Patients receiving observation services can fall through the cracks and stay in the hospital longer than necessary if there’s not a way for the treatment team to easily distinguish between them and admitted patients.
“Hospitals need to have a good process in place so everyone on the healthcare team knows which patients are receiving observation services so they can ensure that they get the tests and procedures they need done in a timely manner with the physician to decide whether to admit them or discharge them,” says Linda Sallee, RN, MS, CMAC, ACM, IQCI, director for Huron Healthcare with headquarters in Chicago.
The best solution is to place observation patients in a dedicated unit, but when that’s not possible and observation patients are scattered all over the hospital, Sallee suggests developing some kind of process so the staff can quickly identify them, such as a sticker on the chart, a sticky note or notice in the electronic medical record, or a note on the white board in the patient’s room.
Make sure that the case managers understand the difference between observation and an inpatient admission and that they stay on top of it, says Beverly Cunningham, RN, MS, consultant and partner at Oklahoma-based Case Management Concepts.
She recommends that case managers make observation patients their top priority every day and collaborate with the admitting physicians to determine if the patient should be admitted or should be discharged as early in the shift as possible.
If your hospital has daily rounds, point out the observation patients, how long they have been in the hospital, and the fact that a decision has to be made to discharge them or admit them as inpatients, she says.
“Case managers need to be focused on observation patients to make sure that decisions are being made so they can move along,” she says. Sallee recommends that case managers see observation patients at least twice a day to see if they are progressing and help get them either admitted or discharged.
“If observation patients meet inpatient criteria and their status isn’t changed to inpatient in a timely manner, there is the potential for patients not to qualify for the three-day inpatient stay necessary for Medicare to cover a nursing home stay. The three-day period doesn’t begin until the inpatient order is written,” Sallee says.
The best solution is to have a dedicated observation unit or clinical decision unit and put all observation patients in one place where the staff can focus on them, Cunningham says. “When observation patients are placed on a busy unit, their status sometimes gets overlooked by nurses, doctors, and case managers. When they’re all in one place, everyone has the same focus to move them along,” Cunningham says.
Sallee recommends that hospitals reserve their observation units strictly for patients receiving observation services. Some hospitals use their observation units for admitted patients when beds on the medical/surgical floors are not available. This defeats the purpose of the observation unit, Sallee points out.
“Observation units are very effective if they are kept as closed units and staffed with nurses who are experienced in monitoring patients and getting them in and out. Case managers and everybody else on the team knows which patients are observation patients and can give them priority,” she adds.
In addition to observation units, some hospitals have instituted clinical decision units for patients who are not being actively treated but who need to stay in the hospital until their physician has the information needed to make a decision on discharging or admitting them, Sallee says. For instance, physicians may be waiting for test results or to see if the antibiotic or pain medicine they prescribed for the patient is effective.
“Clinical decision units are particularly useful when the emergency department is busy because they avoid tying up beds with patients who no longer need emergency treatment but who need to stay in the hospital for a short time,” she says. In some hospitals, units dedicated to observation patients are also called clinical decision units, she adds.
