It may be difficult or impossible to obtain a valid history in the emergency. Additional time in the observation unit (OU) may be needed to determine the etiology of the event, whether a seizure or not.

In the OU, there is time for obtain such information, do a diagnostic workup to determine the etiology of the event, whether a seizure or not and if a seizure, determine the precipitating factors and treat them, repeat vital signs and neurologic checks, observe for any recurrent seizures or monitoring if syncope and dysrhythmias are a consideration. If this was a seizure, evaluation can be done, which may involve testing. In a patient with a known seizure disorder, anticonvulsants may be administered, if needed. Precipitating factors, such as infections or electrolyte abnormalities, known to trigger seizures can be treated in the OU. Dizziness has an extensive differntial

Oral anticoagulantion is used for the prevention and treatment of thromboembolism in patients with nonvalvular atrial fibrillation (NVAF), venous thromboembolism (VTE), mechanical heart valves, and other hypercoagulable states. In the past, warfarin was the predominant oral anticoagulant. Recently, direct oral anticoagulants (DOACs) have replaced warfarin as the preferred agents for the most common indications for oral anticoagulation: NVAF and VTE. The complication of anticoagulants is bleeding. Treatment including withholding the anticoagulant or administering medications to counteract the excessive anticoagulation and monitoring for further bleeding and/or the response to therapy can be done in the OU.

The clinical decision to admit or place in observation patient’s presenting to emergency departments requires complex determinations identifying need for short term diagnostic evaluation or therapeutic intervention with continuous patient monitoring then deciding to discharge the patient to the community or admit as an inpatient. Professionally developed guideline criteria require evidence based accepted standards adopted by general medical practices then widely shared within the health care community, aligned with health care system policies and procedures, then monitored to be certain specified outcomes are achieved.

The importance of cohorting observation unit patients in one location or unit, having adequate nursing staffing with specific nurse to patient ratios, design, equipment/supplies, dealing with variations in hourly and daily census, the negatives of floating nursing/support staff to other units, and nursing/physician administration are discussed.

The components of a continuous quality improvement (CQI) program, a database, documentation, metrics, benchmarks, protocols, pathways, and standardized order sets are discussed.

Care of the patient with gastrointestinal bleeding (GIB) can be difficult, from determination of source to sudden deterioration of condition and hemodynamic instability. Risk stratification can be done to appropriately select patients who will benefit from observation unit (OU) placement. OU diagnostic testing may include early abdominal CTA (CT angiogram) to determine there is no evidence of active hemorrhage, nasogastric tube insertion to screen for upper GIB, bowel prep for colonoscopy and gastroenterology consult. OU management includes guidance regarding medications to avoid (such as NSAIDs). Patients with lower GIB placed in the OU are on track to better outcomes, reduced LOS, all while reducing health care costs.

Clinical rotations should introduce students to the patient types/conditions appropriate for an observation unit (OU), to differentiate factors for observation from inpatient services, to risk stratification, and to disposition decision making. Observation medicine fellowships allow the fellow to gain expertise in the administrative as well as clinical aspects of observation medicine and provide an opportunity for research. Observation medicine may be part of an emergency medicine administration fellowship.

The necessary staffing for an observation unit including physicians, advanced practice practitioners (APPs), residents, and support staff with the need for appropriate consultants and the design/set up needed for optimal functioning of the unit is discussed.

Utilization review of medical records providing guidance for disposition determination as an inpatient or observation level of care based upon the medically necessary conditions of care requires complex clinical decision making by clinicians. With numerous regulatory programs monitoring physician and hospital compliance; Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), Comprehensive Error Rate Testing (CERT), Office of Inspector General (OIG), The Hospital Payment Monitoring Program (HPMP), Program for Evaluating Payment Patters Electronic Report (PEPPER), are a few where familiarity with these programs is vitally important for a successful patient care and clinical practice.

There are many hazards of hospitalization of the older and/or frail adult. Observation units (OUs) are a way of delivering high quality care and an appropriate level of care for older adults, while avoiding a long inpatient hospitalization. Successful intervention in a selected group of elderly patients placed in the geriatric OU from the ED can be achieved with the help of a multidisciplinary team approach.

Despite recommendations for emergency department (ED)-based preventive care, screening and caring for chronic diseases in the ED itself is challenging. The focus on acute care, high volumes, staffing shortages, budget constraints, and lack of time may be barriers for providing ED-based smoking cessation. To bridge this gap in care, observation units (OUs) can be used to facilitate preventive care practices, including smoking cessation. The OU may be a quieter, more private care setting with fewer distractions and time pressures. The OU may also have workflows more conducive to providing preventive care. Previous OU literature indicates that patients perceive admission to the OU as a “cue to action,” which could help facilitate lifestyle changes, including smoking cessation. A 2014 systematic review of 13 trials found that ED-based smoking cessation interventions were associated with higher cessation rates than the national average. The OU is a reasonable place for providers to “Ask, Advise, Refer” for smoking cessation in order to promote behavioral interventions for smoking cessation and to institute pharmacotherapy (e.g. nicotine replacement therapy) for smoking cessation.

Of the hyperemesis gravidarum patients who are not ready to be discharged from the emergency department, but are hemodynamically stable, the majority can be successfully managed in the observation unit (OU) with IV fluids and antiemetics. The OU provides an opportunity to inform patients about non-pharmacologic for the nausea/vomiting of pregnancy, including dietary and lifestyle changes.