http://intranet1.mountsinai.org/epic/ed/docs/SAMPLEObservation%20Status%20Exclusion%20Criteria.pdf
RETU-Observation Exclusion Criteria (Milliman Clinical Guidelines, 17th edition, 2013)
Abdominal Pain
• Peritoneal signs present
• Hemodynamic instability
• Absent bowel sounds with complete ileus
• Signs of intestinal obstruction
Alcohol Intoxication
• Delirium due to alcohol or sedative withdrawal
• Heart rate > 120 bpm
• Tremor
Asthma
• Ventilatory support required
• Peak expiratory flow rate < 25% of predicted or personal best before treatment
• Peak expiratory flow rate < 40% of predicted or personal best after treatment
• Oxygen saturation < 92%
• Hemodynamic instability
• Change in mental status
• Respiratory finding that is severe or persistent (eg, dyspnea, tachypnea, accessory muscle use)
Cellulitis
• Limb-threatening infection
• High-risk comorbid condition as indicated by 1 or more of the following:
o Cirrhosis
o Neutropenia
o Asplenia
o Immunosuppression
• Mental status changes
• Hemodynamic instability
• Suspected necrotizing soft tissue infection
• Orbital infection
• Cutaneous gangrene
• Compartment syndrome monitoring
Chest Pain
• Hemodynamic instability
• Pulmonary edema
• Respiratory distress
• Chest pain indicative of serious diagnosis other than coronary artery disease (eg, aortic dissection)
• Angina with acute coronary syndrome
Congestive Heart Failure (CHF)
• Hemodynamic instability
• Anasarca
• Precipitating cause for acute decompensation (eg, PNA, PE ) requires inpatient care
• Acute cardiac ischemia causing or associated with failure
• Pulmonary edema that is severe or worsening
• Cognitive impairment that is severe or persistent
• Acute renal insufficiency that is severe (reduction > 50% in estimated GFR from baseline) or progressive
Headache
• Lactate >4
• MAP < 65
• Immunocompromised
• Hemodynamic instability
Hyperglycemia
• Diabetic ketoacidosis as indicated by 2 or more of the following:
o Plasma glucose > 250 mg/dL
o Acidosis (eg, arterial pH < 7.30, serum bicarbonate level < 15 mEq/L (mmol/L))
o Moderate ketonuria or ketonemia
• Hyperglycemic hyperosmolar state as indicated by absence of acidosis and 1 or more of the following:
o Altered mental status (eg, lethargy, stupor, coma)
o Plasma glucose > 600 mg/dl
o Serum osmolality > 320 mOsm/kg
• Altered mental status
• Intractable nausea or vomiting
Back Pain / Limb Pain
• Cauda equina or conus medullaris syndrome as indicated by 1 or more of the following
o Bowel dysfunction
o Bladder dysfunction
o Saddle anesthesia
o Neurologic abnormality suggesting distal spinal cord impingement
• Progressive neurologic deficit
• Suspected spinal infection (eg, epidural abscess, vertebral osteomyelitis)
Pneumonia
• Hypoxia indicated by 1 or more of the following:
o Oxygen saturation < 90% while breathing room air
o Chronic lung disease with significant deterioration from baseline oxygenation
• Outpatient treatment failure as indicated by 1 or more of the following:
o Failure to respond to antibiotic (eg, resistant organism)
o Clinically significant adverse effects from medication (eg, vomiting)
o Complications of pneumonia (eg, empyema, bacteremia)
o Significant worsening of comorbid conditions necessitating inpatient care (eg, chronic heart failure)
• Hemodynamic instability
• Moderate-risk or high-risk category patients (Pneumonia Severity Index (PSI) class IV or V, or CURB-65 score of 3 or greater)
• Immunocompromised patients (eg, AIDS, chronic steroid use) at moderate or high risk based on clinical evaluation
Pyelonephritis
• Outpatient treatment has failed or is not feasible (eg, multidrug-resistant organism)
• Pregnancy beyond 24 weeks' gestation
• Hemodynamic instability
• Immunocompromised state (eg, AIDS, diabetes, sickle cell disease)
• Sepsis
• Condition that requires drainage procedure, including 1 or more of the following:
o Urinary obstruction
o Renal or perinephric abscess
o Emphysematous pyelonephritis
o Pyelitis
o Pyonephrosis
• Acute renal failure
Syncope
• Suspicion of imminently dangerous cause (eg, rare causes such as pericardial tamponade, pulmonary embolism)
• Hemodynamic instability that is severe or persistent
• Respiratory distress
• Neurologic signs or symptoms that are severe or persistent (eg, stroke, seizures, altered mental status)
• Continuous intravenous infusion of anticoagulation, platelet inhibitor, vasoactive, or antiarrhythmic medication