This chapter contains order sets for giving various types of intravenous fluids. Radiology studies and special tests

Alcohol causes more harm than any other substance. Despite this, a large majority of patients with alcohol use disorder go untreated.  As emergency medicine providers, we are uniquely positioned to bridge this treatment gap.  As such, the observation unit (OU) can be an effective site to manage the consequences of alcohol use disorder (AUD) and initiate treatment.  This initiation in the emergency department OU has shown to be more effective than a simple referral. OU management may involve OU pathways for the treatment of mild alcohol withdrawal and alcohol intoxication. The OU allows time for initiation of treatment for the AUD including medications (e.g. naltrexone or acamprosate).

Syncope is a common presenting complaint to emergency departments, and can lead to costly and often fruitless inpatient hospitalizations. Observation units can be particularly helpful in the assessment of an unexplained syncopal event by providing a period of monitoring and a chance to obtain further testing in those patients who are not deemed low risk enough for immediate discharge and outpatient follow-up, nor high risk for adverse events. This chapter will discuss some of the tips and pitfalls in the assessment of the syncope patient and some of the traditional diagnostic options during the patient’s evaluation.

This chapter contains order sets according to the electrolyte abnormality.

Observation medicine in New Zealand has grown considerably in the last decade, driven by the shorter stays in emergency departments health target and the growth of emergency medicine as a specialty. Evidence that the growth of this service has mostly been appropriate and within suggested guidelines, is indicted by most hospitals admitting < 20% of patients to their emergency medicine governed observation unit and most subsequently admitting < 20% of these to an in-patient ward. Average lengths of stay are less than 12 hours and caseloads commonly include toxicology, low-risk chest pain and abdominal pain although the gamut of minor medical and surgical conditions are seen.

The protocol for evaluation of a new mass is outlined.

The role of case managers as patient advocates while upholding the compliance and regulatory requirements for patients assigned to observation status. Defines the role hospital case managers play in managing patients in observation status and why their understanding of the Centers for Medicare and Medicaid (CMS) regulatory rules and compliance mandates is critical to patients. Case managers understand that payment for observation care is covered through Medicare Part B and the financial impact that may have for the patient. Patients must be informed of their status and how it affects access to post-acute care, in addition to possible financial liability for certain medications they receive. Case managers inform patients of their observation status through distribution of the Medicare Outpatient Observation Notice (MOON) letter and their availability to answer questions and provide a safe and expedient discharge from the hospital.

Use of clinical grading systems may be used to help determine the disposition (including to the observation unit [OU]) of the emergency department patient with community acquired pneumonia. Generally parenteral antibiotic treatment should be initiated in the emergency department and continued in the OU with transition to the outpatient regime at the time of discharge.

Hemodynamically stable patients needing transfusions are appropriate for placement in an observation unit. Transfusions of red blood cells (RBCs), platelets, and platelet products: fresh frozen plasma (FFP), cryoprecipitate, and factors including von Willebrand factor (vWF), and factors VIII and IX, can be done in selected patients in the observation unit (OU). Administration of drugs such as DDAVP and TXA (tranexamic acid) can be used to treat bleeding. Patients with anemia, sickle cell disease, hemophilia, and von Willebrand’s disease are among those patients with hematologic and/or bleeding disorders who, if stable, might be treated in an OU instead of as an inpatient. In the OU, transfusions can be given over hours when indicated and patients can be monitored for transfusion reactions.

The importance of an observation unit (OU) to the small to medium hospital in a rural community, the support of hospital administration and the development of the OU as a separate service line is noted. The value of including pediatric patients in a such a OU and overcoming barriers including staff anxiety in order to care for pediatric patients with a specific age range and diagnoses in a OU cohorting both adult and pediatric patients is discussed.

A protocol for the medical management of low-risk pulmonary emboli with anticoagulation therapy is the focus of this chapter.

Increasingly outpatient observation services are used to treat patients arriving in emergency departments when the patient is not well enough to be discharged home, the diagnosis has not been substantiated, or therapeutic management has not been completed. Using electronic health record (HER) dashboards and reports assists managing observation patients whether cohorted in specific observation units or scattered through the hospital. Specific observation and admission criteria templates or severity illness indices compliment clinician medical decision making to continue observation, discharge patients home, or transition to admission.

The same processes used in developing observation units for hospitals are also useful for pandemic management. Initially, hospital leadership must preplan for anticipated volume, anticipate increased surge capacity during the upswing of the disease state, staff the steady state process, and contract during the wind down process as the incidence of the disease decreases. Observation center design for pandemics is similar to standard observation design and is illustrated in three phases: preplanning stage, execution stage, and feedback/ongoing quality assurance phase (ongoing operations).

Many patients with skin and soft tissue infections (SSTIs) are ideal candidates for management in an observation unit (OU). More severe SSTIs including necrotizing fasciitis or extensive cellulitis with septicemia require inpatient management. OU care can be a cost-effective option for patients who may only require a day or two of intravenous antibiotics to assure sufficient response while monitoring for clinical progression to more serious conditions. It may be a useful venue to establish a definitive diagnosis in patients who may have been initially misdiagnosed (pseudocellulitis).

Although the principles of pediatric observation medicine are the same as for adults; e.g. more efficient, safer, cost-effective care with decreased length of stay and equivalent or better patient outcomes; there are differences between pediatric and adult observation unit (OU) patients. The diagnoses are somewhat different with asthma, dehydration, gastroenteritis among the top pediatric diagnoses. Pediatric patients tend to need less cardiac monitoring, fewer medications and fewer laboratory and radiologic studies than adults and have a shorter length of stay. Respiratory illnesses, infections and dehydration/gastroenteritis are the predominant pediatric presenting complaints versus cardiac complaints for adults.

Observation unit (OU) design is based on the 3Ps: proximity, personnel and process. Key considerations involved in OU design include location, room size, unit size, personnel, and patient flow.