CONCEPTS observation medicine
Observation Medicine Curriculum
From the Observation Medicine Committee o f the Society for Academic Emergency Medicine, East Lansing, Michigan. This paper was developed by the Observation Medicine Committee of SAEM and approved by the Board of Directors on December 14, 1991.
Observation Medicine Committee, Society for Academic Emergency Medicine Louis G Graft, MD, FACEP,FACP Lala Dunbar, MD, PhD W Brian Gibler, MD, FACEP Lewis Goldfrank, MD, FACEP Jerrold Leikin, MD, FACEP Carl Schultz, MD Harry Severance, MD Roy Watkins, MD Donald M Yealy, MO, FACEP Leslie S Zun, MD, FACEP
[Graft LG, Dunbar L, Gibler WB, Goldfrank LI Leikin J, Schultz C, Severance H, Watkins R, Yealy DM, Zun LS: Observation medicine curriculum. Ann EmergMeflAugust 1992i21:963-966.] PURPOSE Observation services are offered frequently in emergency departments. Observation units are present in 27% of EDs in the United States, 1 50% of EDs in Australia, 2 and most EDs in the United Kingdom and Canada. In the past decade, many EDs have offered observation services as the use of inpatient services has been restricted and the use of outpatient services has increased. These services are extensions of basic ED services and place additional requirements on the ED staff. They are governed by extended care principles r a t h e r than by episodic care principles. They require personnel and expertise differen t from those involved in other types of emergency services. The purpose of this curriculum is to teach the areas of additional knowledge needed by emergency physicians to provide observation services.
GOALS This curriculum is a resource for emergencymedicine educators in the training of emergency physicians in accordance with the goals identified by the American College of Emergency Physician on the use and management of observation units: 3 1) familiarity with the structure, functioning, and staffing of the ED-attached observation unit; 2) education on the types of services that are a p p r o p r i a t e to provide in an ED-attached observation unit (eg, diagnostic evaluation, short-term therapy); 3) understanding of the characteristics of different services that are a p p r o p r i a t e to provide in an observation unit (eg, duration and intensity of service, site of care); 4) experience in provision of services in an observation unit; and 5) active involvement in the management of an observation unit, including billing for services, utilization review, and quality assurance. The curriculum is divided into four topics: history of observation medicine, types of services, characteristics of services, and management of the ED observation unit. The types of services reviewed are those offered most often in observation units. Subtopic areas are listed for each topic with reference material. The extent to which the educator
AUGUST1992 21:8 ANNALSOF EMERGENCYMEDICINE
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will use the material in the curriculum will depend on the amount of time available. A minimum curriculum would comprise a one-hour lecture that reviews the basics on providing observation services. It would include the four general topics and the major subtopics (eg, 4.1. Diagnostic Evaluation). With more time available, a series of lectures should be planned with each lecturer describing in detail the varied subtopics (eg, 4.1.2. Syndromes Commonly Evaluated, 4.1.2.1. Abdominal Pain). CURRICULUM
1.History of Observation Services 1.1 Early ED Observation Units 4-8 1.2 Policy Statements3,9,10 2.Characteristics of Observation Services 2.1. Duration and Intensity of Service 2.2. Sites for Observation 2.3. Staffing the Observation Bed 11 2.4. Admission Decisions 12 2.5. Continuing Care in the Outpatient Setting 2.5.1. Continuing care versus episodic care 13 2.5.2. Holding beds and overcrowding versus observation beds9, la 2 . 5 . 3 . 2 3 - H o u r beds versus observation beds 15-17 2.6. Limitations of ED Observation Services 18 3.Management of Observation Services 3.1. Utilization Review 12,19 3.2. Quality Assurance3,2°-22 3.3. Financial Analysis23-25 3.4. Policies and Guidelines3,9-1° 4.Types of Observation Services 4.1. Diagnostic Evaluation 4.1.1. Indications for observation for diagnostic testing 4.1.1.1. Probability theory in testing26 4.1.1.2. Threshold theory of testing27 4.1.2. Syndromes commonly evaluated 4.1.2.1. Abdominal pain 28-3° 4.1.2.2. Chest pain31.,32 4.1.2.3. Confusion33 4.1.2.4. Dizziness34 4.1.2.5. Fever 35,36 4.1.2.6. Gastrointestinal/genitourinarybleeding37,38 4.1.2.7. Headache 39-41 4.1.2.8. Overdosea2, 43 4.1.2.9. Seizure 44,45 4.1.2.10. Syncopea6-47 4.1.2.11. Trauma 23 4.1.2.11.1. Abdominal trauma 48 4.1.2.11.2. Head trauma 49-51 4.1.2.11.3. Thoracic t r a u m a 52,sz 4.1.2.12. Vaginal bleeding54-56 4.2 Procedure-Related Observation2~
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4.3 Meeting Psychosocial Needs 4.3.1. Psychiatric emergencyST,sa 4.3.2. Alcohol and substance abuse 59,6° 4.3.3. Social problems 61,62 4.4 Short-Term Therapy 4.3.1. Conditions commonly treated 4.3.1.1. Asthma 25,63 4.3.1.2. Congestive heart failure 64 4.3.1.3. Chronic obstructive pulmonary disease 65,66 4.3.1.4. Dehydration 67 4.3.1.5. Hyperglycemia/hypoglycemia68,69 4.3.1.6. Hypertensive urgencies 70,71 4.3.1.7. Hematologic (sickle cell anemia, hemophilia)72 4.3.1.8. InfectionT3,74 4.3.1.9. Pancreatitis 75 4.5. Pediatric Patient Care 76,77 4.6. Geriatric Patient Care 78,79 REFERENCES 1. yealy DM, DeHart DA, Ellis 6, et al: A survey of observation units in the United States. Am J Emerg Med 1989;7:576-580. 2. Jelinek GA, Galvie GM: Gbservation wards in Australian hospitals. MedJAust 1989;151:80-83. 3. Practice Management Committee, American College of Emergency Physicians: Management of observation units. Ann Emerg Med 1988;17:1348-1352. 4. Boose LA: The use of observation beds in emergency service units. Hasp Forum 1965;30:38-39. 5. Taubenhaus LJ, Robilotti 6D: The holding area: New arm of the ED. JACEP1972;1:15-19. 6. Diamond NJ, Schofferman JA, Elliott JW: Evaluation of an emergency department observation ward: JACEP 1976;5:29-31. 7. Babzien WF: The observation holding area: A prospective study. JACEP 1979;8:508512. 8. Landers 6A, Waeckede JF, McNabney WK: Observation ward utilization. JACEP 1975;4:123-125. 9. American College of Emergency Physicians: Emergency department observation units. Ann Emerg Med 1988;17:95-96. 10. Joint Commission on Accreditation of Healthcare Organizations: Accreditation Manual for Hospitals 1988.Chicago, JCAHO, 1987, p 39. 11.6raft LG, Radford M J: Formula for emergency physician staffing. Am J Emerg Med 1990;8:194. 12. 6raft LG, Mucei D, Radford MJ: Decision to hospitalize: Objective diagnosis-related group criteria versus clinical judgment. Ann Emerg Med1988;17:943~952. 13. Hurst JW: The art and science of presenting a patient's problems as an extension of the Weed system. Arch Intern Med 1971;128:463. 14. Lynn SG, Kellermann AL: Critical decision making: Managing the emergency department in an overcrowded hospital, Ann Emerg Med 1991;20:289-297. 15. Graft LG: Control of observation medicine: Emergency medicine versos utilization review? Am J Emerg Med 1989;7:649. 16. Holland C, Cox L, Johnson R: Medical short stay--A viable alternative. Nurs Mgmt 1988;19:38-39. 17. Kaye J, Russ GH: Observation Status: Definition--Philosophy--Procedure. Greenville, North Carolina, Gail Hardy Russ and Associates, 1988. 18. Zun LS: Observation units: Boom or bust for emergency medicine. J Emerg Med
1990;8:485-490.
ANNALS OF EMERGENCY MEDIOINE
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AUGUST1992
OBSERVATION MEDICINE SA£M
19.Jacobs CM, Lamprey F: ISD (Intensity of Service, Severity of illness, and Discharge Screens):A Guide to Systematic Utilization Monitoring. North Hamptorn, New Hampshire, ]nterqual, Inc, 1983. 20. Greene CS (ed): Quality Assessment in the Emergency Department--A Practical Handbook.Des Plaines, Illinois, Illinois ACEP, 1984.
46. Martin GJ, Adams SL, Martin HG: Prospective evaluation of syncope. Ann Emerg Med 1984;13:499-504. 47. Kapoor WN: Evaluation and outcome of patients with syncope. Medicine 1990;69:160.
21.Schneiderman N, Wiseman M (eds): Quality Assurance Manual for Emergency Medicine. Dallas, American College of Emergency Physicians, 1987.
48. Henneman PL, Marx JA, Cantrill SC, et ah The use of an emergency department observation unit in the management of abdominal trauma. Ann Emerg Med 1989;18:647650.
22. Grossfield AG: Navigating through JCAH's new quality assurance and medical staff standards. Healthspan 1987;4:3-9.
49. Dacey RG, Alves WR, Rimel RW, et ah Neurosurgical complications after apparently minor head injury. J Neurosurg 1986;65:203-210.
23. Conrad L, Markovchick V, Mitchiuer J, et ah The role of an emergency department observation unit in the management of trauma patients. J Emerg Med 1985;4:325-333.
50. Fischer RP, Carlson J, Perry JF: Postconcussive hospital observation of alert patients in a primarytrauma center. J Trauma 1981;21:920-924.
24. Farrell RG: Use of an observation ward in a community hospital. Ann Emerg Med 1982;11:353-357.
51. Fouerman J, Wackym PA, Gade GF, et al: Value of skull radiography, head computed tomographic scanning, and admission for observation in cases of minor head injury. Neurosurgery 1988;22:449-453.
25.Zwiche DL, Donohue JF, Wagner EH: Use of the emergency department observation unit in the treatment of acute asthma. Ann Emerg Med 1982;11:77-83. 26.Sex HC: Probability theory in the use of diagnostic tests. Ann Intern Med 1986;104:60-66.
52. Ammons MA, Moore EE, Rosen P: Role of the observation unit in the management of thoracic trauma. J Emerg Med 1986;4:279-282.
27. Pauker SG, Kassirer JP: The threshold approach to clinical decision making. N Engl J Med 1980;302:1109-1117.
53. Weigelt JA, Aurbakiken CM, Meier DE, et ah Managment of asymptomatic patients following stab wounds to the chest. J Trauma 1982;22:291-294.
28.White JS, Santillana M, Holly JA: Intensive in-hospital observation: A safe way to decrease unnecessary appendicitis. Ann Surg 1975;41:793-799.
54. Farrel] RG, Stormington DT, Ridgeway KA, et al: Incomplete and inevitable abortion: Treatment by suction curretage in the emergency department. Ann Emerg Med 1982;11:652-658.
29. Graft LG, Radford M J, Werne C: Probability of appendicitis before and after observatioG.Ann Emerg Med 1991;20:503-507. 30. Nase HW, Kovakik PJ, Goss GT: The diagnosis of appendicitis. Ann Surg 1981;46:504507. 31. Gibler WB, Young GP, Hedges JR, et ah Acute myocardial infarction detection in chest pain patients with nondiagnostic ECGs:Serial CK-MB sampling in the ED. Ann EmergMed 1991;19:1359-1366. 32. Lee TH, Cook EF, Rouan GW, et al: Ruling out myocardial infarction: Prospective multicenter validation of a 12-hour strategy for low risk.patients. N Engl J Med 1991;324:1239-1246. 33. Inouye SK, van Dyck CH, Alessi CA, et ah Clarifying confusion: The confusion assessment method. Ann Intern Med 1990;113:941-948. 34. Herr RD, Zun L, Mathews J: A directed approach to the dizzy patient. Ann Emerg Med 1989;18:664-672. 35. Leibovici L, Cohen O, Wyssenbeek A J: Occult bacterial infection in adults with unexplained fever: Validation of a diagnostic index. Arch Intern Med 1990;150:1270. 36. Baker MD, Auner JR, Bell LM: Failure of infant observation scales in detecting serious illness in febrile, 4-8 week old infants. Pediatrics 1990;85:1040-1043.
55. Anderson DJM: Management of severe secondary postpartum hemorrhage. J Obstet Gynaeco11990;10:225. 56. Weckstein LN: Current perspectives on ectopic pregancy. Obstet Gynecol Surv 1985;40:259-272. 57. Motto JA, Heilbran DL, Jaster RP: Development of a clinical instrument to estimate suicide risk. Am J Psychiatr 1985;142:680-686. 58. Scc HC: A medical algorithm for detecting physical disease in psychiatric patients. Hosp CommunityPsychiatry 1989;40:1270. 59. Taylor C, Kilbane P, Passmore N, et ah Prospective study of alcohol related admissions in an inner city hospital. Lancet1986;2:265-267. ~ 60. Cherpitel CJS: Prediction of alcohol related casualties among emergency room admissions. Intern J Addict1989;24:725. 61. Ettinger WH, Casini J, Coon J, et al: Pattern of use of the emergency department by elderly patients. J Geronto11987;42:638-642. 62. Eliastam M: Elderly patients in the emergency department, Ann Emerg Med 1989;18:1222.
37. Macleod IA, Mills PR: Factors identifying the probability of further hemorrhage after acute upper gastrointestinal hemorrhage. BrJ Surg 1982;69:256-258.
63. Murphy DG, Zalenski RJ, Raucci JC, et al: The utility of extended emergency department treatment of asthma: An analysis of improvement in peak expiratory flow rate as a function of time. Ann Emerg Med1989;8:467.
38. Bordley DR, MusNin AI, Dolan JG, et ah Early clinical signs identify low-risk patients with acute upper gastrointestinal hemorrhage. JAMA 1985;153:3282-3285.
64. Peele-Wilson PA: Future perspectives in the managment of congestive heart failure. Am J Cardio11990;66:457-462.
39. Solomon S, Cappa KG, Smith GR: Common migraine: Criteria for diagnosis. Headache 1988;28:124-129.
65. Orient JM: When do patients with chronic obstructive lung disease need hospital admission? Reflections based on a VA experience. South Med J 1983;76:573-598.
40. Bonita R, Thomson S: Subarchnoid hemorrhage: Epidemiology, diagnosis, management, and outcome. Stroke 1985;16:591-594,
66. Reluck AS, Chapman KR, Albound R, et ah Nebulized anticholinergic and sympathomimetic treatment of asthma and COPD in emergency room. Am J Med 1987;82:59-64.
41. Fantanarosa PB: Recognition of subarchnoid hemorrhage. Ann Emerg Med 1989;18:1199.
67. nottlieb RP: Dehydration and fluid therapy. Emerg Med Clin North Am 1983;1:113-123.
42. Brett AS, Rothschild N, Gray R, et ah Predicting clinical course in intentional drug overdose: Implications for use of the intensive care unit. Arch Intern Med 1987;147:133-137.
68. Kitabachi AE, Ayagari V, Guerra SM: The efficacy of low-dose versus conventional therapy of insulin for treatment of diabetic ketoacidosis. Ann Intern Med 1976;84:633-638.
43. Callaham M, Kassel D: Epidemiology of fatal tricyc!ic antidepressant ingestion: Implications for mariagernent. Ann Emerg Med 1985;14:7-9.
69. Yealy DM, Wolfson AB: Hypoglycemia. Emerg Med Cfin North Am 1989;7:837-848.
44. Rcsenthal RH, Hein ML, Waeckerle JF: First-time major motor seizure in emergency departments. Ann Emerg Med 1980;9:242-245. 45. Hopkins A, Garman A, Clarke C: The first seizure in adult life. Value of clinical testing, electroencephclcgy, and computerized tomographic scanning in prediction of seizure recurrence. Lancet 1988;1:721-726.
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70. Calhoun DA, 0paril S: Treatment of hypertensive crisis. N EnglJ Med 1990; 323:11771183. 71. Houston MC: Treatment of hypertensive emergencies and urgencies with oral clonidine loading and titration: A review. Arch Intern Med 1986;146:586-589. 72. Friedman EW, Webber AB, Osborn HH, et al: 0ral analgesia for treatment of painful crisis in sickle cell crisis. Ann Emerg Med 1986;15:783-791.
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73. Israel RS, Marx JA, Lowenstein SR: Observation unit treatment of pyelonephritis. Ann EmergMed 1989;18:444.
Address for reprints: Louis Graft, MD, FACEP, FACP, 34 Paper Chase Drive, Farmington, Connecticut 06032.
34. Ward 6LH, Jorden RC, Serverance HW: Management of pyelonephritis in an observation unit. Ann EmergMed 1989;18:443-444. 75. Saunders CE, 6entile DA: Treatment of mild exacerbations of recurrent alcoholic pancreatitis in an emergency department observation unit. South Med J 1988;81:317320. 76. Ellerstein NS, Sullivan TD: Observation unit in Children's Hospital: Adjunct to delivery and teaching of ambulatory pediatric care. NYState J Med 1980;80:1684. 77.6ururaj VJ, Allen JE, Rusgo RM: Short stay in an outpatient department: An alternative to hospitalization. Am J Dis Child 1972;123:128. 78. Harrop SN, Morgan W J: Emergency care of the elderly in the short-stay ward of the accident and emergency department. Arch Emerg Med 1995;2:141-t47. 79. Jenner 6H: Medical patients aged 65 and over admitted to an accident and emergency department. BrMedJt985;291:113-114.
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Observation Medicine Curriculum
From the Observation Medicine Committee o f the Society for Academic Emergency Medicine, East Lansing, Michigan. This paper was developed by the Observation Medicine Committee of SAEM and approved by the Board of Directors on December 14, 1991.
Observation Medicine Committee, Society for Academic Emergency Medicine Louis G Graft, MD, FACEP,FACP Lala Dunbar, MD, PhD W Brian Gibler, MD, FACEP Lewis Goldfrank, MD, FACEP Jerrold Leikin, MD, FACEP Carl Schultz, MD Harry Severance, MD Roy Watkins, MD Donald M Yealy, MO, FACEP Leslie S Zun, MD, FACEP
[Graft LG, Dunbar L, Gibler WB, Goldfrank LI Leikin J, Schultz C, Severance H, Watkins R, Yealy DM, Zun LS: Observation medicine curriculum. Ann EmergMeflAugust 1992i21:963-966.] PURPOSE Observation services are offered frequently in emergency departments. Observation units are present in 27% of EDs in the United States, 1 50% of EDs in Australia, 2 and most EDs in the United Kingdom and Canada. In the past decade, many EDs have offered observation services as the use of inpatient services has been restricted and the use of outpatient services has increased. These services are extensions of basic ED services and place additional requirements on the ED staff. They are governed by extended care principles r a t h e r than by episodic care principles. They require personnel and expertise differen t from those involved in other types of emergency services. The purpose of this curriculum is to teach the areas of additional knowledge needed by emergency physicians to provide observation services.
GOALS This curriculum is a resource for emergencymedicine educators in the training of emergency physicians in accordance with the goals identified by the American College of Emergency Physician on the use and management of observation units: 3 1) familiarity with the structure, functioning, and staffing of the ED-attached observation unit; 2) education on the types of services that are a p p r o p r i a t e to provide in an ED-attached observation unit (eg, diagnostic evaluation, short-term therapy); 3) understanding of the characteristics of different services that are a p p r o p r i a t e to provide in an observation unit (eg, duration and intensity of service, site of care); 4) experience in provision of services in an observation unit; and 5) active involvement in the management of an observation unit, including billing for services, utilization review, and quality assurance. The curriculum is divided into four topics: history of observation medicine, types of services, characteristics of services, and management of the ED observation unit. The types of services reviewed are those offered most often in observation units. Subtopic areas are listed for each topic with reference material. The extent to which the educator
AUGUST1992 21:8 ANNALSOF EMERGENCYMEDICINE
963/89
OBSERVATION MEDICINE SAEM
will use the material in the curriculum will depend on the amount of time available. A minimum curriculum would comprise a one-hour lecture that reviews the basics on providing observation services. It would include the four general topics and the major subtopics (eg, 4.1. Diagnostic Evaluation). With more time available, a series of lectures should be planned with each lecturer describing in detail the varied subtopics (eg, 4.1.2. Syndromes Commonly Evaluated, 4.1.2.1. Abdominal Pain). CURRICULUM
1.History of Observation Services 1.1 Early ED Observation Units 4-8 1.2 Policy Statements3,9,10 2.Characteristics of Observation Services 2.1. Duration and Intensity of Service 2.2. Sites for Observation 2.3. Staffing the Observation Bed 11 2.4. Admission Decisions 12 2.5. Continuing Care in the Outpatient Setting 2.5.1. Continuing care versus episodic care 13 2.5.2. Holding beds and overcrowding versus observation beds9, la 2 . 5 . 3 . 2 3 - H o u r beds versus observation beds 15-17 2.6. Limitations of ED Observation Services 18 3.Management of Observation Services 3.1. Utilization Review 12,19 3.2. Quality Assurance3,2°-22 3.3. Financial Analysis23-25 3.4. Policies and Guidelines3,9-1° 4.Types of Observation Services 4.1. Diagnostic Evaluation 4.1.1. Indications for observation for diagnostic testing 4.1.1.1. Probability theory in testing26 4.1.1.2. Threshold theory of testing27 4.1.2. Syndromes commonly evaluated 4.1.2.1. Abdominal pain 28-3° 4.1.2.2. Chest pain31.,32 4.1.2.3. Confusion33 4.1.2.4. Dizziness34 4.1.2.5. Fever 35,36 4.1.2.6. Gastrointestinal/genitourinarybleeding37,38 4.1.2.7. Headache 39-41 4.1.2.8. Overdosea2, 43 4.1.2.9. Seizure 44,45 4.1.2.10. Syncopea6-47 4.1.2.11. Trauma 23 4.1.2.11.1. Abdominal trauma 48 4.1.2.11.2. Head trauma 49-51 4.1.2.11.3. Thoracic t r a u m a 52,sz 4.1.2.12. Vaginal bleeding54-56 4.2 Procedure-Related Observation2~
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4.3 Meeting Psychosocial Needs 4.3.1. Psychiatric emergencyST,sa 4.3.2. Alcohol and substance abuse 59,6° 4.3.3. Social problems 61,62 4.4 Short-Term Therapy 4.3.1. Conditions commonly treated 4.3.1.1. Asthma 25,63 4.3.1.2. Congestive heart failure 64 4.3.1.3. Chronic obstructive pulmonary disease 65,66 4.3.1.4. Dehydration 67 4.3.1.5. Hyperglycemia/hypoglycemia68,69 4.3.1.6. Hypertensive urgencies 70,71 4.3.1.7. Hematologic (sickle cell anemia, hemophilia)72 4.3.1.8. InfectionT3,74 4.3.1.9. Pancreatitis 75 4.5. Pediatric Patient Care 76,77 4.6. Geriatric Patient Care 78,79 REFERENCES 1. yealy DM, DeHart DA, Ellis 6, et al: A survey of observation units in the United States. Am J Emerg Med 1989;7:576-580. 2. Jelinek GA, Galvie GM: Gbservation wards in Australian hospitals. MedJAust 1989;151:80-83. 3. Practice Management Committee, American College of Emergency Physicians: Management of observation units. Ann Emerg Med 1988;17:1348-1352. 4. Boose LA: The use of observation beds in emergency service units. Hasp Forum 1965;30:38-39. 5. Taubenhaus LJ, Robilotti 6D: The holding area: New arm of the ED. JACEP1972;1:15-19. 6. Diamond NJ, Schofferman JA, Elliott JW: Evaluation of an emergency department observation ward: JACEP 1976;5:29-31. 7. Babzien WF: The observation holding area: A prospective study. JACEP 1979;8:508512. 8. Landers 6A, Waeckede JF, McNabney WK: Observation ward utilization. JACEP 1975;4:123-125. 9. American College of Emergency Physicians: Emergency department observation units. Ann Emerg Med 1988;17:95-96. 10. Joint Commission on Accreditation of Healthcare Organizations: Accreditation Manual for Hospitals 1988.Chicago, JCAHO, 1987, p 39. 11.6raft LG, Radford M J: Formula for emergency physician staffing. Am J Emerg Med 1990;8:194. 12. 6raft LG, Mucei D, Radford MJ: Decision to hospitalize: Objective diagnosis-related group criteria versus clinical judgment. Ann Emerg Med1988;17:943~952. 13. Hurst JW: The art and science of presenting a patient's problems as an extension of the Weed system. Arch Intern Med 1971;128:463. 14. Lynn SG, Kellermann AL: Critical decision making: Managing the emergency department in an overcrowded hospital, Ann Emerg Med 1991;20:289-297. 15. Graft LG: Control of observation medicine: Emergency medicine versos utilization review? Am J Emerg Med 1989;7:649. 16. Holland C, Cox L, Johnson R: Medical short stay--A viable alternative. Nurs Mgmt 1988;19:38-39. 17. Kaye J, Russ GH: Observation Status: Definition--Philosophy--Procedure. Greenville, North Carolina, Gail Hardy Russ and Associates, 1988. 18. Zun LS: Observation units: Boom or bust for emergency medicine. J Emerg Med
1990;8:485-490.
ANNALS OF EMERGENCY MEDIOINE
21:8
AUGUST1992
OBSERVATION MEDICINE SA£M
19.Jacobs CM, Lamprey F: ISD (Intensity of Service, Severity of illness, and Discharge Screens):A Guide to Systematic Utilization Monitoring. North Hamptorn, New Hampshire, ]nterqual, Inc, 1983. 20. Greene CS (ed): Quality Assessment in the Emergency Department--A Practical Handbook.Des Plaines, Illinois, Illinois ACEP, 1984.
46. Martin GJ, Adams SL, Martin HG: Prospective evaluation of syncope. Ann Emerg Med 1984;13:499-504. 47. Kapoor WN: Evaluation and outcome of patients with syncope. Medicine 1990;69:160.
21.Schneiderman N, Wiseman M (eds): Quality Assurance Manual for Emergency Medicine. Dallas, American College of Emergency Physicians, 1987.
48. Henneman PL, Marx JA, Cantrill SC, et ah The use of an emergency department observation unit in the management of abdominal trauma. Ann Emerg Med 1989;18:647650.
22. Grossfield AG: Navigating through JCAH's new quality assurance and medical staff standards. Healthspan 1987;4:3-9.
49. Dacey RG, Alves WR, Rimel RW, et ah Neurosurgical complications after apparently minor head injury. J Neurosurg 1986;65:203-210.
23. Conrad L, Markovchick V, Mitchiuer J, et ah The role of an emergency department observation unit in the management of trauma patients. J Emerg Med 1985;4:325-333.
50. Fischer RP, Carlson J, Perry JF: Postconcussive hospital observation of alert patients in a primarytrauma center. J Trauma 1981;21:920-924.
24. Farrell RG: Use of an observation ward in a community hospital. Ann Emerg Med 1982;11:353-357.
51. Fouerman J, Wackym PA, Gade GF, et al: Value of skull radiography, head computed tomographic scanning, and admission for observation in cases of minor head injury. Neurosurgery 1988;22:449-453.
25.Zwiche DL, Donohue JF, Wagner EH: Use of the emergency department observation unit in the treatment of acute asthma. Ann Emerg Med 1982;11:77-83. 26.Sex HC: Probability theory in the use of diagnostic tests. Ann Intern Med 1986;104:60-66.
52. Ammons MA, Moore EE, Rosen P: Role of the observation unit in the management of thoracic trauma. J Emerg Med 1986;4:279-282.
27. Pauker SG, Kassirer JP: The threshold approach to clinical decision making. N Engl J Med 1980;302:1109-1117.
53. Weigelt JA, Aurbakiken CM, Meier DE, et ah Managment of asymptomatic patients following stab wounds to the chest. J Trauma 1982;22:291-294.
28.White JS, Santillana M, Holly JA: Intensive in-hospital observation: A safe way to decrease unnecessary appendicitis. Ann Surg 1975;41:793-799.
54. Farrel] RG, Stormington DT, Ridgeway KA, et al: Incomplete and inevitable abortion: Treatment by suction curretage in the emergency department. Ann Emerg Med 1982;11:652-658.
29. Graft LG, Radford M J, Werne C: Probability of appendicitis before and after observatioG.Ann Emerg Med 1991;20:503-507. 30. Nase HW, Kovakik PJ, Goss GT: The diagnosis of appendicitis. Ann Surg 1981;46:504507. 31. Gibler WB, Young GP, Hedges JR, et ah Acute myocardial infarction detection in chest pain patients with nondiagnostic ECGs:Serial CK-MB sampling in the ED. Ann EmergMed 1991;19:1359-1366. 32. Lee TH, Cook EF, Rouan GW, et al: Ruling out myocardial infarction: Prospective multicenter validation of a 12-hour strategy for low risk.patients. N Engl J Med 1991;324:1239-1246. 33. Inouye SK, van Dyck CH, Alessi CA, et ah Clarifying confusion: The confusion assessment method. Ann Intern Med 1990;113:941-948. 34. Herr RD, Zun L, Mathews J: A directed approach to the dizzy patient. Ann Emerg Med 1989;18:664-672. 35. Leibovici L, Cohen O, Wyssenbeek A J: Occult bacterial infection in adults with unexplained fever: Validation of a diagnostic index. Arch Intern Med 1990;150:1270. 36. Baker MD, Auner JR, Bell LM: Failure of infant observation scales in detecting serious illness in febrile, 4-8 week old infants. Pediatrics 1990;85:1040-1043.
55. Anderson DJM: Management of severe secondary postpartum hemorrhage. J Obstet Gynaeco11990;10:225. 56. Weckstein LN: Current perspectives on ectopic pregancy. Obstet Gynecol Surv 1985;40:259-272. 57. Motto JA, Heilbran DL, Jaster RP: Development of a clinical instrument to estimate suicide risk. Am J Psychiatr 1985;142:680-686. 58. Scc HC: A medical algorithm for detecting physical disease in psychiatric patients. Hosp CommunityPsychiatry 1989;40:1270. 59. Taylor C, Kilbane P, Passmore N, et ah Prospective study of alcohol related admissions in an inner city hospital. Lancet1986;2:265-267. ~ 60. Cherpitel CJS: Prediction of alcohol related casualties among emergency room admissions. Intern J Addict1989;24:725. 61. Ettinger WH, Casini J, Coon J, et al: Pattern of use of the emergency department by elderly patients. J Geronto11987;42:638-642. 62. Eliastam M: Elderly patients in the emergency department, Ann Emerg Med 1989;18:1222.
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Address for reprints: Louis Graft, MD, FACEP, FACP, 34 Paper Chase Drive, Farmington, Connecticut 06032.
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