Cardiology, Cardiology, Improving Outcomes, Improving Throughput, Mythbusting, Pulmonary, Pulmonary, Twelve Trials of Christmas!

Day Five of Christmas- where’s the Obs EBM?

Welcome to the Twelve Trials of Christmas series on EMinFocus!  This is the fifth of twelve posts in a series where I ramble on various topics for which I would love to see an EM study done.  I’ve taken morsels of prior studies (case series, small trials, etc) and highlight reasons on why I believe this study would benefit EM.  Some may pan out, some may not.  All of them I would be highly interested in assisting with in any way possible to continue to advance our fine specialty.

I believe that the longer a patient stays in the hospital, the more likely they are to develop new and exciting pathology (pulmonary emboli, VRE, general deconditioning, an unhealthy affinity for tuna sandwiches, etc).  t’s not that I want to throw people out so to so to speak, it’s that their risk of developing hospital acquired badness is higher than their risk of adverse outcome from their diagnosis (like, say, low / no risk chest pain).  As such, I’ve recently taken an affinity towards our observation unit to see which, if any, of the classically admitted COPD’ers / CHF’ers, etc, can be placed in observation for <24 hours (actually need to be there), and do well.

We need to see some studies for who is a candidate for observation – and perhaps some data on why ED providers put no risk chest pain and other similar low yield findings in observation. There is little to no data on observation units, despite over a third of hospitals in the US having them.  Despite guidelines for observation, there are few evidence based guidelines.  We know that increasing age is associated with an increased rate of admission from observation status (about 26% vs 18 %); and there are also cellulitis guidelines for observation units, but that is about it.  While there are Ottawa guidelines for admission for CHF and COPD, and the famous PORT scores, these rules were designed to identify low risk patients, not necessarily those that needed a day or two in the hospital.

 So, perhaps, much like we have recently begun to risk stratify PE’s into going home and being lysed, so we will have to do the same for utilization of observation & inpatient resources.  What delineates which patients in the grey area between obvious discharge home and ICU admission can go to observation – not just the ED provider saying “yeah, they look ok for observation” – some actual evidence that suggests the patient can be turned around in under 24-36 hours.  I suspect for CHF, we’ll see that most of these patients, once properly cared for in the ED (cough, nitro nitro nitro, cough), can go to observation, which will likely surprise most ED & inpatient providers – thus, hopefully decreasing the risk of hospital acquired badness for these patients.


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