Published in the June 2016 issue of Today’s Hospitalist
KEELY DWYER-MATZKY, MD, can see the future of her hospitalist-run observation unit from her office window. The 26-bed multimillion dollar unit is being built in response to a surge in observation patients that has overwhelmed the current 13-bed medical observation unit at Highland Hospital in Rochester, N.Y. Hospitalists will be responsible for the medical patients when the building opens at the end of this year.
The 261-bed Highland Hospital has had an ED-run unit for several years. But three years ago, administrators decided that they needed an additional unit for medical patients on an inpatient floor. Until that time, observation patients had been scattered throughout the hospital, creating challenges for the hospitalists who managed most of them.
The move reflects a change that is sweeping across U.S. hospitals—and affecting hospitalists. Five years ago, few hospitals had dedicated observation units. Now, hospitalists around the country are heading up their own observation units, either in tandem with a separate ED-run unit, as is the case at Highland, or taking over observation management outright.
“We need to get better at this because it’s not going away.”
~ Rebecca Ramirez, MD, Kettering Health Network
Observation status continues to generate a great deal of controversy, with plenty of confusion and anger among clinicians and patients alike. But even hospitalists who strongly believe that observation status should be scrapped and replaced with low-acuity inpatient codes say that transitioning to an “observation mindset” is not only desirable, but imperative.
“This is becoming more and more the mode of health care delivery,” says Rebecca Ramirez, MD, medical director for hospital medicine for the seven-hospital Kettering Health Network in Kettering, Ohio. “We need to get better at this because it’s not going away.”
Under new management
What’s behind the push to have hospitalists head up observation? In addition to volume, there’s patient complexity, says Aziz Ansari, DO, observation unit medical director and associate division director of hospital medicine at Loyola University Medical Center in Maywood, Ill.
“Often, there is a lot of ambiguity that requires an internal medicine consultation to manage the patient,” Dr. Ansari points out. “It is best for these patients to be managed by physicians with expertise in hospital medicine.”
Then there’s hospitalists’ track record with improving systems and quality. “I believe hospitalists were asked to head up the unit at UVA based on our demonstrated ability to lead new initiatives, improve operational efficiency and provide high-value care,” says George Hoke, MD, section head of the hospital medicine program at the University of Virginia Medical Center in Charlottesville, Va. “This means we know how to use the EMR and work the system better than anyone else.”
And given reimbursement changes, observation status now comes with higher stakes. “Medicare allows up to 48 hours, but reimbursement is so poor that we try to have 24 hours as our goal,” says Bruce Waldon, MD, director of the hospitalist division at Northwest Medical Center in Bentonville, Ark., and medical director of the hospitalist program at Siloam Springs Regional Hospital in Siloam Springs, Ark. Both are part of the Northwest Health System.
With the two-midnight clock ticking, there is a premium on quickly determining patient disposition. “If you can’t figure out the status,” says Dr. Waldon, “the tendency is to put the patient in observation.” But that increases length of stay, he adds, because some patients actually should be admitted.
“Most hospitals lose money on observation stays because they treat patients like inpatients.” Instead, observation management and staff need to bring a hurry-up offense, with stat labs, tests and consults, and often dedicated 24/7 staffing. All that makes it possible to turn an entire unit over in only a day or two.
Closing the unit
According to Ohio’s Dr. Ramirez, the biggest barrier to discharging patients within 24 hours at her hospital’s observation unit had been the inconsistent rounding patterns of the providers.
“The obs unit was open—both medical and surgical— and any and all providers could see patients there,” she points out. As a result, the average length of stay used to be between 34 and 36 hours.
When the hospitalist service restructured the unit in 2015, its first move was to close the unit so only hospitalists and the advanced practice providers they work with can treat patients under a hospitalist medical director. Subspecialists can admit their own patients to observation, but if they want to treat those patients while in observation, the patients cannot be housed in the observation unit.
And because the observation unit is run as an extension of the ED, Dr. Ramirez points out, ED physicians play an enormous role. As part of the restructuring, ED triage was changed so that only ED doctors can determine which patients are admitted to the observation unit, based on the expectation that those patients will go home within 24 hours.
The results have been on the mark: After the restructuring, observation length of stay decreased to 21 hours, a drop per patient of between 12 and 15 hours. The 22-bed unit sees 40 patients or more on a busy day, and Dr. Ramirez is planning to start similar units in other network hospitals.
At previous facilities where he has worked, Arkansas’ Dr. Waldon says he has had no problem with an “open” unit, allowing different physicians to place and manage patients.
But “it’s the medical director’s job”—and Dr. Waldon believes observation units need a medical director and associate director—”to make sure specialists comply with processes and respond to nurses when they say a patient is ready to go.” Other hospitalist programs that manage open units recommend tracking admitting groups’ length of stay and other benchmarks. (See “Observation measures to track,” below.)
Protocols and exclusion lists
At Arkansas’ Northwest Medical Center, Dr. Waldon is looking forward to the opening of a new six-bed observation unit this month. That unit, he explains, will focus exclusively on low-risk chest pain patients, the most common observation diagnosis.
Managing those patients already comes with proven protocols, including structured order sets and discharge criteria and the need to repeat tests three hours later. Because care for those patients is so protocolized, the ED will direct that unit in coordination with a hospitalist.
The next step, says Dr. Waldon, will be to add an eight-bed hospitalist-directed unit on a higher floor for patients with such conditions as nausea, vomiting, diarrhea, altered mental status, weakness, falls in the frail elderly, nonsurgical fractures that need pain control overnight, or mild to moderate dehydration that needs IV overnight. That unit is scheduled to open this fall.
At Highland Hospital, Dr. Dwyer-Matzky says she and the ED have worked out which observation patients are seen in the 13-bed ED-run unit and which are seen in the hospitalist-run unit, which likewise has 13 beds. The ED-run unit has a length of stay of less than 24 hours, reflecting the patients that unit manages, including those who need only a couple of doses of IV antibiotics for localized cellulitis or those with kidney stones who need IV fluids.
Dr. Dwyer-Matzky worked with the ED to craft an inclusion and exclusion list for the ED to use when evaluating patients. The exclusion list includes surgical and ob/gyn patients and those with mental health disorders and alcohol withdrawal. “We excluded patients with a high chance of flipping to inpatient,” Dr. Dwyer-Matzky explains.
She is also working on how to handle patients who do flip to inpatient status. Sometimes the hospitalist who treated the patient in observation will continue to follow the now inpatient if he or she thinks the patient will leave soon. That patient may even stay on the observation unit for efficiency.
In Ohio, Dr. Ramirez and her team have likewise focused on common diagnoses like abdominal pain and low-risk chest pain. She looked online for protocols and adapted them to order sets in her hospital’s Epic EHR.
Staffing the unit
Staffing a unit depends on a hospital’s size and budget and on ideas of how to best use advanced practitioners. But hospitalists who head up these units agree that dedicated providers are a must.
Dr. Dwyer-Matzky says shifting away from having eight different hospitalists round on 13 patients required a stepwise approach. First, she dedicated one physician assistant to the unit as well as a part-time care coordinator and part-time social worker. Dr. Dwyer-Matzky, who gets a small stipend as the unit’s medical director, joins the other hospitalists in rounding in the unit a week at a time.
She notes that rotating hospitalists works well at a smaller hospital as long as you have dedicated nursing staff for consistency. “You may lose some of the efficiency of having a dedicated observation doctor,” says Dr. Dwyer-Matzky, “but you also have variety so maybe less burnout.”
Hospitalists at Loyola rotate into observation with a 7 a.m.-7 p.m. shift; the group takes doctors’ individual preferences into account, which allows a smaller group of physicians to manage observation patients. Physicians in the unit also have weekends off, with teaching-service attendings covering weekends. The nurses are dedicated to the unit, and Dr. Ansari plans to add advanced practice nurses when the unit expands later
this year.
And in an unusual twist for Loyola, Dr. Ansari points out that housestaff are not involved in observation care. That enables nurses to hone their critical thinking skills and collaborate more with physicians, he says.
A role for advanced practice providers
At the 246-bed Chambersburg Hospital in Chambersburg, Pa., R. Lucas Shelly, DO, associate medical director of Summit Hospitalists, says that observation nurses must be skilled in quick follow-up to achieve faster turnaround. When he was asked to dedicate one of his already busy physicians to staff the unit, he decided instead to rely on nurse practitioners under hospitalist supervision.
“We recruited very specifically for observation care,” says Dr. Shelly, who hired two NPs with long-term ED experience. Under the new model, observation length of stay dropped from an average of 36 to 28 hours.
Michael Cratty MD, PHD, is director of the hospitalist program and chief medical officer for the Heritage Valley Health System, which consists of a 179-bed hospital in Sewickley, Pa., and a 334-bed hospital in Beaver, Pa. In 2014, the Sewickley hospital established dedicated observation beds while the Beaver hospital launched an observation unit. At that time, the names of observation patients would be highlighted in yellow in the patient lists on hospitalists’ iPads.
That way, “I could pull them up in the morning and make sure they were seen first to try to reduce the length of stay to within 24 hours,” says Dr. Cratty. Now, an advanced practice provider sees those patients first thing, then texts hospitalists who rotate in as tests come back. That’s helped reduce length of stay on the open unit from 36 to between 28 and 30 hours.
Finding space
Sources point out that location has a big impact on length of stay. Observation patients at Loyola, for instance, were initially spread throughout the floors, where physicians tended to spend time with sicker inpatients. That increased observation length of stay and slowed down bed flow.
In 2009, the hospital moved observation to a wing of the hospital with between 13 and 15 beds. A few years later, it expanded the unit to 19 beds in what Dr. Ansari says is the ideal location—near the ED.
“Having your own unit makes it easier to be focused on the task at hand and allow for better efficiencies,” he says. Patients also notice the difference. “Patients feel like they’re in an observation unit and have a sense of urgency to be discharged.” At the same time, patient satisfaction scores for physician and nurse communication have remained up.
The unit admits approximately 50 patients per week, with 20% converting to inpatient, and length of stay has dropped 50%. In a few months, his next move will be to a bigger area. The unit will increase to 30 beds, with 10 devoted to postsurgical and certain cardiology cases.
At the University of Virginia Medical Center, physical space has been a major hurdle since the hospitalists were commissioned last year to spearhead a new observation service. Given the center’s high occupancy rate, says Dr. Hoke, real estate is at a premium.
The hospital planned to use four or five beds from the post-procedure area, but “it became clear that people who used that space didn’t want to part with it,” he explains. For now, observation patients remain scattered in inpatient beds, and stays are longer than doctors would like—48 vs. 24 hours. Dr. Hoke says the hospital plans to revisit observation location when it expands in 2020.
Ongoing review
Achieving faster turnaround also means getting consultants on board. According to Dr. Shelly, his hospital’s chief medical innovation officer met with subspecialists, educating them about observation and asking for their cooperation.
“For our main consultants within the observation unit— pulmonology, cardiology, neurology—the response is usually within a couple of hours or first thing in the morning,” Dr. Shelly says. “For office visits, our care coordinators can often get patients seen within one to three days.”
Plus, the observation staff at Chambersburg Hospital holds a multidisciplinary huddle every day at 9:30 a.m. The collaborating physician, NP, social worker, care coordinator, utilization manager and nurse manager run the observation list. They review the care plan for patients admitted the previous afternoon or night by dedicated admitters or nocturnists.
Dr. Ramirez points out that the multidisciplinary observation team—headed up by the unit’s medical director, hospitalist Sylvia Polenakovik, MD—meets once a week to review observation patients, paying special attention to those who became inpatients as well as those who were admitted but left in less than 48 hours. They also review status denials to figure out how to provide adequate documentation to justify converting a patient to inpatient status.
And at Heritage Valley Health System, Dr. Cratty says hospitalists discuss the observation unit at every monthly meeting with a nod to trying to reduce length of stay. “We constantly reinforce that we want this down to 24 hours.”
Paula Katz is a freelance health care writer based in Vernon Hills, Ill.
EVEN AS HOSPITALISTS have streamlined and standardized observation care, they say that many challenges remain. For one, hospitalists often find themselves explaining—or defending—the decision to place in observation.
“It’s unfortunate that hospitalists are put in the middle of this because it can alienate the patient,” shifting the relationship from care to finance, says Keely Dwyer-Matzky, MD, who directs the 13-bed medical observation unit at Highland Hospital in Rochester, N.Y. At her hospital, that conversation falls to utilization management nurses.
Later this summer, the federal NOTICE Act will mandate notifying patients within 36 hours, both verbally and in writing, of being in observation status. In the meantime, hospitals can use visual cues to clarify observation care, says Michael Cratty MD, PHD, chief medical officer of Heritage Valley Health System in western Pennsylvania. Signs in that system’s ED and in patient rooms explain the observation process and copays. ED staff also walk patients through the implications of being in observation.
Patients at Chambersburg Hospital in Chambersburg, Pa., get a packet explaining observation status. Dedicated care managers give what R. Lucas Shelly, DO, associate medical director of Summit Hospitalists, calls “the observation speech,” and patients in the unit wear dark blue gowns, not the pale blue ones used in the rest of the hospital. Each patient room has a white board with a fluorescent orange tag that says “observation.”
Hospitalists can also help by clarifying expectations when they talk to patients and families, says Bruce Waldon, MD, director of the hospitalist division at Northwest Medical Center in Bentonville, Ark. “Say, ‘When we get this test back or after this period of time, depending on results and how you’re feeling, we will make the decision of whether you should go home or become an inpatient.'”
In such discussions, he recommends being very specific. For example, “We’re waiting on a second cardiac marker test to come back and if it’s negative and you’re not having chest pain, we’ll send you home and you’ll have a follow-up with Dr. X.” At the same time, Dr. Waldon adds, “patients need to understand that they may be sent home at 10 p.m. or 7 a.m.”
