This document provides information about observation status in a hospital setting. It defines observation as allowing a physician time to determine the most appropriate care setting for a patient within 23 hours. Severity of illness refers to a patient's clinical symptoms, while intensity of service means interventions ordered by a physician to treat the patient. Some examples that may warrant observation are complications from surgery like bleeding or inability to void, as well as medical issues like chest pain or nausea. Proper documentation of an observation order is required for every observation patient. Several case studies are presented to demonstrate potential observation scenarios.

1. Observation - what the? Everything you wanted to know about observation but were afraid to ask

2. Objectives At the end of this session, the participant will be able to: Define severity of illness and intensity of service Define observation and give examples Actively assist in identifying errors in the chart documentation

3. Reason for Observation – to allow the physician time to make a decision and then RAPIDLY move the patient to the most appropriate setting within a 23 hour time frame Observation is not a holding zone

4. Interqual/McKesson Guidelines Medical interventions based on medical practice that has been proven to be best practice. It is commonly termed “evidence based medicine”. Evidence based medicine comes from the 14 evidence based practice centers. Those centers include Duke, John’s Hopkins, Tufts university and Vanderbilt.

5. Severity of Illness Severity of illness is defined as the clinical presentation of symptoms. These are measurable in nature. Examples are: Mental status Lab and radiology results Vomiting/Diarrhea

6. Intensity of Service Intensity of service is defined by interventions ordered by the physician to treat the patient. Examples: IV orders Medications Assessments Monitoring

7. Surgical Observation Observation can not be ordered prior to surgery. Observation for surgery cases can occur due to unforeseen events either intra or post operatively.

8. Some patients can have problems intra-operatively such as: Bleeding Dehydration Electrolyte imbalance These can usually be treated in an observation setting.

9. Post operative complications can include: Inability to void Nausea Vomiting Decreased oxygenation

10. Medical Observation Medical observation is assessed prior to being admitted This can be done either in the doctor’s office or the emergency room Usually medical observation is ordered when the physician feels treatment can be given and patient can improve within 23 hours

11. Examples of common observation diagnosis: Chest pain Shortness of breath Dehydration Nausea/Vomiting/Diarrhea Pain Failed outpatient treatment

12. Documentation All observation patients MUST have a written observation order This order must be signed or cosigned by the admitting physician It is EVERYONE’S responsibility to make sure there is a level of care order on every chart

13. Case study # 1 69 yo male presents to ER with an airway obstruction. Obstruction removed by ENT in procedure room. Light anesthesia was given. Pt has no further complications. It is 2230. He lives alone and wants to walk home.

14. Case study #2 35 year old pt has a tubal ligation. Patient was slow to wake but by hour 4 is alert and oriented. Patient has not voided. No attempts to void have been made at this time.

15. Case study #3 47 yo woman presents to ER with chest pain. She states she has had mid-sternal pain for the last four hours without relief. Serial cardiac markers are ordered. Patient is given 2 of morphine iv and patient is now pain free.

16. Case study #4 Patient has scheduled a capsule endoscopy ordered. She is 90 yo, confined to a wheel chair and from a nursing home.

17. Case study #5 Patient comes directly to hospital from doctors office. Patient is currently receiving chemotherapy as an out patient. Patient complains of weakness, low urine output, pain and shortness of breath. Patient’s temp is 101.2.

18. Last thoughts All orders, especially radiology orders should be treated as ASAP. This will help the physician make a determination regarding level of care DOCUMENT, DOCUMENT, DOCUMENT Every order, nurses note, progress note – anything added to the chart MUST have a time and date Call your friendly care manager if you have any questions

19. Questions