How to Enhance Observation Medicine Without Adding Staff

by | Aug 9, 2022

Every day, clinicians face the difficult decision of when to admit patients, when to send them home, and when to keep them in observation. So often, the choice is made to keep the patient in observation whether it is warranted or not. Since patients in observation are typically located throughout the system, there is often ambiguity around who owns the patient, making the decision even more challenging.

One approach that is gaining traction is creating a central observation unit (COU) where all patients in observation can be cared for in a single location by a consolidated team of observation medicine experts. Research shows that COUs lead to shorter lengths-of-stay (LOS) and reduced costs, saving hospitals billions each year.[1]

The question becomes how to staff and manage these units without bringing on personnel or adding to existing clinicians’ already hectic load. The answer for many is to partner with a hospitalist provider group to supply high-quality advanced practice providers (APPs) to manage the unit.

Recent research on the cost-effectiveness of PAs alone found that they delivered “the same or better care outcomes as physicians with the same or less cost of care.”[2] In 15 of the 39 studies included in the research, the PA delivered care equal to that of the physician, and in 18 studies, the PA delivered care that exceeded that of the physician.

Knowing where to begin in creating a COU and finding a hospitalist partner can be challenging. First and foremost, when choosing a partner, look for one that focuses on training. Developing high-performing APPs requires comprehensive training that includes mentorship, supervision, and ongoing support. Make sure the partner you choose uses training that consists of both didactic and clinical components. These comprehensive programs, which often last for several months, provide tremendous value for even the most experienced APPs. This is critical since the quality of your COU is in direct alignment with the quality of your APPs.

It’s also important to make sure the hospitalist group you choose understands the importance of collaborative, multi-disciplinary care. The most effective COU should include weekly meetings with the entire care team, including the nurse manager, director of the observation unit, charge nurses, and managers. This type of collaboration is essential for process improvement and the best outcomes.

The next step is to make sure you’re using evidence-based protocols. For example, while traditional benchmarks call for 15-hour LOS, 24-hour LOS better meet the needs of patients who aren’t quite sick enough to be admitted but likely aren’t ready to go home. This is the patient-centric “kind way” of doing observation medicine while still being cost-conscious.

The third step is to make sure you’re employing the most appropriate inclusion/exclusion criteria such as: LOS greater than eight hours but less than two midnights; further workup or medication is required and/or diagnosis not yet established; no symptomatic vital sign abnormalities; and the patient is age 18 years or older. The best hospitalist partners will be able to help you establish the most appropriate criteria for your patient population.

Finally, it’s important that you’re tracking and sharing the right metrics. These should include your hourly LOS, inpatient conversions, daily census, and the use of consultants. This information should be communicated to everyone on the COU care and management teams and should be used to help drive decision-making and process improvement.

Kasey Schnebly, DNP, CRNP, CPHQ, Director of Quality at Adfinitas Health says, “Succeeding in observation medicine is a fine balance of following rules and inclusion/exclusion criteria, while utilizing the resources and providers that are readily available.” She continues, “An observation mindset is critical to success. Observation units cannot be run like any other unit in a hospital.”

The journey forward
Research shows that protocol-driven observation medicine can lower costs, improve outcomes, increase efficiencies, and enhance the patient experience.[3],[4] Hospitals dealing with staffing shortages don’t have to wait to create a more effective observation medicine program. Creating a COU staffed by high-quality APPs is a great place to begin.