As more physicians become aware of the benefits of OU care for these patients, there has been a >9% increase in the number of OU patients in both 2003 and 2004, according to Medicare data. And the increased use is even more dramatic for CHF patients.
As one looks at the elements to design and staff a functioning OU, it is apparent this falls clearly in the hospitalist’s capabilities. The idea is to develop more than just a place to stay longer in the ED, but to create an evidence-based, cost-effective management solution for difficult patients. Key components would include:
- Criteria for admission and exclusion based on risk stratification models;
- Protocols for treatment using evidence-based practice guidelines;
- Clear discharge process supported by patient education materials and discharge criteria; and
- Performance standards and an ongoing data collection and quality improvement process.
CHF is an expensive condition to manage, fraught with frequent episodes of decompensation and admission. This takes an economic toll on the system and results in a poorer quality of life for those patients burdened with the disease. Because many physician offices are not set up to handle patients with increasing symptoms related to CHF, the ED becomes the treatment center of last resort. Thoughtful management of those patients correctly suited to OU care can lead to more directed treatment and avoid hospitalizations that are expensive to the system and unnecessary for the patient.
All data point to an increased prevalence of OUs as more hospitals develop them and more patients are treated in OUs. In addition, professional societies are establishing guidelines and criteria for the appropriate use of OUs for certain ED patients. At the same time, management of patients in the OUs and for the OU itself is evolving to the hospitalist, who is the expert in longitudinal management of the hospitalized (and near hospitalized) patient.
Once again the hospitalist is at the center of new initiatives that are a win-win-win. OUs can minimize the patient’s time away from home, improve their functional capacity, relieve congestion in the ED, allow the ED physicians to concentrate on true ED patients, uncrowd the hospital and the ED and improve throughput, and save the system money. And hospitalists with a plan can make this happen.
Not bad for a specialty that is still the new kid on the block. TH
Dr. Wellikson has been CEO of SHM since 2000.