Observation Medicine Edited by Sharon E

Cambridge University Press 978-1-107-02234-8 — Observation Medicine Edited by Sharon E. Mace Frontmatter More Information

Observation Medicine

Using sample clinical protocols, order sets, and administrative policies that any hospital can use, this book gives a detailed account of how to set up and run an observation unit (OU) and reviews conditions in which observational medicine (OM) may be beneficial. In addition to clinical topics such as improving patient outcomes and avoiding readmissions, it also includes practical topics such as design, staffing, and daily operations; fiscal aspects such as coding, billing, and reimbursement; regulatory concerns such as aligning case management and utilization review with observation; nursing considerations; and more. The future of OM, and how OM can help solve the healthcare crisis from costs to access, is also discussed. Although based on U.S. practices, this book is also applicable to an international audience, and contains instructions for implementing observation in any setting or locale and in any type of hospital or other appropriate facility.

Sharon E. Mace is Professor of Medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University; Director of Observation Unit, Director of Research, and previously Director of Pediatric Education/Quality Improvement at the Emergency Services Institute, Cleveland Clinic; and a member of the Faculty of MetroHealth Medical Center/Cleveland Clinic Emergency Medicine Residency in Cleveland, Ohio.

Observation Medicine

Principles and Protocols Edited by Sharon E. Mace Emergency Services Institute, Cleveland Clinic, Cleveland, OH

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Contents

Advance Praise x About the Editors xiii Contributors xv Foreword: Onward and Upward xx Greg L. Henry Preface xxiii Sharon E. Mace

Part I Administration: Key 9 Metrics and Performance Improvement: Patient Quality, Safety, and Concepts of Observation Experience 48 Medicine, and Developing and Sharon E. Mace and Elaine Thallner Maintaining an Observation Unit 1 Observation Medicine – Key Concepts: Part II Observation Medicine: Clinical How to Start (and Maintain) an Observation Setting and Education Unit: What You Need to Know : Clinical 10 Issues 2 The Community Hospital Perspective in a Suburban/Rural Setting 58 Sharon E. Mace Ryan Prudoff and Stephen Sayles 2 Observation Medicine – Key 11 60 Concepts: How to Start (and Maintain) The Urban Community Hospital an Observation Unit: What You Robert S. Bennett Need to Know: Administrative 12 The Tertiary Care Hospital and Academic Issues 11 Setting 62 Sharon E. Mace Jonathan Glauser 3 Observation Medicine Development 13 Observation Medicine and the Over Time 23 Hospitalist 64 Louis Graff IV David G. Paje and Peter Y. Watson 4 Observation Medicine Principles 27 14 Training and Education – Residents 66 Louis Graff IV Pawan Suri 5 Design 30 15 Training and Education – Medical David Robinson Students/Fellows 68 6 Staffing Considerations 33 Margarita E. Pena Christopher W. Baugh and J. Stephen Bohan Part III New Developments in 7 Nursing 37 Observation Medicine Sharon E. Mace and Karen Games 16 Extended and Complex 8 Risk Management 43 Observation 72 Gregory L. Henry L. Christine Gilmore and Bret A. Nicks

Table of Contents

17 Extended Observation Services 76 Subpart IVC Clinical – Vascular Catherine T. Puetz Editor’s Comments: Venous 18 78 Hospital Readmissions Thromboembolic Disease: Deep Vein Sharon E. Mace Thrombosis and Pulmonary Emboli 158 19 Level of Care Determination: 31 Deep Vein Thrombosis (DVT) 159 Medical Necessity Risk Carol Lynn Clark and Michelle A. Wiener Stratification 88 32 165 Louis Graff IV Acute Pulmonary Embolism (PE) David G. Paje 20 Accountable Care Organizations 92 33 173 Kayur V. Patel and Igor Kozunov Anticoagulants David G. Paje 21 Acute Medicine in the United Kingdom 95 – Louella Vaughan Subpart IVD Clinical Neurologic 34 Transient Ischemic Attack (TIA) 180 Part IV Clinical Matthew Tabbut and Jonathan Glauser – 35 Headaches 189 Subpart IVA Clinical Cardiac Sharon E. Mace 22 98 Chest Pain 36 Seizures 200 Tertius T. Tuy and W. Frank Peacock Sharon E. Mace 23 107 Heart Failure 37 Dizziness and Vertigo 211 Jieun Kim and W. Frank Peacock Saurin Bhatt 24 114 Atrial Fibrillation 38 Central Nervous System (CNS) Catherine T. Puetz Shunts 222 25 Syncope 121 Mark G. Moseley and Miles P. Hawley T. Andrew Windsor and Amal Mattu – 26 Stress Testing 127 Subpart IVE Clinical Metabolic, Kami M. Hu and Amal Mattu Endocrine 39 Hyperglycemia 225 Subpart IVB Clinical – Respiratory Pawan Suri and Taruna Aurora 40 Hypoglycemia 231 27 Asthma 138 Pawan Suri and Taruna Aurora Eric Anderson 41 Electrolyte Abnormalities 235 28 Acute Exacerbation of Chronic Obstructive Pulmonary Disease Kimberly A. Ressler and Jonathan Glauser and Bronchitis 143 Eric Anderson Subpart IVF Clinical – Hematologic 29 Community Acquired Pneumonia 149 42 Sickle Cell Disease 244 Eric Anderson Matt Lyon, Leah Taylor and Robert W. Gibson 30 Primary Spontaneous Pneumothorax 153 43 Transfusions 250 Chew Yian Chai Rokhsanna Sadeghi and Jonathan Glauser

Table of Contents

Subpart IVG Clinical – Infections Subpart IVL Clinical – Surgical 44 Skin and Soft Tissue Infections (SSTI) 257 Evaluation Robert S. Bennett 56 Abdominal Pain 309 Mark G. Moseley and Miles P. Hawley Subpart IVH Clinical – Gastrointestinal Subpart IVM Clinical – Pain 45 Abdominal Pain 263 Management and Musculoskeletal Louis Graff IV 57 Pain Management, Including 312 46 Upper Gastrointestinal (GI) Bleeding 267 Musculoskeletal and Low Back Pain Abhinav Chandra Nathaniel L. Scott and James R. Miner 47 Dehydration, Gastroenteritis, and Vomiting 271 Subpart IVN Clinical – Trauma Elizabeth A. Rees and Bret A. Nicks 58 Trauma 318 Subpart IVI Clinical – Genitourinary Mark G. Moseley and Miles P. Hawley 48 Urolithiasis 274 Subpart IVO Clinical – Toxicology Claire Pearson and Robert D. Welch 59 Toxicology 323 49 Pyelonephritis and Urinary Tract Steven J. Walsh and Marsha Ford Infections 280 Brian Kern and Robert D. Welch Subpart IVP Clinical – Psychosocial Subpart IVJ Clinical – Obstetrics and Editor’s Comments on Medical 332 Gynecology Clearance 60 Psychiatric Patients 332 50 284 Pelvic Inflammatory Disease (PID) Jonathan Glauser Veronica Sikka and Renee Reid 51 Vaginal Bleeding 287 Subpart IVQ Clinical – Disasters Veronica Sikka and Renee Reid 61 Disasters 339 52 Hyperemesis Gravidarum 289 Constance J. Doyle Veronica Sikka and Harinder Dhindsa – Part V Financial Subpart IVK Clinical Pediatrics and Subpart VA Financial – Coding and Geriatrics Reimbursement 53 Pediatric Observation Medicine 291 62 Physician Coding and Sharon E. Mace Reimbursement 348 54 Pediatric Observation Medicine at a Michael A. Granovsky and David Children’s Hospital 300 A. McKenzie Aderonke Ojo 63 Hospital Coding and Reimbursement 355 55 Geriatric Observation Medicine 304 Candace E. Shaeffer and Michael Fredric M. Hustey A. Granovsky

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Table of Contents

Subpart VB Financial – Case Subpart VIC International – Management Australia/New Zealand 64 Determining the Correct Status 363 73 Australia 406 BK Kizziar John Burke 65 Case Management: Care 74 New Zealand 409 Coordination 366 Michael Ardagh Nancy E. Skinner Subpart VID International – Europe Subpart VC Financial – Medical 75 France 411 Necessity, Denials, and Appeals Said Laribi and Patrick Plaisance 66 Medical Necessity 370 76 Germany 413 Robert H. Leviton Martin Mockel and Julia Searle 67 Denials and Appeals 378 77 Italy 417 Robert H. Leviton Salvatore Di Somma, Angelo Ianni, and Cristina Bongiovanni Subpart VD Financial – The Business 78 United Kingdom 421 of Observation Medicine Louella Vaughan and Dylan Jenkins 68 Ensuring Financial Viability: The Business – Case for Observation Units 382 Subpart VIE International South Christopher W. Baugh and America J. Stephen Bohan 79 Colombia 424 69 Observation Services in the Eyes of the Carlos-Hernan Camargo-Mila Payers 386 Sandra Sieck 70 The Business of Observation Part VII Evidence Basis for Medicine 391 Observation Medicine Sandra Sieck 80 The Evidence Basis for Observation Medicine in Adults Based on Diagnosis/ Clinical Condition 430 Part VI International Christopher W. Baugh, Sharon E. Mace, Subpart VIA International – Africa Margarita E. Pena, and J. Stephen Bohan 71 South Africa 398 81 The Evidence Basis for Age-Related 478 Heather Tuffin and LA Wallis Observation Care Sharon E. Mace, Christopher W. Baugh, and Madeline Joseph Subpart VIB International – Asia 72 Singapore 403 Part VIII Clinical Protocols Malcolm Mahadevan and Chew Author’s and Editor’s Comments: Yian Chai Protocols and Order Sets 511

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Table of Contents

82 Clinical Protocols 514 90 Adult Order Sets: Electrolyte Sharon E. Mace Abnormalities 705 Sharon E. Mace and Matthew J. Campbell Specialized Clinical Protocols 547 83 Spontaneous Pneumothorax 548 91 Adult Order Sets: Trauma 713 Chew Yian Chai Sharon E. Mace 84 Snakebites: Rattlesnake Bites 556 92 Adult Order Sets: Intravenous Fluids, Sean Bush Laboratory, Radiology, and Special Studies 729 85 Snakebites: North American Crotalid Snake (Pit Viper) 560 Sharon E. Mace and Matthew J. Campbell Bret A. Nicks 93 Adult Order Sets: Medications 733 86 Dengue 565 Sharon E. Mace and Matthew J. Campbell Chew Yian Chai 94 Adult Order Sets: Generic or General 748 87 Low-Risk Pulmonary Embolism (PE) 567 Order Set David G. Paje Sharon E. Mace Part IX Administrative Policies Subpart XB Order Sets – Pediatrics 88 Administrative Policies 570 95 Pediatric Order Sets: Medications 752 Sharon E. Mace Sharon E. Mace and Matthew J. Campbell 96 Pediatric Order Sets: Generic or General Part X Order Sets Order Set 762 Sharon E. Mace Subpart XA Order Sets – Adult 89 Medical Center Department of Emergency Medicine Observation Unit Manual: Adult Prologue: Observation Medicine Is Not the Order Sets by Diagnosis/Clinical Same as Observation Status 766 Condition 602 Sharon E. Mace and Robert E. O’Connor Sharon E. Mace Index 769

Advance Praise

This is a wonderful, much needed book by a practice. The included clinical protocols, alone, wonderful, much learned author. Dr. Mace has are worth their weight in gold; they will give you decades of experience in observation medicine an excellent basis for the wide range of problems and even more in emergency medicine leadership. we can safely deal with through observation medi- This book not only includes the best summary to cine. I just wish we had access to the knowledge date of what EM observation medicine has been and wisdom contained in this book when we but also provides a road map to the future. If your started our observation unit in 1979! practice includes observation medicine, you need Stephen V. Cantrill, MD, FACEP this book. Rock on, Dr. Mace. Denver Health Medical Center Nick Jouriles, MD, FACEP Chair, EM, Cleveland University of Colorado School of Medicine Clinic Akron General: Professor & Chair, EM, Northeast Ohio Medical University; President, Observation medicine is the perfect tool for pro- ED Benchmarking Alliance; Past President, gressive emergency physicians to leverage American College of Emergency Physicians improvements in cost, quality and patient satis- faction. I have seen physician groups and hos- “Observation Medicine: Principles and Proto- pitals struggle to collect all the information cols” edited by Dr. Sharon E. Mace is a relevant necessary to build and run an observation medi- and timely textbook to Emergency Medicine. It cine service effectively, sometimes taking years to has unique content as it relates to the development get it right. We have needed this book for a long of both adult and pediatric observation medicine. time, and now it’s here – a single source for the The book is written in an easy to read format with best information on what, why and how to many outstanding ideas on how to implement develop an observation service that lasts and adds observation medicine in the emergency depart- value to your hospital partner. ment. This is an indispensable resource! James R. Blakeman Isabel A. Barata, MS, MD, MBA, FACP, FAAP, Executive Vice President ’ FACEP Emergency Group s Office, San Dimas, CA Associate Professor of Pediatrics and Emergency ’ Medicine, Hofstra Northwell School of Medicine; Dr. Mace s Observation Medicine is a must have Pediatric Emergency Medicine Service Line Qual- for all physicians and administrators who have or ity Director, Emergency Medicine and Pediatrics would like to start an observation unit. Jammed Service Line; Director of Pediatric Emergency with helpful tips, useful clinical protocols and Medicine, North Shore University Hospital administrative guidelines, it will guarantee the success of your program!! Finally! After decades, an up-to-date authority Ann M Dietrich, MD, FAAP, FACEP on observation units and observation medicine. If Associate Professor Ohio University Heritage you are in any way involved in this dynamic College of Medicine aspect of emergency medicine, this book is for Medical Director of Education Ohio ACEP you. From the clinical to the administrative to the convoluted billing and regulatory issues, this As a longstanding residency director, it is diffi- book is a wealth of information that will help you cult to provide the training needed to keep up with navigate this complex area of emergency medical the advancements in emergency care. Observation x

Advance Praise

medicine is proving to be an extremely valuable Chair, Department of Emergency Medicine, addition to emergency care, and emergency medi- Michigan State University Grand Rapids, cine residents need to be exposed and trained in Michigan this facet of emergency care. Dr. Mace’s textbook, Observation Medicine, provides a valuable training The Textbook Observation Medicine: Prin- resource useful to all emergency medicine residen- ciples and Protocols edited by Sharon E. Mace is cies. This textbook provides the background a must have in your Emergency Medicine Library. needed to not only work within an emergency Dr. Mace, an experienced Emergency Physician department that has an Observation unit, but practicing Observation Medicine for Adults potentially to develop one. This is a great resource and Children at the Cleveland Clinic Hospital for training in Observation Medicine. System for decades, has assembled a team of contributors representing the best and brightest of Michael S. Beeson, M.D., MBA Emergency Medicine. In the ninety-six (96) Program Director of Emergency Medicine Chapters of this book, the reader will learn every- Professor | EM | Northeast Ohio Medical thing you need in implementing an Observation University Unit for your Emergency Department and your Director | American Board of Emergency hospital. The breath of this book is exhaustive. Medicine The chapters are organized into multiple sections. Cleveland Clinic Akron General They include: “Administration, Clinical Setting The face of health care is changing and that is a and Education, New Developments, Financial good thing. However, we are a stubborn group and (including coding and reimbursement), Clinical ’ Protocols, Administrative Policies, Order Sets change is difficult. Dr. Mace s book describes ” observation care in a manner that is easily under- for Adults and Pediatrics, and much more. stood by all healthcare providers and administra- Economics and the desire to provide optimal tors. What we are unfamiliar with We are afraid care for Emergency patients who needed just a of... Dr. Mace’s book will provide the knowledge little bit more time to stabilize their care, arrive at you need to embrace the change and leverage the a definitive answer, or prepare patients for safe observation services you deliver. As a nurse, we discharge home without a hospital admission, continue to care for our patients the same as we helped to drive the development of this special- always have but in a shorter span of time, this book ized area of Emergency Medicine. shares invaluable information in resource manage- As written, in the forward by Greg Henry, MD, FACEP, (Past President of the American ment, time management and expedited care man- “ agement. This book is a MUST HAVE for success College of Emergency Physicians), Remember in our evolving health care environment. the goals: cost-effective care, time-efficient care, the best patient outcomes, and more compassion- Ethel Games, RN ate human-centered care. Observation medicine Emergency Room Nurse can achieve these goals.” Fountain Valley Regional Hospital This book can help establish an Observation Fountain Valley, California Unit as part of your Emergency Department through its guidance of Administration, Proto- “ This text will serve as the go to" resource for cols, exploring the types of Clinical Problems that health care providers managing patients in an would best be served by these units. They also observation unit. The book is well organized with bring in the experts of reimbursement to help chapters that focus on the content most relevant you pay for the services you provide. If you to contemporary observation medicine. There is already have an Observation Unit, this book is no doubt it will become required reading for the essential to operating that unit correctly and at a observation medicine curriculum in EM resi- higher level. If it is your responsibility, as an dency programs. Emergency Department Leader (Director, Associ- Michael Brown, MD, MSc ate Director, or responsible for medical or nurs- Professor, Michigan State University College of ing education), the protocols and educational Human Medicine modules will make your life easier.

Advance Praise

Do yourself a favor and purchase this book for symptom-driven approaches and disease specific yourself and your department. You will be glad care. Rather than searching through many texts or you made the investment. sites, Dr. Mace and her team created a singular source that uses a clear and accessible format Andrew I. Bern, MD, FACEP to aid those wanting to start or improve their Past Member, ACEP Board of Directors observation unit. Past, Chairman of the ACEP Board of Directors Donald M. Yealy, MD We currently sit amidst one of the most trans- formational periods in healthcare, with a rise Chair, Department of Emergency Medicine, in consumer based value assessments that are University of Pittsburgh / University of Pitts- driving care. For those with new or worsened burgh Physicians; Senior Medical Director, illness or injury, observation care is a key tool Health Services Division, and Vice President of after emergency department care to optimize Emergency and Urgent Care Services, UPMC; outcomes and enhance value. This Observation Professor of Emergency Medicine, Medicine, and Medicine text assembles the knowledge needed, Clinical and Translational Sciences, University of from organization and oversight through Pittsburgh School of Medicine

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About the Editors

Editor National Science Foundation Research Fellowship, Academic Residency Science Day Award, National Sharon E. Mace, MD, FACEP, FAAP is board Chapter Project Award, State Emergency Medical certified in emergency medicine and pediatrics. Services Council Award for Leadership and Excel- She is a Professor of Medicine at the Cleveland lence in Emergency Medical Services, the Ameri- Clinic Lerner College of Medicine at Case Western can Association of Women Emergency Physicians Reserve University and is full time faculty in emer- Research and Education Award, and Who’sWho gency medicine for the MetroHealth Medical in America and Who’s Who in the World. She has Center/Cleveland Clinic Emergency Medicine served as a course director for numerous medical Residency Program in Cleveland, Ohio. She has courses including many national conferences on over 37 years of administrative and clinical experi- Observation Medicine and has even been a ence in emergency medicine in academic and com- member of the Pediatric Medical Care Subcommit- munity hospital settings including nearly a decade tee for the National Presidential Commission on as a Director of the Emergency Department in a Children and Disasters. Community Hospital. She is currently an attending physician in the Emergency Services Institute at the Cleveland Clinic. She is the Director of Research Section Editors and has been the first and only Director of the Matthew J. Campbell, Pharm.D., BCPS obtained Observation Unit at the Cleveland Clinic for the his Doctor of Pharmacy degree from Ohio North- past 23 years since the inception of the “Clinical ern University and subsequently completed a Decision Unit” in 1994, where she has been able to Pharmacy Practice Residency at MetroHealth mentor medical students, residents and even sev- Medical Center in Cleveland, Ohio. He is a eral international fellows in observation medicine. licensed pharmacist in the state of Ohio and is a The observation unit at the Cleveland Clinic is a Board Certified Pharmacotherapy Specialist 20 bed unit that places about 6,000 patients a year (BCPS). He has received numerous honors and in the Observation Unit. She has also been Director awards including the Ohio Northern University of Pediatric Education and Quality Improvement Presidential Merit Scholarship, Institutional Pre- for the Cleveland Clinic Emergency Services Insti- ceptor of the Year at the College of Pharmacy at tute. She has lectured nationally and internation- Lake Erie College of Osteopathic Medicine, ally on emergency medicine especially observation Pharmacist Mission Award at Cleveland Clinic, medicine. She has served as the Chairman of the and the Promoting the Profession Award at Section of Observation Medicine for the American Cleveland Clinic. He has had numerous presenta- College of Emergency Physicians and on the tions locally and nationally and is actively Observation Medicine Committee for the Society involved with pharmacy resident education at of Hospital Medicine that authored a white paper Cleveland Clinic. He practiced as a Clinical Phar- on observation medicine. She has authored over macy Specialist in the surgical ICU of a commu- 200 articles in the medical literature, over 60 text- nity hospital for several years and is currently the book chapters (excluding this textbook) and edited Lead Pharmacist in the Emergency Services Insti- a previous medical textbook and now this second tute at the Cleveland Clinic in Cleveland, Ohio. authoritative and comprehensive textbook on He is the Section Editor for the Section IX: 1 observation medicine. She has been the recipient Adult Order Sets and Section IX: 2 Pediatric of numerous grants and awards including a Order Sets.

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About the Editors

Karen Games, RN, has over 40 years of Specialty Certification. He has been a member of experience as a registered nurse and as a case the American College of Emergency Physicians manager. She received her nursing degree from (ACEP) for 20 years, a member of the AAPC for South Surburban College in Illinois, and com- 15 years and has served for nearly 15 years on the pleted a Critical Care Specialty Nursing Course ACEP Physicians Coding and Nomenclature at Good Samaritan Hospital in Los Angeles. Her Advisory Committee (CNAC), including three academic credentials include the following years as the CNAC National Chairman. He has training and certifications: FHP Management spoken nationally at numerous conferences and Training – Quality Education System, HFMA has been the author of many articles in profes- Billing Compliance and a five year Certification sional publications dealing with reimbursement, Program in Case Management (CCM). She is also practice management issues, CPT, ICD–9, CMS an InterQual Certified Trainer. She has been a issues and ICD–10. He has served as the course consultant and a national speaker on Case Man- director for the ACEP Coding and Reimburse- agement. With her extensive nursing, case man- ment Conference for over a decade. He has been agement, and administrative experience, she has on the editorial board and served as the editor for had an opportunity to develop multiple programs, ED Coding Alert. He is the Technical Editor of policies and procedures related to nursing, case the AAPC ED specialized CPC–CEDC Emer- management, and observation medicine. Her gency Department Coding Specialty Certification. various administrative positions include serving He is the subject matter expert on the ED as a Regional Case Management Director, a PMI Specialty Exam and Study Guide for the AAPC. Case Management Specialist, the Director of Case His service on national committees includes Management Education and Informatics for the immediate past chairman ACEP National Tenet Health System. She has also been the Dir- Coding Advisory Committee, Work Group Chair ector of Risk Management and Patient Safety for ICD–10 – ACEP Quality and Performance Com- Desert Regional Medical Center in California and mittee, ACEP Expert Technical Panel for Quality most recently, Administrative Director of Collab- Measure Development, ACEP Registry Task orative Care at Los Alamitos Medical Center, also Force and the ACEP Reimbursement Committee in California. She is the Section Editor for – Fair Payment Work Group Chair. Dr. Gran- Chapter 7: Nursing, Chapter 64: Determining ovsky is currently the Chairman of the ACEP the Correct Status and Chapter 65: Care Reimbursement Committee. As the President, Coordination. Division of Coding for Logix Health; he is respon- Michael Granovsky, MD, CPC, CEDC, sible for health policy, coding, education, and FACEP is board certified in emergency medicine. regulatory processes with oversight of seven mil- His certifications in coding include the American lion annual emergency department claims. He is Academy of Professional Coders (AAPC) – Certi- the Section Editor for Section V: Financial Coding fied Professional Coder and AAPC – CEDC ED and Reimbursement and Chapters 1 and 2.

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Contributors

Sharon E. Mace, MD, FACEP, FAAP Karen Games, RN Professor of Medicine, Cleveland Clinic Lerner Director of Process Improvement, Los Alamitos College of Medicine at Case Western Reserve Medical Center University, Faculty, MetroHealth/Cleveland Gregory L. Henry, MD, FACEP Clinic Emergency Medicine Residency Director, Observation Unit and Director, Clinical Professor Department of Emergency Research Cleveland Clinic Cleveland, OH Medicine, University of Michigan Medical School, Ann Arbor, MI, Past President, American College Robert E. O’Connor, MD, MPH, FACEP of Emergency Physicians Chair, Physician-in-Chief, Department of Elaine Thallner, MD, MS Emergency Medicine, University of Virginia Organizational Development and Change Health System, Charlottesville, Va. Chair, Board Management of Directors, American College of Physicians Staff Physician, Emergency Services Institute, Louis Graff MD FACEP FACP FACC. Cleveland Clinic Foundation, Cleveland, OH Professor Surgery and Emergency Medicine. Ryan Prudoff, DO, MS, FACEP Clinical Professor Medicine. Staff Emergency Physician, Cleveland Clinic University of Connecticut School of Medicine. Foundation Chair Utilization Review Committee. Clinical Associate Professor Emergency Medicine Hartford Healthcare Corporation Central Region Ohio University Heritage College of Osteopathic Hospitals Medicine Farmington, CT Cleveland, OH David Robinson, MD, MS, MMM, FACEP Stephen Sayles, MD, FACEP Professor and Vice-Chairman of Director Cleveland Clinic Brunswick Emergency Emergency Medicine, University of Texas Department, Cleveland Clinic Foundation, Medical School at Houston; Cleveland, OH Chief of Emergency Services, Lyndon B. Johnson Hospital, Harris Health System Houston, TX Robert S. Bennett, MD Director, Observation Unit, Highland Hospital Christopher W. Baugh, MD,MBA, FACEP Rochester, NY Medical Director of Clinical Operations and Observation Medicine Jonathan Glauser, MD, FACEP Department of Emergency Medicine | Brigham & Professor Emergency Medicine Case Western Women’s Hospital Reserve University. Assistant Professor Harvard Medical School Faculty Emergency Medicine Residency Boston, MA MetroHealth/Cleveland Clinic Cleveland, OH J. Stephen Bohan, MD, MS, FACEP, FACP David J. Paje, FACP, SFHM Executive Vice Chair, Emergency Medicine Assistant Professor at University of Michigan Brigham and Women’s Hospital Medical School Associate Professor, Harvard Medical School Associate Director, Medical Short Stay Unit, Boston, MA University of Michigan Health System

Contributors

Staff Physician, Ann Arbor VA Healthcare Senior Clinical Research Fellow, Northwest System London CLAHRC Ann Arbor, MI London, UK Peter Y. Watson, MD, FACP, SFHM Tertius T. Tuy, MD Division Head of Hospital Medicine Singapore General Hospital, Singapore, Former Henry Ford Hospital Detroit, MI Research Fellow, Cleveland Clinic Foundation, Emergency Services Institute, Cleveland, OH Pawan Suri, MD Chair, Division of Observation Medicine W. Frank Peacock, MD, FACEP, FACC Program Director, Combined EM/IM Residency Professor, Emergency Medicine Program Associate Chair and Research Director Department of Emergency Medicine Baylor College of Medicine Assistant Professor in Emergency Medicine and Houston, Texas Internal Medicine Virginia Commonwealth University Medical Jieun Kim, MD Center Medical Officer, Singapore General Hospital, Richmond, VA Singapore Former Research Fellow, Cleveland Clinic Foundation, Emergency Services Institute, Margarita Pena, MD, FACEP Cleveland, OH Medical Director, Clinical Decision Unit Associate Program Director, Emergency T. Andrew Windsor, MD, RDMS, FAAEM Medicine Assistant Professor, Department of Emergency St. John Hospital and Medical Center Medicine Detroit, MI University of Maryland School of Medicine Baltimore, MD L. Christine Gilmore, MD Physician, Wake Forest Baptist Medical Center Amal Mattu, MD, FACEP, FAAEM Department of Emergency Medicine Winston- Professor and Vice-Chair, Emergency Medicine, Salem, NC University of Maryland, Baltimore, MD Bret A. Nicks, MD, MHA, FACEP Kami M. Hu, MD Chief Medical Officer, Wake Forest Baptist Critical Care Medicine Fellow, University of Health - Davie Medical Center Maryland Medical Center Emergency Medicine Winston-Salem, NC Departments of Internal and Emergency Medicine Catherine T. Puetz, MD, FACEP Baltimore, MD Attending Physician Department of Emergency Medicine Eric Anderson MD, MBA, FACEP, FAAEM – Grand Rapids, MI Faculty Cleveland Clinic MetroHealth Emergency Medicine Residency Kayur V. Patel MD, FACP, FACPE, FACHE, FACEP Faculty Emergency Medicine Cleveland Clinic Chairman, Access2MD Terre Haute, Indiana Lerner College of Medicine Cleveland, OH Igor Kozunov, MBA, MHA Chief Executive Officer, Wellness For Life Chew Yian Chai, MD, MCEM, FAMS Medical, LLC Consultant/ EDTU Director, National University Indianapolis, IN Hospital Emergency Medicine Department, Singapore Louella Vaughan, MBBS, MPhil, DPhil, FRACP Consultant Physician in Acute Medicine, The Carol L Clark MDMBA FACEP Royal London Hospital Professor, Oakland University William Beaumont Senior Clinical Research Fellow, The Nuffield School of Medicine Trust, Associate Director of Research

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Contributors

Department of Emergency Medicine Director, Center of Ultrasound Education and Beaumont Health Systems- Royal Oak, MI Research Department of Emergency Medicine and Michelle A. Wiener, MD, MS Hospitalist Services Clinical Faculty, Wayne State University School Medical College of Georgia, Augusta University of Medicine St. John Medical Center, Detroit , MI Leah S. Taylor, MA Instructor, Augusta University Matthew Tabbut, MD, FACEP Augusta, GA Attending Physician, Department of Emergency Medicine, MetroHealth Medical Center Robert W. Gibson, PhD, MSOTR/L FAOTA Assistant Professor of Emergency Medicine, Professor, Director of Research Case Western Reserve University School of Department of Emergency Medicine Medicine Medical College of Georgia Cleveland, OH Augusta University, Augusta, GA

Saurin Bhatt, MD, MBA Rokhsanna Sadeghi, MD, MPH Faculty Cleveland Clinic – MetroHealth Finger Lakes Health, Attending Physician Geneva, Emergency Medicine Residency NY Faculty Emergency Medicine Cleveland Clinic Lerner College of Medicine, Cleveland, OH Abhinav Chandra, MD, FACEP Kaiser Permanente Senior Clinician Physician in Mark G. Moseley MD, MHA, FACEP Emergency Medicine, Vice Chairman for Clinical Affairs Director of Emergency Observation Medicine, The OSU Department of Emergency Medicine Kaiser Permanente South Sacramento, CA Medical Director for Utilization Management The Ohio State University Health System Elizabeth A. Rees, MD Columbus, OH Attending Physician, Methodist Medical Center Oak Ridge, TN. (formerly Wake Forest Baptist Miles P. Hawley, MD, MBA Health Medical Center, Winston-Salem, NC) Senior Medical Director, System Hospitalist and Observation Services Claire Pearson MD, MPH Director, Physician Advisor Services Assistant Professor, Department of Emergency OhioHealth Columbus, OH Medicine Division of Clinical Research, Wayne State Taruna Aurora, MD University School of Medicine Assistant Professor, Departments of Emergency & Internal Medicine Robert D. Welch, MD, MS, FACEP Director, Clinical Decision Unit, Emergency Professor , Wayne State University School of Department Medicine Medical Director, Department of Care Director of Clinical Research, Department of Coordination and Utilization Management Emergency Medicine Virginia Commonwealth University Health Detroit Receiving Hospital, Detroit, MI Systems Richmond, VA Brian Kern, MD Attending Physician, Detroit Medical Center, Kimberly A. Ressler, MD, MSN Clinical Assistant Professor, Department of Attending Physician Emergency Medicine, Wayne State University Rochester General Hospital Rochester, NY School of Medicine

Matt Lyon, MD, FACEP Veronica Sikka MD, Phd, MHA, MPH, FACEP Professor and Vice Chairman Veronica Sikka, MD, PhD, MHA, MPH, FAAEM, Director, Emergency Department Observation FACEP Unit Chief, Emergency Medicine xvii

Contributors

Orlando VA Medical Center St Joseph Mercy Hospital Emergency Medicine, Associate Professor, Emergency Medicine Ann Arbor, MI UCF School of Medicine Orlando, FL Michael A. Granovsky, MD, CPC, CEDC, FACEP Renee Reid, MD, FACEP President, Coding for Logix Health Assistant Professor, Virginia Commonwealth Chair, ACEP Physicians Coding and University Richmond, VA Nomenclature Advisory Committee (CNAC) Harinder Dhindsa, MD, MBA, MPH Associate Professor, Attending David A. McKenzie, CAE Physician, Virginia Commonwealth University Reimbursement Director, American College of School of Medicine, Chief of Emergency Emergency Physicians Dallas, TX Medicine, Richmond, VA Candace E. Schaeffer, RN, MBA, RHIA Aderonke Ojo, MBBS Compliance Officer, Optum360 Associate Professor of Pediatrics Baylor College of Medicine BK Kizziar, RN-BC, CCM Attending ED Physician, Texas Children’s Member Case Management Society of America, Hospital, Houston, TX Owner, BK Associates Grandbury, TX Fredric M. Hustey, MD, FACEP Nancy E. Skinner, RN-BC, CCM Attending Physician Cleveland Clinic President, Riverside HealthCare Consulting Associate Professor, Cleveland Clinic Lerner Whitwell, TN College of Medicine Robert L. Leviton, MD, MPH, CI, FACEP Case Western Reserve University, Cleveland, OH Chief Medical Information Officer - Physician Nathaniel L. Scott, MD, FACEP Advisor Program Director, EM / IM Combined Residency Bronx Lebanon Hospital Center, Bronx, NY Program Staff Physician, Emergency Medicine and Sandra Sieck, RN, MBA Hospital Medicine, Hennepin County Medical Chief Executive Officer, Sieck HealthCare Center Mobile, Al Assistant Professor, University of Minnesota Heather Tuffin, MBChB (UCT), DipPEC (CMSA) Medical School Minneapolis, MN Improvement Advisor, Western James R. Miner, MD, FACEP Cape Department of Health, Capetown, Chief of Emergency Medicine South Africa Hennepin County Medical Center LA Wallis, MBChB, FRCS, DIMCRCS, Dip Sport Professor of Emergency Medicine Med, FCEM, FIFEM University of Minnesota, Minneapolis, MN Professor and Head of Emergency Medicine, Steven J. Walsh, MD Stellenbosch University Fellow, Carolinas Poison Center, Chapel Hill, NC Head of Emergency Medicine, Western Cape Government Marsha Ford, MD, FACEP President, International Federation for Former President, American Association Poison Emergency Medicine Control Centers, Adjunct Professor UNC-Chapel Professor and Head of Emergency Medicine, Hill School of Medicine, Toxicoligist/Attending University of Cape Town, South Africa Physician Carolinas Healthcare System Charlotte, NC Malcolm Mahadevan MD, FRCS, MRCP, FAMS Associate Professor, National University of Constance J. Doyle, MD, FACEP Singapore Clinical Instructor Emergency Medicine Head and Senior Consultant, National University University of Michigan, Attending Physician Hospital System, Singapore

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Contributors

John Burke, FACEM Angelo Ianni, MD Deputy Director, Emergency Department Department of Emergency Medicine Royal Brisbane & Women’s Hospital Sant’Andrea Hospital, Rome, Italy Brisbane, Australia Christina Bongiovanni , MD Michael Ardagh, ONZM, PhD, MbChB, DCH, Department of Emergency Medicine FACEM Sant’Andrea Hospital, Rome, Italy Professor of Emergency Medicine, University of Dylan Jenkins, MBBS Otago, Christchurch, New Zealand Consultant, Doncaster Royal Infirmary Said Laribi, MD, PhD Doncaster, United Kingdom Professor of Emergency Medicine, University of Carlos-Hernan Camargo-Mila, M.D., E.A.E.S., A.C.E.P. Tours, France Professor of Surgery and Emergency Medicine Chair of the Emergency Medicine Department, Colegio Mayor del Rosario University Tours University Hospital, France Chairman of the Emergency Department Patrick Plaisance, MD, PhD Fundación CardioInfantil - Instituto de Cardiología Professor of Emergency Medicine, University Bogotá D.C. - COLOMBIA Paris Diderot, France Chair of the Emergency Room, Lariboisière Madeline Joseph, MD, FACEP, FAAP University Hospital, Paris, France Professor of Emergency Medicine and Pediatrics Assistant Chair of Pediatric Emergency Medicine Martin Mockel, MD, PhD, FESC, FAHA Quality Improvement, Department of Emergency Charité – Universitätsmedizin Berlin, Berlin, Medicine Germany University of Florida College of Medicine- Julia Searle, MD, MPH Jacksonville, FL Charité – Universitätsmedizin Berlin, Berlin, Sean Bush, MD, FACEP Germany Professor of Emergency Medicine Brody School Salvatore Di Somma, MD, PhD of Medicine East Carolina University, Attending Physician Vidant Medical Center Greenville, NC Department of Emergency Medicine Sant’Andrea Hospital, Rome, Italy Matthew J. Campbell, Pharm. D., BCPS Department of Medical and Surgery Science and Lead Pharmacist Emergency Department, Translational Medicine Cleveland Clinic. University “Sapienza”, Rome, Italy Cleveland, OH

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Foreword: Onward and Upward

Science in many ways has become an inter- computer for the word machines and you have national bully. It expects everyone to stop their our own age. day-to-day life as “we scientists” prod and probe Fourth, there is no controlled governor on the the human body doing everything we can to belit- current system. Dr. John Rogers once comment- tle human life and reduce the patient to a soulless ing on medicine said, “They gave us an unlimited heart-lung preparation without value, virtue, and budget, and we over spent it.” Will the useless the essence of humanity removed. The more time CPR ever stop? the patients spend in the giant monolith known With these thoughts in mind, let’s predict as the tertiary care hospital, the less real patient’s where medicine will be and why this book should lives become. be extremely useful. The emergency departments Enter this book and more importantly the of America have become centers of clinical deci- field of observation medicine. First things first. sion making. The ED is where all important deci- Most books don’t need a foreword! Get on with it, sions of inpatient v. outpatient care are now being but in the best traditions of foreword writing I’m made. Observation medicine is the new third going to set forth a framework as to where medi- pathway which allows a good alternative to pro- cine is to go if we are to have any economic tect inpatient populations and yet recognize that viability as a profession and still meaningfully time is the only reliable test of therapy. Not all improve outcomes. care fits into the neat four hour maximum of Let’s draw some quick conclusions as to where standard emergency department visits. medicine stands at the year 2016. What have we Hopefully with new opportunities to control learned from the past? First, most things that overall costs, we will take this opportunity and happen in hospitals have unintended conse- seize the day. The real question is, are we going to quences, i.e. “Bad things happen; even with the be able to move the current system to “buy into” a best of intentions.” The sooner we get you out of healthcare product mode which addresses indi- the hospital, the less likely you are to pick up an vidual charges but can concentrate on actual infection we can’t cure or fall and break your hip. costs? No economist would confuse these con- This is a change from my early life in medicine cepts. The bulk purchase of service will require where we assumed that the death rate was lower honesty about what needs to be done for patients inside these huge structures of science than out on as opposed to what can be charged for when the streets or at home. dealing with the government and third party Second, costs count! You can die at home for payers. free and if we can’t make a real contribution to a Just conclude that if the days of big money meaningful life, what are we doing, and why are and “spend at all costs” isn’t over with, it shortly we charging so much money for it? Human flour- will be. Observation medicine should be ready to ishing is not equivalent to having a heartbeat. offer the cost effective alternative. If we can’tdo Third, Charlie Chaplin’s classic film, that than just burn this book and admit everyone. “Modern Times” was made during the machine Lost somewhere in ICD–10 coding, (and what age when there was a wide spread fear that tech- isn’t lost in ICD–10 coding) is the concept of nology was setting the agenda for human life. making life better. Getting patients closer to their “Taylorism” as the Marxist used to put it, was families and friends and out of rooms where the putting rigid unvarying thought before actions mattresses are covered in plastic and the only or consideration of outcomes. Substitute people who touch you wear gloves and masks.

Foreword: Onward and Upward

The new world for providers looks much from 5,700 to slightly less than 4,000. What is the different than the old. It is no accident that organ- correct number of such hospitals which are ized medicine has not asked serious questions needed? What is the number of free standing concerning workforce issues. 75% to 80% of the ERs and urgent care centers which are needed? healthcare costs in America are workforce. There All of these will depend on the blossoming of is almost no real research as to who should be observation medicine. So as you proceed through doing just what. This is as true in urban areas as this book, don’t lose the forest in the ventilators. in rural outposts. It is an embarrassment that we Remember the goals; cost effective care, time effi- do not have these answers which are needed if cient care, the best patient outcomes, and more cost control is to be achieved. Even the simplest compassionate human centered care. Observation questions as to how many facilities do we need per medicine can achieve these goals. population, hinges on the questions of utilization Ars longa vita brevis. and cost. The number of hospital based emergency departments in the last 40 years has gone Greg Henry, MD

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Preface

The purpose of this textbook is to provide a medicine operating with a patient/family centered resource for anyone interested in observation focus can help provide the highest quality of medicine and to be a practical education for patient care with optimal patient outcomes and “how to” do observation in any setting or loca- be cost-effective. tion, even internationally. Currently, there is no I hope that everyone: clinicians, administra- one source that you can reference to learn about tors, nursing, case managers, reimbursement spe- not just the clinical aspects of observation with cialists, utilization review experts, and the many information including protocols and order sets; others involved in any aspect of observation but also the administrative, business, fiscal, nurs- medicine; will find this textbook a valuable ing, case management, utilization review, design, resource in their clinical practice and daily oper- reimbursement, regulatory/governmental, and ations that can provide a useful toolkit for under- other facets of observation medicine. Monumen- standing the many complex issues with tal changes are occurring in health care not just in observation medicine and healthcare, and offer the United States but throughout the world and insights into recent developments and the future. observation medicine can be on the frontlines in With any endeavor, there are many contribu- solving the complex issues facing healthcare now tors. I could not have accomplished this textbook and in the future. without the numerous authors and editors, as well This text is intended to be a practicum for as the individuals at Cambridge University Press. anyone interested in setting up or maintaining a I have had the honor and pleasure of serving as successful Observation Unit (OU). To quote a the Director of the Clinical Decision Unit at the colleague and friend, this textbook is “one stop Cleveland Clinic since its beginning in 1994, more shopping” for observation medicine. Much of the than twenty years ago. The CDU is one of the information in this textbook is not readily avail- oldest OUs in existence. The 20 bed unit has able elsewhere. Some of the Chapters, such as the averaged about 6,000 patients a year and has been protocols and order sets are detailed enough to in operation with the same director since its serve as a “hands on’ manual for observation inception. Indeed, we may have the longest con- medicine. The intent was to provide a concise, tinuously in operation OU with the same OU useful overview of all aspects of observation medi- director anywhere. I would like to acknowledge cine starting with the clinical and expanding to the numerous contributions of my colleagues and the organizational and administrative aspects coworkers over these two decades including the from set-up and staffing; to the regulatory/gov- many outstanding physicians, the exceptional ernmental, the business and financial, and reim- nurses and other personal in the OU and the bursement. This “real world” information should emergency department and the hospital staff/per- be applicable to any given practice setting; sonnel. Thank you for allowing me to work with whether urban, suburban or rural; community- you and improve care for our patients. To my based or academic, in the United States or world- students, residents and fellows, thank you for wide. In the 21st century, medicine including allowing me to participate in your education and observation medicine is an art, a science and a research. May all our patients benefit. Finally, business. This text is intended to address these thank you to my family and friends for their three topics; while detailing how observation encouragement and love.

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