UCLA GondaOBS Unit

1. UCLA GondaOBS Unit Patient Selection, Management Algorithms, & Physician Orientation / Education

2. Why Are you Doing this to Us?

3. Why Are You Doing this to Us?Best Practice Units Focus on guideline based provision of care, patient safety, and clinical outcomes Specially trained staff Focus on patient education

4. Do Obs Units Work? CMAJ Nov 28 2000- A hospitalist run medical short-stay unit showed shorter length of stay, lower rates of in-hospital complications, and lower rates of readmissions within 30days than patients admitted to the general wards “The MSSU appeared to promote the efficient use of hospital beds without compromising patient outcomes”

5. Do Obs Units Work? MJA 2003; 178: 559–563 SOUs have the potential to increase patient satisfaction, reduce length of stay, improve the efficiency of emergency departments and improve cost effectiveness. However, SOUs have commonly been implemented alongside new clinical protocols, and it is not possible to distinguish the relative benefits of each. As demand increases, providing effective and cost-efficient care will become increasingly important. SOUs may help organizations that are attempting to streamline patient care while maintaining their quality of service delivery.

6. Why Are you Doing this to Us? The Numbers game: 45 beds on the old 5W(CHS) 52 beds allotted to General Medicine in Westwood Replacement Hospital Gonda Observation Unit (GOU) has 13beds that can be used to treat our “least sick” medical patients or patients who may be acutely ill but have the potential to respond rapidly to medical treatment

7. CMS CMI Impact Inpatient LOS / Severity of illness

8. “Show Me the Money” Medicare known to reimburse $0 for certain short stays if severity of pt’s illness (as determined by documentation in chart) did not meet their “inpatient criteria.” Observation status in an outpatient service and thus more likely to be reimbursed for certain diagnoses with short stays.

9. Observation Unit Inclusion criteria

10. Chest pain Syncope Gastroenteritis/ dehydration Minor electrolyte abnormalities Asthma Alcohol Withdrawal Cellulitis Symptomatic anemia/thrombocytopenia Post procedural (After usual and standard recovery period related to procedure – usually 6H)

12. Chest pain Syncope CHF

13. Asthma Gastroenteritis/Dehydration Minor electrolyte abnormalities Cellulitis Alcohol withdrawal Symptomatic anemia Sickle Cell anemia with pain Syncope Other

15. Covered by the team who performed the procedure or operation Exception is patients s/p chemoembolization or RFA for liver lesions- cared for by obs team with hospitalist attending

16. Obs/Overflow resident covers all new and old medical patients in the GOU. Works 7-7 shifts. Available on pager 96450 for ED to consult re possible obs admits. Obs/Overflow intern often available during peak admitting hours. Specific focus on serial physical examinations (few radiographic studies in GOU) and developing a focused overall treatment plan (little specialist consultation in GOU).

17. Patient evaluation, completion of orders, and H&P done within 30minutes Pre-printed admission check-box order forms. Templated H&P’s D/C paperwork and Rx’s done at time of admission

18. Observation Order Requirements Order must read: Admit: observation status or Admit to observation Indicate what looking for / purpose of observation If ‘admit’ is only order (status unspecified) defaults to inpatient status (Patient safety issue)

21. Goal is an 80% discharge rate from Gonda DOT Projection = 20% of obs pts will likely be converted to inpatient stays Continuous feedback and real-time adjustments to inclusion/exclusion criteria and management algorithms to meet these goals

22. Social admission: pts in need of nursing facility placement Unknown differential Unable to mobilize Violent Behavioral disorders Pt refusal of appropriate care

27. Acute Gastroenteritis/PO Intolerance/Dehydration  Observation Unit Inclusion Criteria Dehydration with orthostatic hypotension or tachycardia Cause thought to be reversible within 24hrs ie viral or bacterial gastroenteritis Inability to tolerate crucial PO meds

28. Gastroenteritis/POIntolerance/Dehydration Exclusion Criteria Bloody emesis Hematochezia with falling hematocrit Sodium <125 Severe acute renal failure not likely to resolve with hydration (FeNa suggestive of intrinsic renal damage etc) Bicarbonate <12 on chem. Panel Anion gap>15 Impending shock

30. Alcohol Withdrawal Inclusion Criteria Clear diagnosis of alcohol withdrawal or acute alcohol intoxication after a complete history and physical examination Has an objective medical reason for observation (abnormal vital signs, altered level of consciousness needing repeat neuro checks, hypoglycemia, marked electrolyte abnormalities, etc.) High probability of response to treatment and discharge from hospital within 48hours

31. Alcohol Withdrawal Exclusion Criteria Delirium (during current presentation) Seizure (during current presentation) Alcoholic hepatitis Pancreatitis Active GI bleeding Wernicke’s encephalopathy Severe alcoholic ketoacidosis Aspiration pneumonitis/ pneumonia

32. Alcohol Withdrawal Exclusion Criteria (Continued) Hemodynamic instability (hypertensive emergency or hypotension) Rhabdomyolysis Other uncontrolled comorbidities (chf, diabetes, etc.) expected to prolong hospitalization Profound intoxication with inability to protect airway Anticipated need for nursing facility placement at conclusion of current hospitalization Anticipated need for Neuropsychiatric Hospital bed at end of hospitalization (unless NPH bed is currently being held for this patient)

34. Cellulitis Obs Inclusion Criteria Clear or probable diagnosis of cellulitis after complete history and physical examination High probability of response to treatment and discharge from hospital within 48hours

35. Obs Unit Exclusion Criteria for Cellulitis Tissue necrosis or crepitus on examination Severe pain (may indicate a deep infection) Signs of systemic toxicity/ possible early sepsis Neutropenia Diabetic foot with surgical intervention likely prior to discharge

36. Risk Factors for Slow Response of Cellulitis to Treatment  Cellulitis located on hand, periorbital region, scrotum, neck, or over joints Diabetic patient without imminent surgical intervention Peripheral vascular disease Patient with chronic lymphedema or severe chronic venous stasis Collagen-vascular disease on immunosuppressant medications Other conditions associated with immunosuppression (active malignancy, HIV, CKD, cirrhosis, s/p splenectomy) Organ transplant recipients Cellulitis with suspected subjacent osteomyelitis Bite wounds History of IV drug use/ skin popping History of colonization or infection with resistant organisms

37. Symptomatic Anemia/Thrombocytopenia Obs Inclusion Criteria Known cause for anemia and/ or thrombocytopenia (e.g., MDS with transfusion dependence) Anemia should be symptomatic or patient should be at risk of complications (e.g., pts with known coronary artery disease) without urgent transfusion. If these conditions not met, outpatient transfusion services should be arranged. Thrombocytopenia with minor bleeding (epistaxis, gingival bleeding) Thrombocytopenia and clinical assessment reveals increased risk of bleeding without urgent transfusion Patient’s hematologist or oncologist (or primary medical doctor if patient does not see a hematologist or oncologist) should be contacted and verify that a medical short stay is acceptable and that further intensive workup is not currently indicated for a given patient.

38. Symptomatic Anemia/Thrombocytopenia Obs Exclusion Criteria Hemodynamic instability Major bleeding Unknown cause of anemia or thrombocytopenia Further intensive inpatient workup expected (e.g., bone marrow biopsy with discharge decision expected to depend on results) Febrile neutropenia Other active comorbid conditions (pneumonia, CHF, etc.) that would justify inpatient admission Hematologist/ oncologist requests full inpatient admission

39. Sickle Cell Anemia with Acute Pain Crisis Obs Inclusion Known diagnosis of sickle cell disease or sickle cell variant Presenting complaint is pain Pain relief not adequate with a reasonable trial of narcotic analgesics in the outpatient setting or the Emergency Department

40. Sickle Cell Anemia with Acute Pain Crisis Obs Exclusion New infiltrate on chest x-ray New hypoxemia or increased oxygen requirement if on chronic O2 New focal neurologic findings Anticipated need for exchange transfusion Suspected splenic or hepatic sequestration crisis Suspected aplastic crisis Altered mental status Acute renal failure Chronic kidney disease with need to initiate dialysis

41. Sickle Cell Anemia with Acute Pain Crisis Obs Exclusion II Sickle cell anemia with severe asthma exacerbation Ongoing myocardial ischemia Sickle cell anemia with sings/symptoms suggestive of acute left or right heart failure Acute liver failure Decompensated chronic liver failure Acute cholecystitis or ascending cholangitis New diagnosis of osteomyelitis New diagnosis of avascular necrosis

42. Observation stays can be as short as 8H and up to 48H * Patients are continually reassessed by the covering physicians Pts discharged as soon as sustained improvements seen in their acute condition

43. Patient Disposition To Home- Gonda DOT staff with special training in scheduling outpatient diagnostics F/U with PMD, Cards clinic, IMS Urgent Care within 2-7d of d/c depending on diagnosis If transferred to inpatient care, admitting team writes an INPATIENT H&P and orders

44. Discharging from Obs All patients get a discharge summary D/C summary can be very brief and templated (see your hospitalist obs attending for available d/c templates). D/C summaries on the day of D/C (should take less than 5min and needs to be available for f/u appointments- sometimes next day)

45. Key Take Home Message Gonda Diagnostic Observation and Treatment Unit is an Outpatient Unit with a 24 / 7 operation time. Patient discharges are 24/7 similar to the ED. Expectation: When the clinical need for observation has ended the patient can be discharged no matter the time of day or night.

46. “Off Protocol” Possibilities Pneumonia with a severity index of 2-3 Acute pain UTI/pyelonephritis Psychiatry patients needing short term medical monitoring prior to admission Acute intoxications Headache Low Risk GI bleeding

47. New Educational Opportunities Focus on “bread and butter medicine” Focus on bedside physical diagnostics rather than multiple imaging studies Education on cost of care Research opportunities on treatment algorithms, patient safety, patient education

48. Gonda DOT 13 Beds Open for Business!