The Institute of Medicine, in its report “Hospital-Based Emergency Care – At the Breaking Point,” has identified Observation Units (OUs) as a “particularly promising” technique to improve patient flow.1 Many hospitals across the country either already have them or are in the process of establishing such units.
Multiple studies have shown that a highly efficient OU can save billions in health care costs.2 Historically, such units have existed within and are staffed by emergency departments. Since the implementation of the two-midnight rule in Oct. 2013, the complexities of observation care changed dramatically from run of the mill 30- to 40-year-old chest pain patients to 80- to 90-year-olds with multiple comorbidities being placed in observation.3 In many cases, this shifted the care out of the emergency department and into the arena of hospital medicine.
Dr. Bela Nand
OUs are traditionally managed either by emergency medicine or hospitalists. SHM, in a white paper, concluded: “Collaboration between hospitalists, emergency physicians, hospital administrators, and academicians will serve not only to promote outstanding observation care, but also to focus quality improvement and research efforts for the observation unit of the 21st century.”4
At our institution OUs are staffed by internal medicine residents supervised by faculty 24/7 year round. This, we believe, is a unique model. We implemented our model after a mini SWOT (strengths, weaknesses, opportunities, and threats ) analysis in August 2014. The biggest strength was that we were educating the next generation of “Observationists” as we improved the quality of care delivered to our patients. Our biggest opportunity was no existing curriculum for teaching internal medicine residents the art of observation medicine. So we designed our own. Just like Peter Drucker said, “The best way to predict the future is to create it.”
The curriculum is extremely innovative and exposes our residents to both the business and administrative aspect of OUs. Upon surveying our own residents anonymously within 6 months of instituting this rotation, over 90% felt this to be a valuable rotation towards their training. Since we went live, some of our residents who have graduated are now leading OUs at other hospitals.
To measure our program outcomes, we developed a dashboard with multiple metrics for our team. With such data, this rotation became an incubator for our residents for quality improvement projects. They have developed, implemented, and published multiple abstracts, presented posters and even won the first place for innovation at the Midwest Regional Society of General Internal Medicine conference.5-8
We have learned many lessons, and every challenge has been addressed as an opportunity. The first lesson was that we needed strong physician leadership to act as the gatekeeper to the unit. Second, as the rotation matured, we always kept our focus on high-quality patient care; we created a quality dashboard which includes length of stay, falls, and patient satisfaction as examples. Last but not least, we stayed mindful of stakeholder buy in, which for us was primarily our residents. We created the curriculum that provides the next generation of internists the broad experience of medicine, with the appropriate amount of autonomy and supervision. This, we believe, is a win-win proposition for all stakeholders – hospitals, physicians, residents, and most importantly the patients we serve. Additionally, data at our institution shows that our resident-run units are educationally, clinically, and financially beneficial to the residency programs and the hospitals.
Teaching and exposure to observation medicine is not currently a mainstay in many internal medicine residency programs. Our program provides a framework to establish an observation medicine rotation, which exposes residents to quality metrics and expands their scope of medical education.
Dr. Nand is medical director, care management & observation unit, and associate program director, internal medicine residency program, at the University of Illinois College of Medicine/Advocate Christ Medical Center.
References
1. “Hospital-Based Emergency Care: At the Breaking Point” (Washington: National Academies Press, 2006) 2. Baugh, CJ et al. “Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year” Health Aff (Millwood). 2012 Oct;31(10):2314-23
3. Fact Sheet: Two-Midnight Rule. 2015. Available at www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-07-01-2.html. Accessed March 29, 2016.
4. Society of Hospital Medicine. The observation unit white paper. http://www.hospitalmedicine.org, April 3, 2013.
5. Yousuf T. et al. “Intermediate chest pain protocol in an observation unit” Won first place award for innovation at the Midwest Regional SGIM conference, August 2015.
6. Sarfraz S et al. “Hand hygiene intervention increases compliance in observation unit” Poster: May 2016, Macy Midwest GME Conference, Michigan.
7. “Impact of syncope protocol in an observation unit of an academic tertiary care center” Poster for Oct 2016 AAIM skills development conference, National Harbor, Md.
8. Metgud S et al. “Integrating residents in providing high-value care via improved results of the ACGME annual resident survey” Poster: May 2016, Macy Midwest GME Conference, Michigan.