| Observation Centers (OCs) – What are they and Why Build One? Diagnostic Observation Centers (DOC) are rooms in or adjacent to EDs designed for treating patients who have specific symptoms of specific diseases such as chest pain, asthma, and abdominal pain. These centers are commonly referred to as observation centers, chest pain units or diagnostic observation centers. Mike Ross MD, a leader in the field of observation medicine, calls the units “a dedicated area within and under the direction of the Emergency Department where patients are managed to determine the need for admission.” Currently, 50% of hospital inpatients are admitted through the Emergency Department (ED) and approximately 10% of ED patients need 6-24 hours of post ED care. The goal of observation medicine is to safely treat an incoming patient in this 24 hour window. This frees the hospital to admit only those patients who are in critical need of care. These 6-24 hour patients are considered “the lost patients of medicine” because they fall somewhere between needing to be admitted and being ready for discharge. Pressures of staffing shortages, hospital overcrowding, increasing claims of medical malpractice and higher needs for insurance company and government compliance force ED physicians and nurses to discharge patients who may need care or admit them when they may only need less expensive treatment for shorter periods of time. The patients are important to hospitals’ bottom lines for many reasons which include: - Payers historically do not pay for these patients as they usually do not qualify for reimbursement.
- Over 6 billion dollars per year is spent to treat patients free of acute disease
- In the case of chest pain, more than 25,000 patients annually are misdiagnosed in the ED
- EDs are having problems with overcrowding and hospitals are running at over capacity. According to the Lewin Group, over 60% of all hospital EDs are over capacity.
- The aging population is another reason there are more people coming to EDs. In fact, in 2000, Medicare paid hospitals one percent less than the cost of treating Medicare
All of these factors lead to a disturbing and significant shift in patient care to the outpatient setting. The negative effects of a wave of medical malpractice suits and increased medical errors have been brought to the forefront in the last ten years leaving hospitals in a financial bind. They cannot afford to admit these patients since insurance won’t reimburse their expenses. Combine that with the problems of overcrowding, and there’s a significant chance those people will be misdiagnosed and released, thereby increasing the risk of malpractice. Observation centers are a growing trend in EDs but hospitals are having issues managing the patients that come to their centers. With the passage of new reimbursement codes, hospitals have to make a shift in how they manage these patients. For example, the Joint Commission for Hospitals (JCAHO) and the Center for Medicare and Medicaid Services (CMS) require a different set of reporting requirements for handling observation patients. The following table outlines the new requirements and how they impact the hospital: | Process | Impact | | Medical Decision Making – also called “Inclusion / Exclusion” criteria | The hospital must correctly document why they transferred the patient to Observation status. This set of criteria differs for each disease | | Clinical Course in the Unit | The hospital must follow a consistent care pathway for each patient. | | Discharge Summary | Hospital must discharge correctly out of the observation center. Requirements differ from a normal ED based discharge | | Time Reporting | Hospitals must document additional times to prove the patient met the appropriate guidelines for observation. | What Can Observation Technologies Do For You? We specialize in observation center design and development for emergency departments (EDs) and hospitals. Unlike traditional auditing and compliance consultants, we provide solutions to chest pain and other disease presentations through a ‘pathway’ approach tailored specifically to your institution. Strategies are targeted to maximize efficiency, reduce cost and risk, and increase throughput. Our experience in designing observation systems have resulted in the following benefits: - Resource reduction: A ‘evidence based’ systematic approach to chest pain provide guidelines for physicians to provide the highest standards of care.(1) Included are faculty lectures on coding, compliance, and risk reduction. We can show your physicians, nurses, and administration how to save money while delivering a greater standard of care. OT has designed over 40 disease specific care pathways to manage nearly all short term acute disease presentations.
- Risk reduction: After implementing chest pain algorithms designed by the team from Observation Technologies, the University of Maryland in Baltimore reduced the missed AMI rate from a mean national average of 4 to 14% to 0.23% with no AMIs discharged.
- Improved Efficiency and Lower Costs: Resulted in a 40% reduction in costs for moderate risk chest pain versus inpatient observation medicine and using 80% less resources than the ICU and CCU. This process significantly reduced AMI exclusion rates while reducing the coronary syndrome detection rate from 23.1 to 17 hours.(2) More than 82% of chest pain patients were managed and discharged from the ED while the higher risk patients were place into the hospital. (Hermann hospital, Houston, TX) This approach resulted in an annual realized gain of $496000 emergency department profit in the emergency department with a projected hospital revenue increase of $3.3 million. Overall costs to manage all chest pain dropped by 14%.
- Contract Negotiations: Negotiating managed care contracts improve by demonstrating reduced time to disposition and cost, while providing a higher standard of care for contracted patients. This program especially benefits capitation plans and Medicare recipients.
- Satisfaction: Consultant (cardiologist, FP, IM), patient, ED physician and staff.
How Can OT Improve Your Operations? We provide evaluation and management solutions to common presentations in the emergency department. Our consultants develop a site-specific three phase approach to manage chest pain and other common presentations. Disease management pathways are customized specifically for your hospital based on recent standards of care and site specific resources. This approach ensures consistent management standards resulting in reduced through-put times in the ED, improved documentation compliance, better quality assurance tracking, and reduced cost. Below is a sample consultation schedule for chest pain. 1. Initial consultation phase: Site Review 1.1. On-sight presentation discussing the benefits of observation medicine to the department and hospital. Answer questions regarding time commitment, billing, resource utilization, and cost containment in the emergency department. 1.2. Physical plant review with brief interview of staff and ancillary personnel. Start data collection on process flow, chart documentation, and ancillary services to establish site development phase and rapid improvement list 1.3. Prepare a rapid improvement list: a list of recommendations for immediate and short term improvements to present system of management. Return review within 28 days. 1.4. Initiate chart review and analysis for medical standards and charting compliance. Present efficiency reports identifying weaknesses in coding and documentation. 2. Site Development Phase: 2.1. Site review for common delays in evaluation and management of chest pain. 2.1.1. Create advisory list to enhance present system for evaluation and management. 2.1.2. Develop goals for service improvement. Prepare emergency department chest pain management strategies using site specific hospital resources, technologies, and personnel. Create goal execution timeline for department compliance. 2.2. Develop observation pathways or streamline existing approaches to management tailored to your institution. Create site-specific timelines for ancillary personnel such as registration, ECG and radiology. Provide standard orders for nursing. Design targeted history and physical forms for physicians. 2.3. Audit 3 to 5 days of chest pain presentations (25 to 50 chest pain charts) 2.3.1. Present confidential medico-legal risk profile. Prepare recommendations for risk reduction. 2.3.2. Prepare transcript identifying weaknesses in charting and coding along with recommendations. Return within 30 days of receipt of copies. 3. Continued performance phase 3.1. Period site reviews and performance reports to monitor progress and further enhance productivity and throughput in the ED 3.2. Prepare monthly progress reports that include coding and resource rating, risk reduction rating, and cost savings. 3.3. Develop customizable tracking database for payor/ resource mix, follow-up quality assurance, physician standards of care auditing, or other data to suit your needs. 3.4. Develop and employ a compliance template for JCAHO, SCPCP, and other governing bodies One proven solution to these problems is the effective Observation Medicine practiced in ED based Diagnostic Observation Center (DOC). Physicians utilize observation units to monitor patients that are on the border of qualifying for either imminent discharge or potential admission. Also, hospital administrators see benefits from the implementation of such a system. Having a designated space for these patients inside the hospital has many financial and clinical benefits to hospitals and their patients highlighted below: | Fewer Inappropriate discharges | Inappropriate discharge for chest pain patients from the ED is the highest risk of litigation for the emergency department. Up to 30% of people who have heart attacks (MI’s) exhibit none of the traditional risk factors | | Shorter Length of Stay | LOS can be reduced from 3 days to less than 24 hours for and the discharge rate from a DOC is typically over 80% - this means more patients can be safely discharged at much lower costs! |
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