Helen C. D’Souza, MHA ACHE, MGMA Indianapolis, Indiana		Daneil J. Miesle, MHA, CHE ACHE, AHA Indianapolis, Indiana

Recent changes in the health care environment and the evolution of managed care have brought a number of new forces to bear on health care delivery systems, and have heightened some existing forces. Quality and appropriateness of care, patient satisfaction, and cost management remain the cornerstones of an effective system. These tenets are nowhere more applicable than in the emergency department. Emergency care requires intense resource utilization, and costs incurred to the system are therefore significant. Marshaling these resources in a framework of proper and efficient patient care is vital to the survival and continued growth of an institution.

The concept of observation care in the emergency department is not a new one, and has been practiced by default since emergency departments came into existence. In the past, hospitals typically designated a section of the emergency department for patient observation or as a holding area until borderline patients could be admitted ⁽¹⁾. This practice, however, can lead to inefficient use of personnel and equipment, hinder optimal patient care, and prove to be expensive.

Contemporary observation care units/rapid treatment centers (OCUs/RTCs), either contained within the emergency department or closely associated with emergency/acute care in a given system, have more recently evolved in an effort to optimize the quality and efficiency of health care delivery. Two other factors have also contributed to the increase in OCUs/RTCs. In 1992, the Joint Commission on Accreditation of Health Care Organizations (JACK) removed the 12-hour limit for patient observation in the emergency department. This fostered the rise of OCUs/RTCs, as these units were designed to manage patients for 24 hours or more. Shortly thereafter, in l993, the Physicians' Current Procedural Terminology manual began including physician codes for hospital-based observation care, which increased physician awareness of OCUs/RTCs and facilitated reimbursement ⁽²⁾. The OCU is a comprehensive model in which observation requires active, on-going evaluation combined with treatment, intervention, on-going assessment, case management, and clinical outcome analysis. This is a departure from the passive watching and waiting in a traditional holding unit. The OCU/RTC model seeks to reduce the time for diagnostic and therapeutic maneuvers, thereby improving quality of care and cost effectiveness ⁽⁴⁾.

The pros and cons of the development and institution of OCUs have been debated for some time ^(5,6). Proponents of OCUs/RTCs in the emergency department hold that these units lead to improvement of patient care and help overworked emergency physicians, giving them more time and information to make diagnoses and treat patients, which improves outcomes and reduces costs ⁽⁷⁾. Furthermore, these units may reduce the risk of malpractice because patient are less likely to be inadvertently discharged with a serious condition. Critics, however, suggest that the concept is driven by the cost-control efforts of payers and managed care's drive to reduce medically unnecessary hospital admissions. Other criticisms include the assertion that the OCU/RTC increases the workload for already overburdened emergency physicians and staff, thus compromising patient care ^(4,9).

Although the number of OCUs/RTCs nationally seems to be increasing, current data on their effectiveness are limited. This study was initiated to develop a data base on current attitudes about OCUs/RTCs in the health care industry. The subsequent interpretation and analysis of these data provided insight into the development of recommendations to guide a health care institution in considering the planning of an OCU/RTC.

Abstract

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