There is a little-known beacon of health care savings square in the center of our city. One of the state’s busiest combined emergency practices is saving money by implementing protocol-driven observation unit care for emergency room patients. If hospital systems around the country did the same, it could save the American health care system millions.
These units place selected patients on similar clinical pathways — with set end points in a standard way, called a “protocol” — to increase efficiency.
As a physician in the Emory University department of emergency medicine, I have performed considerable research in observation medicine, and I provided medical direction to one of these observation units noted in a recent study.
These units are typically located adjacent to emergency departments and staffed by emergency physicians like me. Here, patients who are generally too sick to go directly home, but not sick enough to warrant a traditional five-day hospital stay, are aggressively cared for in a protocol-driven fashion.
Last winter, one patient in her late 60s — let’s call her Betty — came into the ER with a cough and a fever. She was feeling lightheaded. After a chest X-ray and some blood tests, I told her she had pneumonia and would have to stay in the hospital. Sometimes, the fever and lightheadedness can indicate a severe pneumonia, but Betty felt pretty good before treatment.
I placed her in the observation unit where we could give her fluids and antibiotics. More important, I was able to monitor her response to treatment in a controlled setting. She left the next day feeling less lightheaded, and she completed her course of antibiotics at home.
I have treated hundreds of patients like Betty over the course of my career whose treatment plans were amenable to this type of care. In the observation unit, Betty was frequently evaluated; when, by our protocol, she had met discharge criteria, she was able to go home without a costly hospital admission.
In a hospital without this type of unit, Betty would have been mixed in with patients who need surgery, have had heart attacks or have terrible back pain. She easily could have been lost in the daily shuffle and treated like a patient who needs to stay five days instead of two. Having a place designed for this type of patient’s needs is similar to having an intensive care unit for the sickest patients.
Researchers at Emory and the Agency for Healthcare Research and Quality evaluated over 7,000 visits from observation units at two Emory hospitals and Grady Memorial Hospital. They found these patients had shorter hospital stays than similar groups in national surveys. The average stay in a Grady or Emory observation unit is about 17 hours; the national average is closer to 22 hours.
The decrease in hospital days translated to nearly $1 billion in savings in this study. Researchers at Harvard published a separate analysis that showed a possibility of over $3 billion in savings.
Suffice to say, more observation units are good thing, and it’s not just about money. Observation units have been shown to misdiagnose or overlook heart attacks less frequently. They provide better quality of life following asthma flare-ups. They can provide shorter, less costly hospital stays across a number of diagnoses.
Over the past two years, the term “observation” has come under fire from senior advocacy groups as a way to push costs onto seniors through co-pays. This administrative “observation status” issue is complex, but according to the Office of the Inspector General at the U.S. Dept. of Health and Human Services, most seniors with Medicare pay less in “observation status” than if they had to pay in-patient deductibles.
Atlanta is a hotbed of observation medicine research, along with Detroit and Boston. About one-third of U.S. hospitals have protocol-driven observation units. They save money for all parties involved. Structuring future payment policy at the state and national levels can encourage these units to proliferate.
Patients should appreciate that being placed in an observation unit is a great thing and an innovative way to deliver health care. Finally, our local hospital administrators can encourage these units by recruiting physicians and staff who can develop these protocols and implement them in their hospitals.
Dr. Anwar Osborne is assistant professor of emergency medicine at Emory University School of Medicine.
