September 5, 2018

Observation: Outside the Protocols

Emergency department observation units (EDOU) have increased efficiency and streamlined patient care. In addition to the “ED mentality” being applied in the units, the use of protocols linked to symptoms or diagnoses are a major tool for decreasing variability leading to efficient practice. Assuming a broad set of protocols, the majority of patients can be managed thoroughly and expeditiously in the EDOU, decreasing admissions not meeting medical necessity criteria and improving crowding in the emergency department.1 This article addresses protocolized observation units. The question then comes -  what do you do with a patient who does not meet admission criteria but also falls outside your unit’s observation protocols? These cases occur more often as comorbidities increase, hospitals try to avoid readmission penalties, and more care is shifted to an out-patient setting.

A number of models exist to handle patients who fall in the proverbial gap between EDOU protocols and inpatient admission criteria, or elsewhere described as observation unit versus observation status patients.2 Before further discussion, it is important to note the four types of observation previously described:3

  • Type 1: Protocol-driven in a dedicated observation unit
  • Type 2: Discretionary care in dedicated observation unit
  • Type 3: Protocol-driven in any hospital bed
  • Type 4: Discretionary care in any hospital bed

To account for “gap patients”, some of these models include:

  • Two separately staffed physical units (type 1 and type 2 units)
  • Expanding protocols in a single unit (single type 1 unit)
  • A hybrid where there is a single EDOU but a virtual separation between protocolized and complex observation patients (virtual type 1 within a type 1)
  • An EDOU with the gap patients under the care of an impatient team (type 1 and Type 4)

In the first setting, competition for patients can occur, and blurring of intended patient groups may also occur. Additionally, it may be difficult for hospitals to expand and dedicate often limited physical space to another unit, when from their perspective an observation unit already exists. The second issue is who manages the second unit. Hospitalists have positioned themselves to take on the role of managing the complex observation patient; however, their mission and practice may not align with all the objectives of an ED run OU. Dr. Osborne and colleagues describe a small survey of these “second level” OUs, noting the small number of them. They note that while there are similarities, the metrics and outcome data differ.4 This leads to the second two types of units mentioned.

The second two types of units mentioned are physically the same; however, data and care may vary somewhat between them. In one setting, the EDOU accepts patients beyond their established protocols generally with the condition that the patient has not met admission criteria, and an appropriate disposition (including other factors, ie, need for skilled nurse facilities or other care) can be completed in 24 hours. The more complex patients require more provider time and typically more resources. This can hinder flow and affect overall unit throughput. The benefit of the third type of unit presents itself here. While allowing for the same physical unit, patients placed in a virtual “second level” OU can have their metrics and outcomes separately collected. Additionally, models have been described where care of these “second level” patients is shared with the hospitalists in the same unit.5 The benefit is continuity of care in a group of patients who should be more likely to be admitted after their observation stay and expertise that can differ from the emergency clinician training. Additionally, it allows for collaboration between the ED and hospitalist colleagues.

The last type of unit leaves the EDOU untouched and places the “gap” or status observation patients who do not fit in protocols in inpatient beds in a type 4 OU setting. While this allows the EDOU to operate at peak efficiency on low to moderate risk cases, it places patients who are being billed under observation status and expected, based on status, to only require 24 hours of management for disposition to be mixed with inpatients, often diluting the drive to streamline care with the disposition focus. For hospital systems, it is crucial that these cases receive attention by utilization or care management to align the plan with observation status goals.

Regardless of the type of unit in which complex observation patients are managed, early and regular involvement of care management should be included to assess for and intervene on socioeconomic barriers to care. Additionally, when possible, new complex protocols should be developed to decrease variability, thus increasing care efficiency and, more importantly, patient safety. These protocols may require coordination with more outside services and consulting services than typical EDOU protocols. It is crucial that consultants and outside services are aware of the mission, goals, and expectations for the observation unit. This can lead to expedited follow up appointments and the transition of testing that can be safely performed on an outpatient basis to be performed outside the hospital setting.


  1. Iannone P. Ameliorating the emergency department workflow by involving the observation unit: effects on crowding. Emerg Care J. 2015;11:4957.
  2. Suri P. Letter to the editor: Use of observation units growing. Ann Emerg Med. 2013;62:198-199.
  3. Graff L. The Textbook of Observation Medicine: The Healthcare System’s Tincture of Time. American College of Emergency Physicians. Learn More.
  4. Osborne AD, Farrah H, Wheatley M, et al. There’s another observation unit?: a case series survey of second level observation units. Crit Pathw Cardiol. 2016 Mar;15(1):26-8.
  5. Darves B. Taking charge of observation units. Today’s Hospitalist. 2007 July.

Robert M. Bramante, MD, FACEP

Good Samaritan Hospital Medical Center, West Islip, NY