No Obs Unit

[EpiShock]

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My residency hospital has an awesome and large obs unit. This makes me worried, because having obs feels like having a safety net. If you're working out in the boonies, what do you guys end up doing with the syncope patient that you don't feel safe enough to discharge, or that chest pain who isn't sick enough for the cath lab, but probably isn't safe enough to discharge for follow-up within 72 hours.

 

[BoardingDoc]

My residency hospital has an awesome and large obs unit. This makes me worried, because having obs feels like having a safety net. If you're working out in the boonies, what do you guys end up doing with the syncope patient that you don't feel safe enough to discharge, or that chest pain who isn't sick enough for the cath lab, but probably isn't safe enough to discharge for follow-up within 72 hours.

Admit them.

 

[Janders]

"observation is a status not a location"

which means you can put them into observation status on the hospitalists' service on the medical ward!

Also, despite a true lack of dedicated space, we do keep a limited number of patients in ED obs in our shop. Useful for the elderly fall down weak crowd--- get PT and CM on board first thing in the AM, and you can have home services set up or a realistic transfer to an acute rehab, etc. Need buy in from the hospital side to do this, and space is an issue-- we can only eat a couple beds doing obs before we feel it.

 

[Arcan57]

My residency hospital has an awesome and large obs unit. This makes me worried, because having obs feels like having a safety net. If you're working out in the boonies, what do you guys end up doing with the syncope patient that you don't feel safe enough to discharge, or that chest pain who isn't sick enough for the cath lab, but probably isn't safe enough to discharge for follow-up within 72 hours.

Even without a dedicated obs unit that you can still send people upstairs under an "observation with outpatient services" status. While cohorting them allows for faster turnover (especially with DRG specific protocols) from the hospital side, plenty of hospitals without an obs units admit a decent percentage of their patients to observation status.

 

[The White Coat Investor]

I've worked in 12 different EDs in my career. None of them had a dedicated obs unit. You can obs them in the ED on your "service" (signing them out partner to partner each shift) or you can admit them to obs status on the hospitalist's service. I would say my situation is normal and yours is abnormal. You'll adapt and be fine.

 

[xaelia]

I would say my situation is normal and yours is abnormal.

SNAFU.

 

[shookwell]

Admit them or keep them in the ED. No administrator can make you discharge someone you don't want to. Most internists/hospitalists understand the situation and will work with you, and if they don't, they can come discharge the patient.

 

[Siggy]

Most internists/hospitalists understand the situation and will work with you, and if they don't, they can come discharge the patient.

I don't get it. Assuming anything short of stupid (No, the 35 year old landscaper with trapezius tenderness and pain that radiates down his left arm for 5 days is not a chest pain equivalent with his TIMI of 0 and negative trop), I think I've never seen a hospitalist attempt to block a chest pain admit. Similarly, knowing that cardiac syncope carries up to 33% annual mortality rate, syncope admissions should also be a slam dunk for a day of cardiac monitoring. The only question between atypical chest pain and syncope is which one is easier to admit from a hospitalist perspective.

 

[gman33]

You will be fine.
Don't d/c stuff that you are not comfortable discharging.
If there is no OBS unit, OBS them to the normal admitting team.
More and more stuff is becoming an "OBS" case anyway.

Having an OBS unit isn't always great anyway, especially if it's a separate service.
OBS vs hospitalist will fight over who is stuck with certain cases and you will be stuck in the middle.
You are better off in most cases if the hospitalist service also deals with OBS.

 

[emergentmd]

My residency hospital has an awesome and large obs unit. This makes me worried, because having obs feels like having a safety net. If you're working out in the boonies, what do you guys end up doing with the syncope patient that you don't feel safe enough to discharge, or that chest pain who isn't sick enough for the cath lab, but probably isn't safe enough to discharge for follow-up within 72 hours.

I live by a simple rule in EM medicine. I should always go home not worried about a patient. So If I am concerned, admit or CT something.

No.... I am not an admit everything doc. I actually am more on the risky side. But everyone has their risk limit. If you feel like you are pushing against said limit, Admit/CT/Do something.

Having an Obs unit in the ED is no different than doing an Obs admit in the hospital..

 

[MSmentor018]

obs is just a shell game, another way to bill the pt. they're still occupying a bed, using hospital services, requiring housekeeping, RN, dietary...etc.
don't let terminology change your thinking. if you want them admitted, admit. let the admitting doc call it whatever status they want

 

[deleted109597]

Obs units are abused as clinical indecision units. Well, I don't want to d/c them,so send them to the other doc to do it...

 

[Petypet]

can't decide units

 

[Apollyon]

can't decide units

You got it before I did. We had a CDU - a "clinical decision unit", a/k/a the "can't decide unit", at one of the hospitals where I used to work.

 

[gutonc]

Obs units are abused as clinical indecision units. Well, I don't want to d/c them,so send them to the other doc to do it...

Isn't that what admitting them to the hospitalist is?

 

[deleted109597]

Isn't that what admitting them to the hospitalist is?

Sometimes.
Lots of people out there don't like making decisions. The hospitalist who argues with the admission sometimes pan-consults and watches people for days for the same reason. It happens.

 

[deleted109597]

Isn't that what admitting them to the hospitalist is?

Sometimes.
Lots of people out there don't like making decisions. The hospitalist who argues with the admission sometimes pan-consults and watches people for days for the same reason. It happens.

 

[engineeredout]

Sometimes.
Lots of people out there don't like making decisions. The hospitalist who argues with the admission sometimes pan-consults and watches people for days for the same reason. It happens.

It's tough when they get admitted, even for obs.

When 90 year old grandma gets obs because she "doesn't feel right", she gets evaluated by PT who states she's too weak to get around by herself and is too big of a fall risk. Care management finds out she lives at home alone. Takes a day to get in contact with family. Family doesn't want to take here home. Attempt to arrange subacute rehab/SNF. Her insurance will only cover two in the area. Family takes another day or two to decide on which one. Said rehab doesn't have a bed available at that moment. Grandma gets delirious overnight - ends up medicated, CTs, more labs, neuro eval, etc...

Not saying that the ED doc is originally wrong for bringing Grandma in - we do what we have to do. It's just not always easy to rapidly turn these people around. 35 YO with -trops and -stress? Sure. 90 year old granny? Not so much

 

[bravotwozero]

The can't walk patients are the most difficult to dispo in my experience. I get more pushback from hospitalists for this than anything - particularly if the cause isn't immediately apparent. The patients family will throw a fit storm if you even so much as suggest the possibility of next day pcp follow up.


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[Everglide]

That patient meets admission criteria all day.... Can basically admit anyone over age 85 without any c/o lol (not that we should)

It's tough when they get admitted, even for obs.

When 90 year old grandma gets obs because she "doesn't feel right", she gets evaluated by PT who states she's too weak to get around by herself and is too big of a fall risk. Care management finds out she lives at home alone. Takes a day to get in contact with family. Family doesn't want to take here home. Attempt to arrange subacute rehab/SNF. Her insurance will only cover two in the area. Family takes another day or two to decide on which one. Said rehab doesn't have a bed available at that moment. Grandma gets delirious overnight - ends up medicated, CTs, more labs, neuro eval, etc...

Not saying that the ED doc is originally wrong for bringing Grandma in - we do what we have to do. It's just not always easy to rapidly turn these people around. 35 YO with -trops and -stress? Sure. 90 year old granny? Not so much