Background: Over the past 50 years, observation status patients have been cared for in a variety of settings: in the emergency department, on inpatient floors, and in dedicated observation units. At our medical center, inpatient teams have traditionally cared for observation patients on medical wards. Patients were often unaware of their admission status until they received a Medicare Outpatient Observation Notice (MOON) as required by the recent Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act. The diagnostic evaluation and treatment provided to observation patients was indistinguishable from that provided to inpatients. This model led to less efficient observation care with longer length of stays.
Purpose: We developed a dedicated medicine observation unit to improve efficiency and clarity in the delivery of observation care by attending physicians, nurse practitioners, and residents.
Description: The 1 Memorial Observation Unit at the University of North Carolina Medical Center was created as a 25-bed closed unit in June 2017. The project began as an interdepartmental collaboration between the Departments of Internal Medicine and Family Medicine. Physicians from disciplines of outpatient and inpatient medicine reviewed evidence-based practices to develop 16 protocols for the most common and frequent diagnoses expected to be cared for in observation. Stakeholders committed resources from Case Management, Utilization Management, Pharmacy, Physical and Occupational Therapies, Phlebotomy and Laboratory Services, and Transport Services along with dedicated consultation by physicians within Cardiology and Gastroenterology medicine. An observation team was created that consisted of two attending physicians (one from Internal Medicine and one from Family Medicine), two nurse practitioners, and two residents (one from Internal Medicine and one from Family Medicine). Encounters and length of stay were measured for patients receiving care within the Observation Unit and standard observation care on inpatient medicine teams.
Conclusions: Prior to our Observation Unit opening, medicine observation patients were cared for throughout the hospital on various inpatient teams. For the previous academic year, the average length of stay was 42.27 hours. During the 2017-2018 academic year, our Observation Unit cared for 3617 patients who had an initial patient status of observation. 78.1% of these patients (n=2824) were discharged as observation status, making up 66.8% of all medicine observation patients with an average length of stay of 29.87 hours. 33.2% of medicine observation patients (n=1402) were hospitalized on inpatient medicine teams with an average length of stay of 41.71 hours. In its first year, our Observation Unit cared for a majority of medicine observation patients, delivering efficient evidence-based medicine, while teaching residents about observation care.
