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My hospital administration has asked me to open an observation unit.
What advice do you have about getting one off the ground and operational? Some Common Starting Points The beginning of any development project will have some common themes. Call a friend or a colleague and find a successfully run obs unit that you can take your crew to see their set up and find out what works best and what they would do differently.
Common op-ed topics to write about size and staffing needs of the unit will be determined by how many patients you expect from the ED and how long their average length of stay will be. You also need to track how many of these patients are upgraded from the obs unit to a regular hospital bed.
The key metrics are volume, as new admissions per day, average LOS, and upgrade percentage. The goal is a high efficiency, high turnover unit with quality care.
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The obs unit is like any other part of the hospital— getting the right patient to the right place. You should develop your key principles around your unit metrics but some good starting points are: From these principles you can come up with your list of common appropriate diagnoses, your general exclusion criteria, and certain diagnoses that are specifically excluded.
Like any good project, it will start with having an executive sponsor. Your key stakeholders will form your operations meeting to trouble shoot problems and review data. Nurses, techs, ED docs and hospitalists are obvious starting points for this committee; as is representation from the lab and radiology.
Location and Resources You have likely seen observation done in a variety of ways. This is obviously not a dedicated observation unit.
These virtual obs patients usually have longer than necessary length of stays because there is not the commitment to make these patients a top priority in getting their work up completed. Therefore, an obs unit needs a dedicated space.
Ideally, the space will be adjacent to the ED as there are staffing and communication benefits to this. Deciding on an open or closed unit is also a philosophical discussion. Will the ED own and control all of the beds closed or will some be reserved for other specialists?
In addition to dedicated space, you need to have dedicated resources. Additionally, some OBS units have closed units with consultants, in that only a specific cardiology group or neurology group for example, would be allowed to consult on obs patients to assure timely turn around times.
From a leadership point of view, there should be both a medical and a nursing director. A good staffing ratio is 1 nurse per 5 patients and 1 tech for each 1. Because many of these patients will have serial blood tests, techs should be good phlebotomists.
A unit clerk will be instrumental in keeping the patients moving to tests and handling the paperwork. Depending on the size of the unit, you will likely need 1 full time provider.
Obs units can be staffed by a committed and knowledgeable advanced practice provider, typically with part time ED attending supervision often rounding occurs before and after a day shift.
Some facilities may choose to use a nurse practitioner to run the unit and keep the physician out of the process.
That is certainly possible without a big hit to the billing check with your billing company and expect at least a reduction among Medicare patientsbut I would caution you to be consistent with the culture of your hospital.The Commonwealth Club of California is the nation's oldest and largest public affairs forum.
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