February Spotlight — Hospital Medicine: Observation status

 

Submitted by Colleen O’Connor, MD, Campus Lead, Lankenau HMS

 

As we all know, the challenge of observation status is here to stay. The designation of care in the hospital as inpatient vs. observation continues to be a challenge across all of our campuses, as well as on a national level.  It’s particularly challenging, as “observation” status is considered to be outpatient level care – a conundrum for clinicians previously accustomed to only two tiers of care: inpatient or outpatient!

 

The Centers for Medicare & Medicaid Services (CMS) defines observation status for hospitalized patients as a “well-defined set of specific, clinically appropriate services,” usually lasting less than 24 hours, that in “only rare and exceptional cases” should last more than 48 hours. One can easily see how this may be loosely interpreted with much variation in design and patient care. Within MLH, to help further define and improve our observation process, Hospitalist Medicine Services (HMS) has been closely allied with nursing and administration at each campus.

At Lankenau, we have a dedicated Observation Unit, operational since March of 2013.  We have learned much as the unit has expanded and closely follow trends and guidelines to help improve the process.  Input from multiple departments and providers has been instrumental along the way, and there is little doubt that shaping a successful Observation Unit has involved many contributors!

 

An inescapable fact has been the great variation in our approach toward management of common “observation appropriate” diagnoses.  Data collected thus far across our MLH campuses has proven this to be the case – particularly with resource utilization and length of stay.  Consistent with data gathered from other successful Observation Units, more protocol development leads to more expedited/appropriate care, shorter length of stay, and better outcomes.

 

In the process of building our Observation Unit, we have found that variation in care has necessitated more streamlined “protocols” for high frequency diagnoses.  Chest pain and syncope remain two of the most frequent diagnoses.

 

Our initial efforts at LMC to help minimize variation were aimed at developing a clinical pathway for the evaluation and triage of low risk chest pain. This has been quite successful in bringing to our attention the need for clear guidelines. As HMS cares for a high percentage of admitted medicine patients across all campuses, we have a direct investment in improving the overall process.  We believe our Low Risk Chest Pain Clinical Guidelines have helped us get closer to that goal of more streamlined, consistent care.  It has been shared with our other campuses in hopes of achieving more consistency.  Along with the development of this protocol has come a well designed method to track provider data and adherence – very interesting when comparing trends across campuses.

 

Next steps will focus on our approach to syncope.  This will involve reviewing national trends, gathering input from relevant subspecialists, as well as our Emergency Department colleagues, and our Utilization Management team to design a protocol that supports best practice and appropriate care.   We look forward to development of practical, evidence-based guidelines that can be shared across campuses, and further our goal of more consistent delivery of observation-level care.

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