The South African health system faces a quadruple burden of disease: HIV/AIDS and tuberculosis; maternal and child morbidity and mortality; noncommunicable diseases; and violence, injuries and trauma. This places significant pressure on emergency centres which for many is the entry point into the health care system. With variable clinical case load but finite inpatient bed capacity, emergency centre observation wards (ECOWs) are a novel approach to address the challenge of maintaining effective EC through-put. As part of a strategy to decrease emergency centre (EC) and hospital overcrowding, ECOWs when properly utilised, enable management for subgroups of patients who meet specific clinical criteria and require treatment for longer periods than normal for the EC, but who are deemed likely to stay for less than 24 hours. Additionally, patients admitted to ECOWs remain under the care of emergency and acute care practitioners who routinely review patients on a more frequent basis than the traditional daily inpatient ward review, thus allowing for the high turnover that is necessary to maintain streamlined EC unit flow.

The goal of risk stratification is to place the emergency department patient in the correct level of care. Patients with a moderate to high risk/probability of disease and who need inpatient hospitalization meet the threshold for inpatient admission. Severity of illness and intensity of service are required to justify an inpatient admission. Others are safe to be discharged home. With others in whom it is unclear whether or not they have a serious condition, observation is an appropriate disposition.

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.

Observation documentation requires a medical record that contains nursing notes, physician progress notes and discharge summary outlining the outcome of the observation care services, including patient discharge information, transition to admission, or in the condition code 44 circumstance, when the reason for downgrading a patient from admission to observation. Accurately managing observation length of stay time assists determination for advancing a patient’s care to admission or discharging to the community. Calculating length of stay, determining whether a patient has crossed two-midnights are important considerations for determining a patient’s medically necessary condition for hospital admission. Additionally, documentation of the patient’s severity of illness, potential adverse outcomes if the patient is discharge precipitously, and the intensity of services are important characteristics of observation care documentation.

There has been a steady increase in the use of observation medicine in the emergency department in recent years. There has also been an unfortunate adoption of the use of “observation” to denote patients admitted to the hospital under observation status. Observation medicine is not the same as observation status, and we need to be clear when we use the terms, as they have very different meanings.

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.

Observation medicine and its dedicated units provide hospitals with a high quality, safe, and efficient space to provide care while avoiding increased costs. Observation units (OUs) positively impact inpatient capacity, reduce audits, and improve revenue capture making them a value-added asset for hospitals and their administrators. OUs can turn unprofitable admissions into profitable observation stays. Private and government insurance companies benefit from the structure and efficiency of OUs which provide care at an outpatient payment level that is far less than the payments for inpatient care. Furthermore, by freeing up acute care beds for undifferentiated patients within the waiting room, OUs alleviate strains on emergency department resources – a benefit to both physicians and patients. The medical and financial benefits of OUs, and their viability, ultimately requires the support of several key stakeholders including physicians, advanced practice providers, nurses, hospital administrators, payers and patients.

This chapter gives a protocol for the management of dengue.

Management of pit viper snakebites incorporating the use of antivenom is defined in this chapter. This chapter on adult snakebite treatment chapter reviews the basic management parameters needed in the care of North American pit viper envenomations. The chapter provides a brief overview of the classification of severity grading, indications for antivenom administration, assessment parameters, and disposition criteria. The chapter has an easy-to-follow diagram to assist in treatment evaluation of this patient population.

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.

Dehydration is a frequent diagnosis made in the emergency department (ED) and a common pathway in the observation unit (OU). Gastroenteritis and vomiting are two common causes of dehydration. Patients at the extremities of age are particularly vulnerable to dehydration yet still can be managed effectively in an observation setting. The evaluation of dehydration includes physical and laboratory assessment though both can be nonspecific. Management includes non-invasive versus invasive rehydration as well as electrolyte correction. The first-line therapy of intravenous rehydration is isotonic crystalloid solution. The management of dehydration in an OU is straightforward, typical and effective.

OU patients will be on track to better outcomes, reduced length of stay, all while reducing health care costs.