admissions decisions for the observation unit are made by the attending emergency room physician, a hospitalist from the observation unit, and a case management staffer.

"It should be a closed unit because you can control your metrics better. It's more than outcomes metrics. With the inclusion and exclusion criteria, you have dedicated people in the observation unit who understand exactly what is going on in the unit and understand how it needs to be run," she says.

Although hospitalists rotate through the observation unit, most of the staff are dedicated nurses and physician assistants. The nursing staff has been an essential component in the development of the observation unit, Baker says.

"We needed to have dedicated observation nurses. We needed nurses who understood the process of moving patients through quickly, getting testing done quickly, and discharging quickly. It's a totally different mindset than inpatient status," she says.

The 22-bed unit operates seven days per week, with full staffing from 7 a.m. to 7 p.m. There is hospitalist and nursing coverage overnight rounding every 4 hours. Average full staffing includes:

  • 1.5 clinicians
  • Two case managers
  • Patient-to-nurse ratio of 6:1 or 5:1

Developing strong relationships with ancillary services—particularly laboratory testing—has been a key factor in the efficient operation of the observation unit, Baker says.

"Short of the emergency department or an emergency test, our unit gets testing priority over everything else in the hospital. The goal is that testing and reporting gets done quickly, so we can either order more testing or be ready to discharge the patient," she says.

Shortening stay

Moving quickly and sound decision-making are primary factors that shorten a patient's length of stay in the observation unit, Baker says.

"The way we keep length of stay down is by seeing the patient quickly, ordering appropriate and prioritized testing, and making decisions with swiftness based on testing or whether the patient needs treatment," she says.

Timeliness is essential for the clinicians working in the observation unit, she says. "You have to monitor your time: rounding frequently, engaging the nurses to be more proactive, and making sure you are communicating well with the ancillary staff and case managers."

Another key to lowering length of stay is judicious use of specialist consults. "That keeps your length of stay down because the consultants are not always in the hospital during the day. Even if they are trying to prioritize your patients, they often can't because they are usually seeing their outpatient-practice patients," she says.

Limiting consultations and lab testing is done without compromising quality, Baker says. "We make sure we are practicing based on best practices. We are not over-testing and we are not under-testing just because we are worried about length of stay."

From August 2016 to February 2018, length of stay in the observation unit has fallen from 29.0 hours to 20.7 hours.

Cost control

The observation unit is generating a positive return on investment, including helping the LifeBridge Health hospital avoid readmissions penalties, Baker says. "Making sure the patients are being treated appropriately and not coming back to the hospital has huge return on investment," she says.

Personnel has been the highest cost in operating the observation unit, but staffing with a relatively high number of physician assistants and nurse practitioners has helped curb spending, she says. "To keep costs down, physician assistants and nurse practitioners are fabulous."

Christopher Cheney is the CMO editor at HealthLeaders.

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