PowerPoint Presentation•Pathway driven •Interdisciplinary team model •The Centers for Medicare & Medicaid Services (CMS) defines observation care as a specific, defined set of

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Observation

The Tincture of Time and

Pathways 2.0

Maria Aini, MD

Director of Clinical Operations TJUH ED

Director of TJUH Observation Unit

Associate Professor

Department of Emergency Medicine

Thomas Jefferson University

MCEP Observation Conference

September 2019

Content Summary

• PAST

• Observation defined

• Observation growth and evolution

• Pathways 1.0

• PRESENT

• More Observation growth

• What works best

• FUTURE

• Complex Observation

• Pathways 2.0

• Sustainability

What is Observation Care

• Focused clinical care of select patients for more than 6hours and up to 24hours to assess need for outpatient versus inpatient care

• Pathway driven

• Interdisciplinary team model

• The Centers for Medicare & Medicaid Services (CMS) defines observation care as a specific, defined set of clinically appropriate services, which include ongoing assessment and reassessment and short-term treatment

Brief History of Observation and it’s Pathophysiology

Brief History of Observation and it’s Pathophysiology

• 1984 – Observation services created but ambiguous

• OBS

• 2000 – CMS stopped paying separately for OBS

• IP

• 2003 – CMS starts paying OBS only for CP, CHF, Asthma

• 2007 – CMS removes barriers, pays for all OBS

• +++OBS

• 2012 – CMS defines inpatient with 2MN rule –

• control prolonged OBS

• 2016 – Comprehensive APC, NOTICE Act, MOON

Growth of OBS Services

• Return to baseline when Medicare resumed payment for

observation services in 2008

• Hospital fears of being targeted by RAC auditors for

inappropriate inpatient admission

• Lack of clarity regarding the definition of an inpatient

• Medical innovations shifting care from inpatient to

outpatient settings

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Growth of OBS Services

• ED overcrowding, resource overutilization, squeezed

Medicare payments, avoidable admissions, payer audits and

denials = HIGH COSTS, LOST REVENUE

• Hospital maximizes revenue by being able to accept more ED

patients and by avoiding lost revenue from ambulance

diversion and patients who leave without being seen

• As a result, observation units have grown in numbers

Why Observation in Emergency Medicine

• The health system’s tincture of time

• The ED’s safety net

• The cutting edge of acute healthcare

Why Observation in Dedicated Setting

• Improved patient satisfaction

• Lower health care costs

• Shorter LOS

• Improved use of hospital resources

• Less diagnostic uncertainty

Financial Viability of Emergency Department Observation Unit Billing ModelsChristopher W. Baugh MD, MBA Pawan Suri MD Christopher G. Caspers MD Michael A. Granovsky MD, CPC, CEDC Keith Neal MBA, MHL, CHFP Michael A. Ross MD

Critical outcomes

• Reduce the number of unnecessary inpatient admissions

• Evolve to manage complex observation patients

• CREATE INPATIENT CAPACITY, OPTIMIZE ED THROUGHPUT

What works best

• Know the history and rules of the game

• Staff – Dedicated MDs, APPs, RNs, plus

• Case management – level of care support, disposition planning

• Prioritization

• Rules – General guidelines, limitations, challenges

• Space – Dedicated – Type 1

• Access - 24/7

• Know your benchmarks

• Pathways and order-sets – evidence based practice model

• Use your data - Metrics, dashboards, scorecards

It takes a village…

• RN

• APP

• CM

• Core MD group

• Consultants

• SW

• Support staff – transport, unit clerk, EVS

• All team members vested in observation care model

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https://onlinelibrary.wiley.com/doi/10.1111/acem.13452

https://onlinelibrary.wiley.com/action/doSearch?ContribAuthorStored=Baugh,+Christopher+W

https://onlinelibrary.wiley.com/action/doSearch?ContribAuthorStored=Suri,+Pawan

https://onlinelibrary.wiley.com/action/doSearch?ContribAuthorStored=Caspers,+Christopher+G

https://onlinelibrary.wiley.com/action/doSearch?ContribAuthorStored=Granovsky,+Michael+A

https://onlinelibrary.wiley.com/action/doSearch?ContribAuthorStored=Neal,+Keith

https://onlinelibrary.wiley.com/action/doSearch?ContribAuthorStored=Ross,+Michael+A

9/12/2019

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Observation Guidelines

• 80% probability of discharge within 24 hours - if

managed actively

• Focused patient care goal

• Limited intensity of service and severity of illness

• Defined and supported endpoint

Observation Limitations

• Incomplete charting

• High severity or illness

• High intensity of service

• Inpatient level of service is required

• Age and gestational age limitations

• High risk of self-harm

• Anticipated LOS less 6hrs or greater 48hrs

Observation Challenges

• Ambulatory dysfunction

• Altered mental status

• New, persistent neurologic findings

• Patients receiving inpatient-type procedures, such as renal

or liver biopsy

• Post-operative recovery

• Patients who meet inpatient criteria *

ACEP policy recognizes care in a dedicated ED observation area,

rather than a general inpatient bed or an acute care ED bed, as a

best practice

Where Can Observation Services Be Provided

CDU Background and Mission

• The clinical decision unit [CDU] was created by the

Department of Emergency Medicine to help decrease ED

boarding, control resource over-utilization and create

inpatient capacity

• Mission to be a top-functioning observation unit

that provides efficient, high-quality care that is Emergency

Medicine driven, evidence-based, and patient-centered

Growth Strategy

• Simple to complex model

• Pathways 2.0

• Business proposal

• Project cost savings from geographic EM OBS placement

• Project new revenue from improved OBS LOS->Increased IP capacity and increased CMI

• Created division of OBS Medicine under EM

• Separated Tax IDs for MDs to optimize pro-fees

• Closed unit

• No to low boarders policy

• OBS->IP prioritized off floor

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Benchmarks – Simple Model Observation

Type 1 OBS Units [protocol driven; highest evidence for favorable outcomes]:

• Target 5-15% of ED volume

• Turn 1-1.5 patients per room per day

• Mean LOS 15hrs **

• Inpatient conversion 20%

• RN staffing 1:4 to 1:5

• APP staffing 1:10 to 1:12

• MD staffing variable from 8-32hrs/day based on proximity to ED, complexity of unit

Pathways

• Generic:

• Abd pain

• Allergic reaction

• Asthma exacerbation

• Back pain

• SOB

• Cellulitis

• COPD exacerbation

• Dehydration

• DVT

• Headache

• Hyperglycemia

• Hypoglycemia

• Pneumonia

• Pyelonephritis

• Syncope

• Urolithiasis

• General

• Collaborative:

• EM Cardiology Chest pain

• EM Cardiology CHF

• EM Ortho Post op wound infection

• EM Ortho Post op pain

• EM Ortho Post op DVT

• EM Hepatology Refractory Ascites -Paracentesis

• EM Hematology Sickle cell vaso-occlusive crisis

• EM GI Chronic abd pain

• EM GI UGIB

• EM Neurology TIA

• EM Atrial fibrillation

• EM Low Risk PE

• EM Bariatric Post-op dehydration

• EM OB Hyperemesis gravidum

• EM Spine Back pain

• UCC to CDU

Dedicated vs Non-dedicated Observation

CDU Non-CDU

Average/Median LOS 21.1/18.6hrs 32.1/26.5hrs

IP Conversion 16.58% 38.28%

30 Day Returns 11.80% 11.4%

Encounters 2,531 [63%] 1,466 [37%]

April 1, 2017 – Sept 30, 2017

Portion of TJUH/MHD Observation Patients

The CDU cares for almost half of all patients who are at Jefferson in

observation status. The CDU plays a vital role in hospital throughput

by timely efficient care.

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14% 15%

ED CDU MDH Observation TJUH Hospitalist

% of All Obs

Rehab Utilization

Rehab Utilization for All Observation Patients July 2016 - August 2017

ED/10P Discharges MDH Discharges

Metric FY17 FY17

TJUH-CC Observation Visits 3,822 2,639

Speech Cases 4 24

PT Cases 125 318

OT Cases 72 86

PT + OT Cases 148 335

Speech Utilization Rate 0.1% 0.9%

PT Utilization Rate 3.3% 12.1%

OT Utilization Rate 1.9% 3.3%

PT + OT Utilization Rate 3.9% 12.7%

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Ectopic Observation CDU Heatmap

Sickle Cell Utilization

HUH Closure

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Philadelphia Opioid Epidemic Pathways Development

• EM Cardiology Intermediate risk Chest pain

• EM Ortho Post op infection

• EM Ortho Post op pain

• EM Ortho Post op DVT

• EM Hepatology Refractory Ascites - Paracentesis

• EM Hematology Sickle cell vaso-occlusive crisis

• EM GI Chronic abd pain

• EM GI Low risk GIB – AIMS 65 score 0-1

• EM Neurology TIA – ABCD2 score 0-3

• EM Neurology Headache

• EM Atrial fibrillation - CHA2DS2-VASC score 0-3

• EM Low Risk PE - sPESI score 0



• EM Opioid MAT

• EM Psychosis

• EM Trauma

• EM Low Risk PTX

• EM Low Risk TBI – BIG 1 Criteria

CDU Pathway 2.0 and EBM

• EM GI Low risk GIB – AIMS 65 score 0-1

• EM Neurology TIA – ABCD2 score 0-3

• EM Neurology Headache

• EM Atrial fibrillation - CHA2DS2-VASC score 0-3

• EM Low Risk PE - sPESI score 0



• EM Opioid MAT

• EM Psychosis

• EM Trauma

• EM Low Risk PTX

• EM Low Risk TBI

EM Primary Ambulatory Dysfunction Pathway

Inclusion Criteria:

- Probability of discharge within 24 hours > 80%

- Failed ED trial of ambulation

Review ED diagnostic tests, monitor vital signs, case

management review within 12 hours, home care

coordination as needed, PT/OT evaluation/treatment

Disposition

Home if observation course completed and stable

Hospital if:

- Unstable vital signs, suspect SIRS/sepsis

- Deterioration in clinical status

- LOS exceeds 48 hours

Exclusion criteria:

- Meets criteria for inpatient admission

- Probability of discharge home witnin 24 hours < 80%

EM Ortho Post op infection/pain/DVT

INCLUSION CRITERIA

Probability of discharge within 24hrs >80%Orthopedic consult in ED and Ortho Fellow/Attending evaluation within 12hours of arrival

EXCLUSION CRITERIA

2+ SIRS criteriaComplicated deep infection requiring OR washout

TYPICAL OBSERVATION INTERVENTION

Monitor VSLaboratory tests

Elevation of extremityMark area of involvement

AntibioticsAnalgesia

Serial examsImaging as indicated

Discussion with ortho nurse and/or clinical navigator to ensure follow upCase management review within 12hrs

DISPOSITION

Home

Observation course stableClinical improvement

Tolerating medicationsFollow up arranged

HospitalChange in clinical status

Progression to complex infection requiring ORSIRS/Sepsis

Meets criteria for inpatient admissionLOS exceeds 23hrs

EM Hematology Sickle cell vaso-occlusive crisis

INCLUSION CRITERIA

Probability of discharge within 14hours >80%

Patient enrolled in TJUH Sickle Cell Program

EXCLUSION CRITERIA

Meets criteria for inpatient admission

Fever, pregnancy, concern for Acute Chest Syndrome

Probability of discharge home within 24-48 hours < 80%

TYPICAL OBSERVATION MANAGEMENT

Initiate individualized pain pathway

Monitor vital signs

Case management review within 12 hours

Home care coordination as needed

DISPOSTITION

Home

Observation course completed and stable

Hospital

Unstable vital signs, suspect SIRS/sepsis

Deterioration in clinical status

LOS exceeds 14hours

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EM Pediatric Pathway

Inclusion Criteria:


- Age >14, AND Weight > 100 lbs.


management review within 12 hours, home care coordination as

needed

Disposition


Hospital if:




Transfer if :

- They require pediatric specialty care not available at Jefferson

Exclusion criteria:



- Age < 14 or Age < 18 AND < 100 lbs.

EM Peds GI ERCP Pathway

Inclusion Criteria:


- Age >14, Weight > 100 lbs.

- Discussion with GI in conjunction with pediatric GI

- Procedure within *** hours


management review within 12 hours, home care coordination

as needed, moniotor post-procedure

Disposition


- Arrange GI followup

Hospital if:




Exclusion criteria:



- Age < 14 or Age < 18 and < 100

EM GI Low risk GIB INCLUSION CRITERIAHistory of melena in 24-48hours

Bright red rectal bleeding requiring urgent GI evalGI consultation for endoscopy/colonoscopy

Rectal exam performed and consistent with GIBProbability of discharge within 24hours >80%

EXCLUSION CRITERIA


Probability of discharge home within 24 hours < 80%

Unstable vital signsRelated syncope

Active massive bleeding requiring IR consultationConcern for ischemic bowel

Signs of cardiac ischemia

AIMS65 Score >2

TYPICAL OBSERVATION MANAGEMENTReview ED diagnostic tests, labwork, imaging

Monitor vital signs - Q2 hours X2, then Q4hrs Serial CBCs, T&S

IVFsPPI bolus and drip

NPOHold antiplatelets, AC, and cardioactive medications

Endoscopy/colonoscopy prepGI final recommendations

Case management review within 12 hoursHome care coordination as needed

DISPOSTITIONHome

Observation course completed and stableCBC stable

If endoscopy - no active bleeding, and follow-up arranged on PPI

HospitalUnstable vital signs, suspect SIRS/sepsis

Deterioration in clinical statusContinual decrease in CBC

Active bleeding by endoscopy LOS exceeds 48hours

EM Hepatology Refractory Ascites - ParacentesisInclusion Criteria:Probability of discharge within 24 hours > 80%History of cirrhosis and refractory ascites in need of large volume paracentesisTime of ER assessment from Sunday evening through Friday morning (i.e. access to U/S guided paracentesis within 12 hours of being seen)Hepatology fellow consult in ED with attending evaluation within 12 hours of arrival

Exclusion Criteria:Presence of hepatic encephalopathy (Stage 2 or greater: presence of asterixis and disorientation)New acute kidney injury (creatinine > 0.3mg/dL above baseline or > 1.5x above baseline)Presence of fever (Temp > 38.5ºC/101.3ºF)

New/initial episode of ascites

Typical observation intervention:Weigh patientMonitor VSLaboratory tests: CBC/diff, CMP, PT/PTT/INR, blood type and crossUltrasound-specials consult for large volume paracentesisPre-LVP transfusion with platelets (if count < 50,000) and FFP (if INR > 2): per radiology recommendationsFluid analysis: cell count with diff, culture, albumin, total protein

Post-paracentesis: replace ascites volume removed:- < 4L removed: no albumin replacement

- 4-5 L removed: 25g 25% albumin (two 50cc bottles)- 5-7 L removed: 50g 25% albumin (four 50cc bottles)- 7-9 L removed: 62.5g 25% albumin (five 50cc bottles)- > 9L removed: 75g 25% albumin (six 50cc bottles)Case management review within 12 hours

Disposition:HomeObservation course stableParacentesis results show no evidence of SBPFollow-up arranged in hepatology clinic

HospitalSBP diagnosed (ascites absolute neutrophil count > 250)> 100,000 RBC’s in ascites or procedure-related complicationsPost-procedure hypotension unresponsive to IV albumin resuscitation or new-onset encephalopathy LOS exceeds 23 hours

EM Neurology TIA INCLUSION CRITERIAProbability of discharge within 24hours >80%

Neuro consultation notified in ED with Neuro Fellow/Attending evaluation within 12hours of arrivalABCD2 score 0-3

EXCLUSION CRITERIA

tPA givenMeets criteria for inpatient admission

Suspected acute CVAABCD2 score greater than 3

Hypertensive crisis requiring IV antihypertensivesConcern for worsening neurological exam

Motor deficit or cortical symptomsNewly depressed level of consciousness

Probability of discharge home within 24 hours < 80%


Review ED diagnostic tests, labwork, imagingMonitor vital signs

TelemetryNeuro checks every 4hours

CT/MRI/MRA as indicatedEchocardiogram + bubble (PFO)

Carotid dopplers as indicatedAntiplatelet therapy as indicated

Neuro consultation completionCase management review within 12 hours


DISPOSITION

Home


Stable or improved neurologic exam

HospitalAbnormal imaging requiring hospitalization

Unstable vital signs, suspect SIRS/sepsisDeterioration in neurologic exam

ABCD2 score greater than 3LOS exceeds 48hours

EM Atrial fibrillation

Inclusion Criteria:


- Acute onset of atrial fibrillation

- Review ED diagnostic tests, lab work and imaging

- Telemetry, monitor vital signs,

- Labs to include BMP, Mg, thryoid panel and BNP

- Cardiology consultation as neeeded

- Consider TTE if clinical or laboratory evidence of heart

failure

- Intitiation of anticoagulation unless contraindicated

- Case management review within 12 hours, home care

coordination as needed

DIsposition

Home

- Conversion to NSR for 1 hr or continued atrial fibrillation with

rate control

-Outpatient anticoagulation coordinated

- Expedited cardiology follow up

Hospital

- Unstable vital signs

- Suspect SIRS/sepsis

- Failure to control heart rate < 100


- LOS > 48 hours

Exclusion criteria:



- Hemodynamic instability -altered mental status or low blood

pressure

- HR > 100 after ED treatment

- CHADS-VASC score > 4

- Evidence of sepsis/PE/MI/CHF

- Concern for concurrent intoxication/toxicity

- Requuiriing IV drip for rate control

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EM Low Risk PE INCLUSION CRITERIA

Probability of discharge within 24hours >80%Imaging consistent with non-central PE

sPESI score of zeroNo other contraindications to outpatient anticoagulation.

JATS consultation notified in ED with JATS evaluation within 12hours of arrival

EXCLUSION CRITERIAMeets criteria for inpatient admissionsPESI score greater than or equal to 1

Patient not a candidate for anticoagulation due to bleeding risk.Elevated troponin

Right heart strain on imagingMultiple co-morbidities

Renal insufficiency defined as CrCl < 30mL/minInability to care for self, noncompliance, or recent lost to follow up

Pregnancy Dementia with no caregiver present for education

Necessity for heparin gttProbability of discharge home within 24 hours < 80%


Review ED diagnostic tests, labwork, imagingMonitor vital signsTelemetry

Labs to include BMP, LFTs, CoagsTTE to evaluate for R heart strain if necessary

Initiation of outpatient DOAC regimen per JATS consultationAnticoagulation teaching

Case management insurance verification and case reviewPharmacy verification


DISPOSITIONHome

Observation course completed and stableStable or improved exam

Anticoagulation initiated and teaching completed

EM Low Risk PTX Pathway

EM Trauma Pathway

Inclusion Criteria:


- Primary/Secondary survey complete and documented

- Trauma consultation


management review within 12 hours, home care coordination as

needed, PT/OT evaluation/treatment, tertiary

survey

Disposition


Hospital if:




Exclusion criteria:



- Anticipated OR need

EM Surgery Pre-op Pathway

Inclusion Criteria:


- Surgical consultation

Review ED diagnostic tests, monitor vital signs, serial exams, case management review within 12 hours,

home care coordination as needed

Disposition


- Arrange surgicalfollow up

Hospital if:




Exclusion criteria:



EM Trauma Spine NH Spine Pathway EM Trauma Spine NH Spine Pathway

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EM Opioid MAT

INCLUSION CRITERIAProbability of discharge within 24hours >80%

Age >18History of active OUD with symptoms of intractable, acute withdrawal requiring further observation

Desire for MAT with Buprenorphine (BUP)Opioid Counsellor contacted in the ED to facilitate warm handoff (phone number: 215-219-9661)

EXCLUSION CRITERIA

Meets criteria for inpatient admissionPatient not eligible for BUP due to allergy or severe liver disease

Concomitant alcohol or benzodiazepine dependence/abuse requiring monitored detoxificationPregnant Patients

Use of pathway system within the last 30 days or otherwise ineligible for acute detox therapy Concomitant, acute psychiatric emergency

TYPICAL OBSERVATION MANAGEMENTReview ED diagnostic tests, labwork, imaging

Progression of diet as tolerated IV hydration as needed

Alternative symptomatic control PRN (antiemetics, antihistamines, clonidine) Buprenorphine Initial Dosing:

Low Tolerance/Withdrawal (COWS ≥5-12): 4mg PO Daily or 2mg PO BIDModerate Tolerance/Withdrawal (COWS ≥13-23): 4mg PO BID or 8mg PO Daily

High Tolerance/Withdrawal (COWS ≥24): 8mg PO BIDBuprenorphine Repeat Dosing:

If no response to initial dose, a 4mg repeat dose may be provided after 1 hour and repeat dose after 4 hours is appropriate depending on COWS/symptoms.

Maintenance dosing is typically 8-16mg/day (Daily or divided BID) in most patients, no more than 24mg/day

Serial exams to assess response to BuprenorphineVital signs q 4hours

Opioid Counsellor through Mary Howard Clinic or (if patient prefers due to location, CleanSlate)

DISPOSITION

To Mary Howard/CleanSlate for warm handoff:Observation course stable

Clinical improvementTolerating medications

Follow up arranged

Inpatient:Incomplete response to Buprenorphine with persistent/severe withdrawal symptoms

Unstable vital signs, suspect sepsis or other underlying acute medical issuePersistent PO Intolerance

LOS exceeds 48hours

EM Psychosis Pathway – ED only

Inclusion Criteria:


- Clinical probabilty of psychosis or self-harm NOT associated witha cute illness

- ED LOS approaching 6 hours with continued obseration for disposition

decision

- Psychiatry Consult in ED with psychiatric attending evaluation and disposition

within 12 hours of arrival

- ED diagnostic tests, labwork, tox screening, EKG, imaging as needed

- Monitor vital signs

- 1:1 observation as needed for pateints at risk for self- harm

- SW consulatation

- Home care coordination as needed

Disposition

Home

- Clinical improvement

- Observation course completed and stable

- Psychiatry consultation completed

Hospital if:

- Psychiatric consultation determintes need for inpatient psychiatric admission



Exclusion criteria:

- Medical illness necessitating inpatient admission (toxic ingestion, withdrawal

syndrome requiring parenteral medications)

- Unstable vital signs

- Probability of discharge within 24 hours < 80%

UCC to Observation Pathway EM Low Risk TBI

Exclusioncriteria:

DoesnotmeettheBig1criteria

Probabilityofdischargewithin24hours>80%

InclusionCriteria(Big1criteria):NoLOC,normalneruologicalexam,nointoxication,noCoumadin/aspirin/plavix,noskullfracture,SDHandepidural

hematoma(lessthanorequalto4mm,intraparenchymalbleedlessthan4mminone

location,tracesubarachnoidandnointraventricularhemorrhage,spinalcleared,noothertraumaticinjuriesthatneedcontinuedevaluation,nointractablepain/vomiting,stablevitals

Serialneurologicalexams,

advancedietastolerated,antiemetic/analgesicsasneeded

repeatCTaswithanymentalstatuschangesandperneurosurgery/trauma

Home

GCSremaines15,normalneurologicalexam,toleratingPO

Admit

focalneurologicalfinding,alteredmentalstatus,nottoleratingPO,CTwith

worseningfindingsornewfindings

traumavsneurosurgery

EM General Pathway

INCLUSION CRITERIA

Probability of discharge within 24hours >80%

EXCLUSION CRITERIA


Probability of discharge home within 24-48 hours < 80%


Review ED diagnostic tests, labwork, imaging

Monitor vital signs

Case management review within 12 hours


DISPOSTITION

Home


Hospital

Unstable vital signs, suspect SIRS/sepsis

Deterioration in clinical status

LOS exceeds 48hours

Lessons learned

• Prioritization and institutional support

• Limit provider variation

• Creating guidelines and an endpoint

• Need for CM

• APP CDU lead

• Interdisciplinary care model

• Active engagement

• Repeated rounding

• Focused plan of care limiting over testing and consultation

• Early identification of imminent patient dispositions

• Streamlined documentation of care

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2018 Updates

• Type 1 Unit – Dedicated and protocol driven patient selection

• Complex Model – CM driven

• Dedicated RN, APP, MD group

• Tax ID separation in process

• Increased LOS and IP bc complex patients

• General pathway utilization

• CDU boarders in ED, IP boarders on 10P

2019 Goals

• Obs pathway 3.0

• SIPS data

• ENT pre-adm

• Surgical obs – Trauma obs

• Peds obs

• Cards, GI, Neuro

• Closed unit pilot

• Obs -> IP @ 2MN -> off floor

• APP staffing

• Prioritization and institutional support

Collaboration and Prioritization

• Cardiology

• Stress and TTE lab

• Neurology

• Radiology

• GI

• Surgery

• Ortho

• Hematology

• Case management, Social work

• PT

• Support services

Looking ahead

• 30+ beds

• Hybrid EM/IM/FM model

• Division of observation

• Educational curriculum

• Direct to observation placements

• SIPS

• Leveraging metrics

• Care coordination, Appointment scheduling

Future of Observation

• It’s not JUST about the $$$ and creating space

• Tincture of time

• Evidence-based medicine not metrics medicine

• Complex observation

• Hybrid provider model

• Novel pathways

• Education

• Research

Future of Observation in Emergency Medicine

• Division of Observation Medicine

• Research/Publication

• Education - UME, GME, Fellowship, APP

• Operations, Informatics

• Quality and Safety

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Thank you!

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Documents

PowerPoint Presentation•Pathway driven •Interdisciplinary team model •The Centers for Medicare & Medicaid Services (CMS) defines observation care as a specific, defined set of