This chapter investigates how belonging is constructed through language in Belize. Inspecting linguistic landscapes, interviews, and ethnographic observations, the study reveals the sometimes paradoxical ways languages are ideologically positioned within local, national and transnational contexts. Kriol is central to constructing national belonging and serves as a unifying symbol of a diverse population. It is also tied to racial and transnational belonging, connecting to Afro-Caribbean cultural spaces. Conversely, Spanish is associated with immigration and Guatemala, despite its historical presence and ongoing use. This tension results in contradictory discourses, where Spanish is simultaneously seen as ‘foreign’ and as a home language. English occupies a dual role as both a foreign and national language. While it indexes Belize’s colonial ties and distinguishes Belizeans from their Hispanic neighbours, it is also regarded as essential for education and economic mobility. The chapter concludes that language ideologies and practices do not always align, reflecting the coexistence of diverse historical, social, and political discourses in shaping linguistic belonging in Belize.

This chapter will provide a foundation for the provision of quality visual arts educational experiences in early childhood and the primary years. Practical suggestions for planning a high-quality visual arts program are linked to recent theory in a way that helps you construct your own visual arts program. Visual arts concepts, language, elements and principles will be defined and explained, with examples of the progression in visual arts education from early childhood through the primary years. Practicalities such as classroom management, safety and materials are addressed and additional interactive material can be found through the icons.

Disaster plans must do the greatest good for the greatest number, preserve the medical infrastructure for the sickest and most injured patients and evenly balance medical care across the entire medical spectrum of observation and acute care. Multiple venues for observation, along with limited evaluation and treatment at off-site facilities (e.g. outside the hospital) with attention to an ethical and equitable distribution system for all patients will allow for appropriate, compassionate patient and family centered treatment of individuals including the special health care needs (SHCN) patients/patients with access and functional needs, and provide quality medical care. Plans made in advance, agreements across medical and community and state entities tailored to the unique disaster and in a tiered modular surge system including observation can facilitate the most appropriate distribution and best care possible for the most patients under the difficult situation and constraints of a disaster or pandemic.

This chapter discusses (1) the medical complexity and specialized subspecialty care that is part of the tertiary care hospital which may involve “complex” or “second level” units and (2) academic centers and the inclusion of education and research in academic centers.

Compared to hospitalization, the use of an observation unit (OU) can result in equal to or improved patient care, decreased length of stay, increased patient satisfaction, and lower cost of care and is an efficient and safe utilization of limited health care resources. Treatment of asthmatics in the OU allows time for administered corticosteroids to take effect and for other pharmacologic agents including inhaled short-acting beta-adrenergic agonists and anticholinergics, and magnesium to be administered. Initiation of controller/long-acting medications, patient education and assessment of social determinants of health can occur in the OU.

The observation unit (OU) is an alternative to hospitalization for selected patients and allows the clinician to assess patient response to therapy, and to detect any other hidden pathology or complications. In the OU, management includes IV antibiotics, antiemetics, IV fluids, and treatment of fever and pain. By reducing the number of hospital admissions for acute cystitis and pyelonephritis there can be significant cost savings for both the patient and the health care system.

Optimal care for the abdominal pain patient includes early diagnosis, urgent surgical consultation when required, and appropriate imaging and disposition. In some cases, patients may require serial re-evaluations, nonoperative treatment and /or further diagnostic workup to determine the severity of their illness and whether they require further inpatient care or can be safely discharged home with follow-up. Emergency department observation units have been shown to provide efficient and effective care while being more cost-effective compared to inpatient care

Hospice is under-utilized, especially for non-cancer illness deaths. People from communities of color are less likely to receive hospice services. Identifying patients with terminal illnesses in the emergency department (ED) and initiating the hospice discussion or process could be one way to rectify this. Most patients have an ED visit within the last 6 months of life. This suggests that EDs are missing opportunities to offer hospice care to patients. When hospice is under consideration, many EDs admit patients to arrange hospice, but this is not necessary. Transition to hospice care can be coordinated out of the ED or ED observation unit (OU). Admission for hospice placement is rarely necessary, and in one ED study, 89% of ED patients qualifying for and wanting hospice had less than a 2-day stay. Creating an ED to hospice protocol for your OU could improve the provision of patient-oriented care and decrease strain on hospital resources by decreasing unnecessary admissions.

Patients with electrolyte abnormalities may be appropriate for the observation unit (OU) depending on the severity of the disturbance, the patient’s comorbidities, and the suspected etiology of the imbalance. Patients with potential for requiring life-saving interventions or prolonged treatments are better suited for inpatient admission. Abnormalities, both hyper (high) and hypo (low), of potassium, calcium, magnesium, sodium and phosphate may be treated in the OU.

Vaso-occlusive episodes (VOE) are the most common complication resulting from sickle cell disease (SCD) in adults. VOEs are caused by ischemic tissue injury as a result of occlusion of microvascular beds from abnormal sickle shaped red blood cells (RBCs). Individuals with SCD display a host of complications associated with micro and occasionally macro vascular occlusion, including stroke, leg ulcers, spontaneous miscarriage, and renal insufficiency. The acute pain crisis is the most common reason patients with SCD seek medical care in emergency departments (EDs). Due to the recurrent nature of acute pain crises, possible inadequate knowledge of health care providers about the disease, and the intensity of treatment needed, patients with VOEs may be undermedicated in the ED. This can lead to low patient satisfaction, low provider satisfaction, and increased cost of care. Through the use of an ED observation unit (OU) or clinical pathway, patients experiencing VOEs can be effectively managed to improve outcomes, improve satisfaction, and decrease cost of care.

This chapter includes sample medication content that can be used to design order sets for a variety of clinical conditions that are commonly managed in an adult emergency medicine observation unit setting and are intended to be used as examples for clinicians practicing in this setting. The medication content includes typical dosing regimens for selected adult medications as well as listings of commonly-encountered formulations. Clinical highlights relating to adverse effects and place in therapy are also included in selected instances.

Hypoglycemic patients are often hospitalized for further management. Most of these patients can be successfully managed in an observation unit (OU). OU management includes determining the cause of the hypoglycemia, lab tests (basic metabolic panel and renal function, other tests as indicated), correction of the hypoglycemia, frequent monitoring of serum glucose, administration of medications including dextrose, glucagon, and occasionally octreotide, patient education, and at discharge adjustment of daily medications if needed.

Management of transient ischemic attack (TIA) patients in an observation unit (OU) results in reduced risk for subsequent stroke, greater compliance with diagnostic evaluation, shorter length of stay, lower cost, decreased hospital overcrowding and ambulance diversion. OU management should evaluate TIA mimics, differentiate TIA from stroke, and detect high-risk pathologies that require immediate intervention and admission.

Hyperglycemia ranges from new onset diabetes to nonketotic hyperglycemia (hyperosmolar hyperglycemic state [HHS]) and diabetic ketoacidosis (DKA). The treatment goals in selected patients with DKA and HHS can be achieved in the observation unit (OU) and include frequent monitoring, IV fluids and insulin to correct hypovolemia, hyperglycemia, hyperosmolality, electrolyte abnormalities and in the case of DKA, correct the metabolic acidosis. For new-onset diabetics, medications can be started and education can be provided. The OU provides an opportunity to address related lifestyle and health issues that affect patient outcomes in diabetes; including diet, exercise, weight loss, and smoking cessation. Patients with elevated lipids can be started on statin therapy and those with established cardiovascular risk factors begin a daily aspirin. An OU stay allows for expedited consultation with endocrinology in select patients with poorly controlled diabetes, which has shown to improve quality of care.

Reflecting on the many changes, waivers, and flexibility provided during the COVID-19 Pandemic event, there are numerous lessons from the emergency management arena that may be applied to observation medicine. When considering geographic vs. non-geographic observation units, the use of tele-observation may be a practical option creating an observation unit distant from the emergency department. Here physician services required under Medicare may be substituted using independent licensed practitioners who keep directly in contact with the remote observation service physician using tele-health audio-video devices. Developing Job Action Sheets for key observation unit team members can outline immediate response actions and activities, documentation requirements, communication systems, and disposition determination guidance for admission, discharge, or continuing observation.

Trauma is one of the leading global causes of mortality. In spite of more liberal use of CT scans, some patients will still have occult injuries and require a short period of observation and may need treatment of pain, etc. Emergency department observation units (ED OUs) have been used for the short-term management of trauma patients since the 1980s. OUs have proven to be a cost effective and safe alternative to inpatient admission for patients who need short-term management of their injury. OUs were found to decrease length of stay, increase efficiency, and decrease the utilization of resources.

The key components mandatory for observation services: hospital site of service, acute care staffing, continuous care in outpatient setting, intensive managerial review and economical service are enumerated.

This chapter provides a general overview of the disease process of atrial fibrillation beginning from the pathophysiology of the disease to the financial impact on the health care system, includes up to date guidelines on the management and treatment of atrial fibrillation, and demonstrates the impact of an emergency department observation unit in the care of patients with atrial fibrillation.

The treatment of pain and painful complaints in the observation unit (OU) is dependent on appropriate assessment, frequent re-assessment, recognition of any underlying medical conditions, and individualized treatment. Patients referred for observation should meet OU criteria. OU protocols should include provisions for the regular assessment of pain. In addition to non-geriatric adults, special populations including pediatric patients and the elderly, with painful conditions may be managed in the OU. Specific conditions that may be managed in the OU include acute low back pain, acute exacerbation of chronic pain, and the pain of malignancy.

This chapter discusses the unique opportunities provided by an emergency department-based observation unit in a community hospital based in an urban area. These include the ability to pivot to specific unexpected needs such as a pandemic and providing focused care to a population of geriatric patients. In addition, these units are known to be cost effective and patient customer satisfiers.