running an obs unit

[MSmentor018]

anyone here running ED obs units?
I went though the whole sermon the other day by my CMG....not really sure about it
was hoping someone had advice, thoughts...etc
thanks

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[deleted109597]

anyone here running ED obs units?
I went though the whole sermon the other day by my CMG....not really sure about it
was hoping someone had advice, thoughts...etc
thanks

My thoughts, especially if it's your CMG.
"Hey, can you do extra work, that we get extra money for, doing things you weren't trained in? Sure, we'll *pay* you for it"

Inpatient medicine is best performed by inpatient docs.

 

[MSmentor018]

My thoughts, especially if it's your CMG.
"Hey, can you do extra work, that we get extra money for, doing things you weren't trained in? Sure, we'll *pay* you for it"

Inpatient medicine is best performed by inpatient docs.

the concepts and the numbers seem to work, although i think it's the ancillary services is what makes it really tick.
if every IM guy admitted a pt for obs, hospital services give them priority (radiology, cards, consults...etc) then they'd have a rapid d/c rate too
I think you just summed it up.

 

[dotcb]

My department tried an obs unit. It fell on its face in less than a year. We've let the corpse lie and no one is thrilled to resurrect it.

 

[Psai]

I do enough obs by watching the drunks and the druggies, everyone else can be watched by the midlevels upstairs.

 

[shoal007]

My thoughts, especially if it's your CMG.
"Hey, can you do extra work, that we get extra money for, doing things you weren't trained in? Sure, we'll *pay* you for it"

Inpatient medicine is best performed by inpatient docs.

incorrect. at the MCEP Obs conference right now.

its been shown in literature that observation units run by EPs are more likely to get guideline care, shorter stay, lower recitivisitum, and have higher satisfication.

its not really rocket science but as an obs director, im biased. my shop has significant incentive for observation admissions. the intermediate group, ie cannot go home, cannot be admitted, are great obs unit candidates that let you go home and sleep.

if you want to get into admin, its a great option that will be only growing in the future secondary to reimbursement pressures.

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[shookwell]

I agree. It's the way of the future. Some patients are better off being observed by the ED if they only need simple workups or therapy. Good way to get your foot in the door if you are interested in admin. Around here a lot of people who did EM/IM training and didn't end up in critical care are getting into starting or running obs units.

 

[goodoldalky]

IMO this is a no brainer. We run several obs units at different hospitals. We also capture the billing for this work, and most of it is done by midlevels off of protocols. When you put an obs unit in there's an immediate improvement in every productivity / throughput metric in your main ED. Total win win.

 

[deleted77919]

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[shoal007]

I can see how an obs unit can be nice.

I however, hate ours. It seems to be a dumping ground for patients our hospitalists don't feel like admitting. "Hey that nursing home patient with HCAP, and worsening anemia with a hemoglobin of 7, well, no admission criteria... why don't you just put her in your obs unit." Or the chest pain, shortness of breath missed dialysis patient with a positive trop.

Our unit is run by PAs who will do most of the work, but ultimately the poor physician who is working the next day gets their name on the discharge stuff for these patients.

having clearly defined criteria for observations can and will avoid these issues. i agree neither one of these patients would be admitted to our edou.

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[shookwell]

I however, hate ours. It seems to be a dumping ground for patients our hospitalists don't feel like admitting. "Hey that nursing home patient with HCAP, and worsening anemia with a hemoglobin of 7, well, no admission criteria... why don't you just put her in your obs unit." Or the chest pain, shortness of breath missed dialysis patient with a positive trop.

Our unit is run by PAs who will do most of the work, but ultimately the poor physician who is working the next day gets their name on the discharge stuff for these patients.

Having worked in hospitals that have it both ways, I agree, it's extremely annoying when the hospitalist can push patients onto ED obs who should really be admitted.

If you are setting up a new obs unit/protocol, I would strongly encouraging you to set it up so that it's the ED doc who makes the decision on obs vs. admit or ED obs vs. hospitalist obs. This should be clearly written in the protocol. It's ok for the hospitalist or internist to ask whether you want to put the patient on obs but the ED doc has the patient in front of them and should have the final say.

 

[deleted77919]

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[WilcoWorld]

My department tried an obs unit. It fell on its face in less than a year. We've let the corpse lie and no one is thrilled to resurrect it.

Can you identify factors that led to failure?

The Obs fails I saw at my previous jobs mostly fell into 2 categories:

1 - Obs'ing patients for one thing found on ROS (chest pain), then completely ignoring the other complaints that the patient actually came in for (dyspnea).

2 - Lazy docs treating Obs as a clinical indecision unit - essentially passing the liability to the discharging doc rather than figuring out the case on first pass.

 

[MSmentor018]

running the numbers an obs unit is obviously lucrative....for somebody. is it salary, hourly...etc? what's the pay range?

 

[shoal007]

as a director i get administrative pay each month decreasing my total shifts without effecting my salary.

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[MSmentor018]

as a director i get administrative pay each month decreasing my total shifts without effecting my salary.

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hmm, I'll bring that concept up.
but are you on call 24/7? or do u pull shifts/supervise in obs?

 

[deleted109597]

incorrect. at the MCEP Obs conference right now.

its been shown in literature that observation units run by EPs are more likely to get guideline care, shorter stay, lower recitivisitum, and have higher satisfication.

its not really rocket science but as an obs director, im biased. my shop has significant incentive for observation admissions. the intermediate group, ie cannot go home, cannot be admitted, are great obs unit candidates that let you go home and sleep.

if you want to get into admin, its a great option that will be only growing in the future secondary to reimbursement pressures.

Sent from my VS986 using Tapatalk

Oh, I get it. It's a goldmine if you run an FSED. And the hospital makes money off if it for sure. However, in a hospital, it is simply another case of someone else not doing their job good enough, and the ED has to make up for it. There's no reason a well educated internist couldn't run an obs unit to guidelines. I'm sure if you look at sepsis bundles with direct admissions vs ED admissions it's the same.

On the flip side, Medicare/Medicaid patients hate it, because it costs them a ton.

 

[shoal007]

Oh, I get it. It's a goldmine if you run an FSED. And the hospital makes money off if it for sure. However, in a hospital, it is simply another case of someone else not doing their job good enough, and the ED has to make up for it. There's no reason a well educated internist couldn't run an obs unit to guidelines. I'm sure if you look at sepsis bundles with direct admissions vs ED admissions it's the same.

On the flip side, Medicare/Medicaid patients hate it, because it costs them a ton.

Incorrect. Copay for Medicare admission is $1288. For a observation admission its 20 percent of total bill. Although administered meds will get charged up the wazoo. Most people obs admission is cheaper. Hit total out of pocket yearly, yes obs more costly.


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[shoal007]

hmm, I'll bring that concept up.
but are you on call 24/7? or do u pull shifts/supervise in obs?

We have 24/7 APP coverage, the EP supervises and is available to discuss cases. We have a small Ed obs unit, <10 beds.


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[Greenbbs]

Our ED keeps the obs unit under our wing but it's staffed by IM trained observational medicine people. It's fantastic! Once they leave the dept, they're out of our hair, however, we are their backup for when someone crashes.

 

[Psai]

Our ED keeps the obs unit under our wing but it's staffed by IM trained observational medicine people. It's fantastic! Once they leave the dept, they're out of our hair, however, we are their backup for when someone crashes.

This is genius

 

[MSmentor018]

We have 24/7 APP coverage, the EP supervises and is available to discuss cases. We have a small Ed obs unit, <10 beds.

as a director i get administrative pay each month decreasing my total shifts without effecting my salary.

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we're approaching it in a similar fashion. what I don't get is, with decreased total shifts do see pts on your off days? or do you purely take call at home in case the pa has questions?

 

[shoal007]

we're approaching it in a similar fashion. what I don't get is, with decreased total shifts do see pts on your off days? or do you purely take call at home in case the pa has questions?

i dont do either. I perform administrative duties only. the EP in the ED provides direct care. i take care of complaints, education, protocols and staffing issues (nursing, APPs).

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[Greenbbs]

This is genius

You have no idea. There is a list of exclusions (positive trop, active GI bleed, neutropenia fever, etc, need for peritoneal dialysis, etc). But, if we need to do a 2 trop rule out, we give them an initial HEART score, then they re evaluate the patient and will decide whether they need just a second trop or provocative testing. I can get more done this way.

However, the best part is that we have nothing to do with the unit unless someone turns south. They have their own attending/APP staff and function completely independent of the ED, even though they're technically run by us.

 

[MSmentor018]

I can see how an obs unit can be nice.

I however, hate ours. It seems to be a dumping ground for patients our hospitalists don't feel like admitting. "Hey that nursing home patient with HCAP, and worsening anemia with a hemoglobin of 7, well, no admission criteria... why don't you just put her in your obs unit." Or the chest pain, shortness of breath missed dialysis patient with a positive trop.

Our unit is run by PAs who will do most of the work, but ultimately the poor physician who is working the next day gets their name on the discharge stuff for these patients.

so who's liable if something is done wrong, ie; no med given on d/c, change of med that causes harm, you don't fully address additional complaints....etc.
exactly what are you co signing anyways? you don't see the pt right? so if they go home and it's not appropriate do you call them back?

 

[deleted77919]

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[MSmentor018]

Presumable the DC physician is liable. They want us to see everyone prior to DC and attest the PAs discharge note with a "Rounded with PA such and such on Ms. So and so. Agree with plan to discharge patient blah blah blah."

If we don't want to send them home we can make them consult the hospitalists who can write a note about how they still don't want to admit the patient.

In some cases we bend the rules and keep them up to 48 hours if we really can't get a safe dispo but that is often just kicking the can.

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now that actually makes sense. so you're pretty much going in daily kinda like pulling a shift. at my shop from what i am seeing in the guidelines it's totally PA protocol driven, don't see the pt, sign off on their chart and "physically round every monday morning and call in twice daily".

 

[deleted77919]

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[MSmentor018]

This is during our regular ER shifts. There's a PA over there and we have to swing by and see the patient before DC. The patients get signed out from shift to shift from ED doc to ED doc.

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oooooh that's the part I couldn't figure out. I don't think that would work at our shop. we have 15 beds on the other side of the hospital....that could lead to a long sign out.
wait, so how do you get paid for this? seems like a chunk of your shift time is devote to this plus increased liability

 

[deleted77919]

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[TrumpetDoc]

However, the best part is that we have nothing to do with the unit unless someone turns south. They have their own attending/APP staff and function completely independent of the ED, even though they're technically run by us.

Does this structure allow you to bill for the obs? I was under the impression that ED obs units can't double collect for the ED and the Obs.
Talking with a doc at ACEP last year he said something to the affect of his group forming a whole different "group", an obs medical groups, that was simply their own peeps and their shifts in obs were paid from this new group.

 

[WilcoWorld]

The person who places the patient in obs gets the RVUs associated with the admission. The discharge doc gets nothing. It is a really fair and we'll designed process.

Ha-ha! You're being sarcastic, right?

It raises a good point - one should get minimal credit for admitting a patient to an ED Obs unit, and maximal credit for dispositioning a patient from an Obs unit.

 

[MSmentor018]

Does this structure allow you to bill for the obs? I was under the impression that ED obs units can't double collect for the ED and the Obs.
Talking with a doc at ACEP last year he said something to the affect of his group forming a whole different "group", an obs medical groups, that was simply their own peeps and their shifts in obs were paid from this new group.

obs is basically a shell game for billing and yes we the ED group bill for obs...and it's per hour !!! (commercial insurance only, govt insurance is bundled)
they told us as long as the same doc that admitted isn't the same one that is in obs, it's ok to double bill because the pt is considered a different "status".

The person who places the patient in obs gets the RVUs associated with the admission. The discharge doc gets nothing. It is a really fair and we'll designed process.

ouch! all the liability, work and no pay