ABSTRACT
Objective: An emergency department observation unit (EDOU) opened in April 2006 staffed by physician assistants (PAs) and nurse practitioners (NPs). This study describes the complexity and outcomes of the EDOU patients to determine the effectiveness of staffing by PAs.
Methods: A retrospective chart review was performed of chest pain and trauma patients in the EDOU from April 2006 through May 2007. Patient characteristics, length of stay (LOS), and admission rates were recorded. Adverse events were monitored, and trauma patients were followed for 30 days to evaluate for missed injuries.
Results: 531 chest pain patients and 364 trauma patients were admitted to the EDOU during the study period. Average chest pain patient LOS was 14 hours and 32 minutes, and 12.2% of patients were admitted from the EDOU to an inpatient unit. For trauma patients, average LOS was 12 hours and 46 minutes, and 11.5% of patients were admitted to an inpatient unit. There were no deaths, intubations, or loss of vital signs. In 30-day follow-up, there were no significant missed injuries among trauma patients.
Conclusion: PAs effectively cared for patients of moderate complexity in the two largest groups of utilizers of the EDOU.
Emergency department observation units (EDOU) have a long history of being utilized to care for emergency department (ED) patients who require more than 4 to 6 hours of ED treatment.
1 Many studies have described the success of these units in caring for ED patients.
2-8 The use of physician assistants (PAs) in the ED has also been studied,
9-11 and the successful use of PAs in other settings has been well-evaluated.
12-19 In addition, a trend of staffing EDs with PAs has been documented.
20 However, staffing of EDOUs has not been described previously. The University of Utah Emergency Department opened an EDOU in April 2006 that is staffed predominately by full-time PAs and two part-time nurse practitioners (NPs).
The University of Utah Medical Center is one of two adult level I trauma centers located in metropolitan Salt Lake City, Utah. The hospital serves as a tertiary care center for Utah and parts of Nevada, Idaho, and Wyoming. It has 425 beds, and the ED sees approximately 39,000 patients every year. The main function of the 10-bed EDOU is to monitor patients who do not clearly meet criteria for admission to the hospital yet who would benefit from a period of observation or continued treatment intervention prior to final disposition.
This descriptive analysis and retrospective chart review sought to describe the operation of the EDOU and investigate which types of patients were under the care of PAs in the EDOU. The goal was to better understand both the numbers of patients and their medical complexity and risk factors. Second, the outcomes of these patients were evaluated to determine whether patients of this medical complexity can be safely evaluated in an EDOU primarily under the care of PAs.
BACKGROUND
The EDOU presents an option for ongoing care of emergency department patients who may require extended evaluation and treatment but do not meet specific criteria for admission. These patients may be awaiting the results of testing, may require IV antibiotics or serial laboratory tests, or would benefit from
a period of observation to ensure clinical improvement.
From its inception in April 2006, the 10-bed EDOU was staffed by physician assistants. As the hours of coverage in the EDOU have increased, staffing has increased to eight full-time PAs and two part-time NPs covering shifts in the EDOU as well as in the ED. This staffing allows for rounding on patients, re-examination, evaluation of overnight laboratory or radiographic studies, direction of any further evaluation, coordination with consulting services, and ultimately disposition. PAs currently staff the EDOU for 21 hours per day, from 7 am until 4 am. Outside of these hours, attending physicians in the ED are available for consultation by nurses or for patient care decisions.
The EDOU treats a wide variety of patients and is largely protocol driven. The EDOU utilizes 19 different protocols that provide guidelines and ordersets specific to the diagnosis or chief complaint for admission to the EDOU (Table 1).
Initial EDOU orders are written by the attending ED physician prior to transfer to the EDOU. Once the patient is in the EDOU, care is assumed by the PA. This includes, but is not limited to, reexamination, following up on all pending results, ordering medications and additional tests as appropriate, and coordinating with nursing, consultants, or ancillary services. The PA also assumes responsibility for admitting the patient to the hospital for any decline in the patient's condition as well as for the morning disposition decision. Attending ED physicians are available at all times for consultation as needed.
The maximum length of stay in the EDOU is 23 hours. This time period allows for multiple interventions such as serial examinations, laboratory tests, radiographic studies, consultations with specialty services, case management, or physical therapy.
In addition to the above protocol-driven criteria, the EDOU may also be used to care for patients who have been admitted to the hospital but must wait for a bed to become available. Traditionally, these patients would remain in the ED, making it more difficult to care for new ED patients. Having the EDOU PA and nursing staff provide care for the patient instead reduces ED overcrowding with stable patients for whom disposition has been determined.
METHODS
A retrospective chart review was performed of patients admitted to the University of Utah EDOU over the first 14 months of its operation: April 2006 through May 2007. The authors looked specifically for adverse events among patients and followed trauma patients for 30 days to evaluate for missed injuries as markers to determine the effectiveness of care provided by PAs. The greatest number of patients were found to fall under the chest pain and trauma protocols. In evaluating the safety of patient care in the EDOU, the authors focused specifically on these two groups. Chest pain and trauma patients were the two largest groups of patients in the observation unit, and focusing on these two groups allowed use of standard definitions for risk factors, patient characteristics, and outcomes, thus ensuring a certain amount of uniformity in the data abstraction and comparison.
Chest pain and trauma patients are two groups of patients that have been fairly well-studied, particularly in the emergency medicine literature, and thus it was possible to employ standard definitions to describe the complexity of the patients seen as well as evaluate for any adverse outcomes among these groups. Second, these two groups were considered most generalizable to other emergency departments. EDOUs typically utilize a protocol for chest pain patients. While a protocol may not be as widely accepted for trauma patients as for chest pain patients, EDs may also choose to employ such a protocol given the large numbers of patients that would be admitted under it. This was the reason for inclusion of this group of patients.