We have one at BIDMC. We are putting them into our community hospitals. When well run, they are wonderful. When badly run, they are a nightmare.
First I agree that you need to be paid for the work of caring for these patients. Without that, just say no. However, this should not be too difficult. Hospital subsidation for low payor mix hospitals is standard. If the payor mix is good, billing for the professional work is very good.
It is absolutely something you want to control. Do not to hand over the control of an observation unit to internal medicine. Every IM obs unit I have seen has very effective admission criteria to acheive their #1 goal: "Do as little work as possible". When you try an admit a patient to an IM Obs unit, the admitting MD will find that they are either too well or too sick. Obs works when the access is easy with minimal paperwork, no painful hand-offs, and an easy quick discharge process.
A CDU allows EM physicians to deliver low acuity inpatient care with great patient satisfaction, low cost, record short lengths of stay, and good margin for the hospital. It helps mitigate crowding by allowing you to protect the inpatient beds you need by keeping the easier and less acute patients in obs. And, unlike with crowding, you get to bill for the services. If your payor mix isn't horrible, it can be very lucrative as well.
Not doing this as the health care crisis worsens is quite risky. The payors are forcing more and more inpatients to be classified as observation. This badly hurts the hospital's bottom line. By building a successful observation unit, the ED can gain political strength by improving the hospital's bottom line and serving as a more effective gate keeper.
The real danger of the CDU is that it becomes a "Can't Decide Unit" for some of our providers. There need to be some basic rules and a mechanism to hold providers accountable to avoid this:
1. Only EM physicians can admit to this unit.
2. Patients admitted to the CDU must have a greater than 85% chance of being discharged within 24 hours and a plan to be admitted if not discharged within that time frame.
3. A clear plan before admtting to obs and a simple patient with little needs that so the discharge is quick, safe and easy.
4. Because the hospital will staff the unit with much higher patient/nurse ratios, the nursing needs of these patients must be limited (patients should be able to ambulate, communicate easily, and not require frequent checks).
Happy to provide more details, samples of admission packages, observation protocols, and billing information, if you need it. Feel free to IM me.
