Health policy and clinical practice/original researchThe Recidivism Characteristics of an Emergency Department Observation Unit
Introduction
It is estimated that 31% of US emergency departments (EDs) either have or are planning an observation unit, and 81% of emergency medicine residencies have or are planning an ED observation unit.1, 2 These units manage ED patients beyond their initial ED visit to determine their need for inpatient admission. For most patients, this serves as an alternative to either inpatient admission or management under “observation status” in an inpatient bed. These units are often managed by emergency physicians using protocol-driven care.1, 3, 4, 5 Several studies of care in the ED observation unit have demonstrated improved health care outcomes for adults and children, such as lower costs, decreased length of stay, improved hospital resource utilization, improved patient satisfaction, and better diagnostic performance.4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 A measure commonly used to assess ED observation unit performance is hospital return visit rate, or recidivism.6, 12, 21 If patients are efficiently managed yet prematurely discharged, only to return and be admitted, then the efficiency benefit is less meaningful. Recidivism rates of other groups, such as ED patients and Medicare Fee-for-Service inpatients, have been studied.22, 23, 24 However, recidivism rates for ED observation unit patients have been studied only for selected patient groups, and the recidivism characteristics of an ED observation unit have not been reported to our knowledge.4, 6, 25 The purpose of this study is to describe the recidivism rates of patients discharged from an ED observation unit that manages several conditions and to examine whether rates differ according to patient demographics or clinical subgroups.
Section snippets
Selection of Participants and Data Collection
This prospective observational cohort study took place during a 6-month period (January 1 to June 30, 2002) in the ED observation unit of a high-volume suburban teaching hospital. We chose to sample a 6-month period on the assumption that it would allow us to capture at least 50 index visits for our 10 most common ED observation unit conditions during 14 days. With an estimated 10% return rate, this method would lead to reviewing at least 5 return visits, the minimum number we believed would be
Results
During 6 months there were 55,727 ED visits, with 4,348 (7.8% of ED census) patients admitted to the ED observation unit and 80.7% (3,509) being discharged from the ED observation unit (Figure 1). These 3,509 ED observation unit discharge visits (made by 3,369 unique patients) formed the population of index visits for our study. Descriptive statistics for these index visits were as follows: mean age 56.9 years (SD 19.5 years), 40% men, and mean length of stay 15.0 hours (SD 6.0).
Of the 3,509
Limitations
This study has several inherent limitations. First, it represents the experience of a single institution with a specific type of ED observation unit, one that is managed by emergency physicians and protocol driven. It is not clear how these results might apply to other observation settings. As such, these findings should be validated in other ED observation unit settings. We did not examine return visits of admitted ED observation unit patients, because the focus was whether discharged ED
Discussion
We found that 7.9% of patients discharged from a protocol-driven ED observation returned within 14 days for symptoms related to their index visit, and 46% of these patients were subsequently admitted. Most returns were for related conditions and were clustered within the first week after discharge, suggesting that a 7-day audit may capture the majority of related returns. Unrelated returns were less common and did not show the same temporal pattern that related revisits did. With the exception
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Cited by (40)
The feasibility of emergency department observation units in the management of mild to moderate hyponatremia
2024, American Journal of Emergency MedicineThe Impact of Virtual Care in an Emergency Department Observation Unit
2023, Annals of Emergency MedicineCitation Excerpt :A 30-day recidivism data was not available for this study and was not included. Prior studies have shown that 30-day recidivism rates among EDOU patients are comparable to or superior to patients managed in an inpatient setting.17,18 Patient and provider satisfaction and experience were not studied but have been reported in similar settings.18-20
The impact of emergency department observation units on a health system
2021, American Journal of Emergency MedicineBeyond observation: Protocols and capabilities of an Emergency Department Observation Unit
2019, American Journal of Emergency MedicineCitation Excerpt :A 30 day return rate of 16.8% is better than that reported for overall ED patients at other academic emergency departments (22–23%) [18,19]. We did not locate any studies that reported 72-hour return rates for Obs Units, however, Ross et al. studied 14-day return rates for an Obs Unit and observed that many return visits occurred within the first 3 days following discharge [16]. Previously reported 72-hour return rates for the entire ED population range between 1 and 15% depending on the hospital and patient population, which is consistent with our return rate of 5.3% for observation unit patients and comparable to our non-Observation ED patient population (6.2%) [20,21].
Management of dyspepsia—The role of the ED Observation unit to optimize patient outcomes
2018, American Journal of Emergency MedicineAdditional Conditions Amenable to Observation Care
2017, Emergency Medicine Clinics of North AmericaCitation Excerpt :Vaso-occlusive crises requiring care beyond the initial ED visit are likely to require greater than 15 to 18 hours recommended for EDOU cases. In addition, painful conditions most frequently require hospital admission from the EDOU or lead to ED recidivism.28 Meeting with stakeholders from internal medicine and hematology is essential before undertaking an EDOU protocol.
Please see page 35 for the Editor's Capsule Summary of this article.
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Supervising editor: Donald M. Yealy, MD
Author contributions: MAR and KS conceived and designed the study and were involved in data collection and validation. CC obtained institutional review board approval. MAR, RRH, JA, KS, and CC were involved in data analysis and article preparation. All authors were involved in final article revisions. MR takes responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.
Publication date: Available online March 29, 2010.
Reprints not available from the authors.