With the advent of Hospital Medicine and the availability of 24-hour inpatient physician coverage, there is significant opportunity for co-management of patients who require hospital admission.
Many large EDs contain an ED-based observation unit, and observation medicine is rapidly developing into a subspecialty within Emergency Medicine (see Chapter 123, Co-management of Patients in the Emergency Department). As Emergency Medicine evolves to become the interface and fulcrum between outpatient and inpatient medicine and as more care, diagnostics, and therapeutics are shifted to the outpatient arena, many patients may need more than a brief ED visit without needing a full admission. Most ED-based observation units are protocol based and designed for patients who will have an anticipated length of stay of less then 24 hours, although some observation units will function similarly to short-stay units and accommodate patients up to 72 hours. Staffing is variable and usually includes nurses as well as physician extenders. CMS has developed guidelines for reimbursement within short-stay observation units and approved four diagnoses for reimbursement for observation unit admissions: chest pain, heart failure exacerbation, asthma exacerbation, and nonketotic hyperglycemia, although most observation units will treat far more diagnostic categories.
A 2007 Institute of Medicine report focused on the critical issue of ED overcrowding. The report described the rapidly increasing number of ED visits (up 32% between 1996 and 2006), which directly correlated with increased ED wait times and an associated increase in untoward events and decreased compliance with certain specific quality metrics. As both emergency physicians and hospitalists are increasingly striving to reduce length of stay while meeting specific quality and safety metrics, seamless transitions in care as patients transition from the ED to inpatient environment are paramount. Transfers in care among providers are potential sources of error, and the use of structured, codified mechanisms and processes for transfers in care can reduce error. In order to effectively and safely manage transitions in care, strong communication and teamwork as well as mutually agreed upon structure are required.
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In order to optimize safe handoffs and care transitions, unambiguous accountability is paramount to achieve the safest possible care, keeping in mind that a rapidly decompensating patient may require personal attention by the most immediately available clinician. Clear, direct, and timely communication from one care provider to another will facilitate safe handoff. The ED physician should concisely report the patient's presentation, evaluation, ED management, pending results, and expected plan of continued care, including ongoing medical concerns, risk assessment, and social aspects of care. The hospitalist should clearly ask questions and share thoughts and recommendations regarding the next steps in care, including the initiation of any urgent orders and communication with other physicians involved in the patient's care. Interactive collegial communication between clinicians along with respectful feedback will facilitate the optimal care of patients individually and globally. Patients and families should take an active role in all aspects of care, especially during the time of handoff. They should receive clear information about care transfer and the new inpatient clinicians responsible for their care.