Observation

ED observation is utilized extensively for multiple types of patients:

Many of our ED care protocols (DKA, cellulitis, chest pain, etc) have defined observation pathways. These can be referenced under “Important Info” on the dashboard.

Admission requests will be placed for patients undergoing ED observation with “CDU observation” selected as the location instead of inpatient admission. Admission orders through Main-POE must also be completed. Make sure each patient has their home medications written for at the time of admission. For our psych patients, however, we typically await our ED psychiatrist consultants to recommend the necessary standing medications while they are in the ED.

General Approach

The general approach for the Team 3 Morning attending, otherwise known as the "Obs attending", is to re-evaluate and safely discharge patients, such as alcohol intoxication, as soon as possible to make beds available before the morning rush begins around 11am. Conduct a re-evaluation carefully, as there have been instances where the initial team missed something that the Obs attending picked up during the subsequent day.

Physical Therapy/Case Management

Our hospital physical therapists and ED case managers arrive in the hospital at 7am. Hospital physical therapy leaves by 5pm, while our ED case manager has their office in the ED and typically does not leave until 10-11pm. Thus, many patients will be in observation overnight after a traumatic injury for Physical Therapy to arrive in the morning to evaluate the patient's mobility and make a decision about rehabilitation vs home PT. Our case manager will then work on getting the patient dispositioned to the appropriate facility. These patients are typically signed out as "waiting for PT/Case Management". When you inherit them in the morning, it is wise to make sure the patient gets their PT evaluation in a timely manner,\ and to touch base with our case manager about their progress in securing a rehab facility.

Charting on Observation Patients

Each observation patient must have an observation chart completed for each 24 hours that they are in the ED.  Generally, that means that the Obs attending must write an observation note for every Observation patient that is signed out to him or her in the morning.

Stress Testing

A patient can obtain several types of stress tests in observation, including an exercise treadmill test (ETT), stress echo, and nuclear stress test (sestamibi stress test or "stress mibi"). An ETT is generally adequate for patients who can run on a treadmill and have no prior changes in their EKG which would make the testing EKG uninterpretable. Certain patients who cannot walk or have baseline EKG changes may be better served with a stress mibi. There are inclusion and exclusion criteria for types of stress tests listed on Important Information.

Stress mibi's typically cannot be obtained on weekends or holidays. However, there may be up to 2 spots available and you can page Ernie Gervino to see if one of these is available. Occasionally, ETTs cannot be obtained on holidays and this will be communicated via email.

Patients can and should take their home beta-blockers even on the day of their stress test as this mimics real life and helps validate the stress test as a mimic of what they will do on discharge home (per Dr. Grossman).

The ED attending caring for the patient is responsible for following up the results of the stress test, which can be checked under WebOMR (hospital note system) -> Reports -> Cardiovascular. If the stress test results are equivocal or ischemic, you should consult cardiology for further assistance and risk stratification.

Consults on Observation Patients

As the Observation attending, many patients will be signed out to you in the morning pending a re-evaluation by a consulting service. It is always good to re-page the service in the morning to make sure they are indeed intending to re-evaluate the patient.