Crenshaw Libby A, Lindsell Christopher J, Storrow Alan B, Lyons Michael S
Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267-0769, USA.
Am J Emerg Med. 2006 May;24(3):271-9. doi: 10.1016/j.ajem.2005.11.002.
Appropriate patient selection is critical for maximal observation unit (OU) effectiveness. We hypothesized emergency physicians underuse the OU for admitted patients and overuse the OU for patients who would otherwise be discharged.
Treating emergency physicians were asked about patient suitability for admission to an OU at a busy, urban, academic emergency department (ED) as part of a prospective cohort study of ED patients who were admitted or had an ED length of stay exceeding 4 hours. The OU was closed for renovation during the 2-month study, so physician opinion could be compared with patient course in the absence of observation services. Two blinded emergency physicians reviewed charts using structured forms and explicit definitions to determine actual patient course. Hospitalized patients were considered potential OU candidates according to a priori criteria: (1) hospital length of stay less than 48 hours, (2) no procedure or diagnosis requiring hospitalization, and (3) no death.
Of 1747 enrolled patients, 131 were excluded with incomplete data. Median age was 45 years. Patients were 40% white and 48% men. Emergency physicians identified 363 (23%) patients as observation candidates. Of these, 182 (50%) were actually discharged directly. The remaining 181 (50%) were hospitalized; 101 (56%) were observation candidates based on chart review. Of 799 admitted patients not selected for observation, 232 (29%) were suitable for observation by chart review.
Selection of patients for observation was suboptimal; emergency physicians routinely identified patients as OU candidates who were not ultimately admitted, and they missed many admitted patients who might have been appropriate OU candidates. Both over- and underuse should be addressed to maximize the effectiveness of OUs.
恰当的患者选择对于最大程度提高观察单元（OU）的效能至关重要。我们推测急诊医师对入院患者未充分利用OU，而对于原本会出院的患者过度使用OU。
作为对入院或急诊留观时间超过4小时的急诊患者进行的前瞻性队列研究的一部分，在一家繁忙的城市学术急诊科，询问负责治疗的急诊医师患者是否适合入住OU。在为期2个月的研究期间，OU因翻修关闭，因此可以在没有观察服务的情况下将医师的意见与患者病程进行比较。两名盲法急诊医师使用结构化表格和明确的定义查阅病历，以确定患者的实际病程。根据先验标准，住院患者被视为潜在的OU候选者：（1）住院时间少于48小时，（2）无需要住院治疗的操作或诊断，（3）无死亡。
纳入的1747例患者中，131例因数据不完整被排除。中位年龄为45岁。患者中40%为白人，48%为男性。急诊医师确定363例（23%）患者为观察候选者。其中，182例（50%）实际上直接出院。其余181例（50%）住院；根据病历审查，101例（56%）为观察候选者。在799例未被选作观察的入院患者中，232例（29%）经病历审查适合观察。
患者观察的选择并不理想；急诊医师常规将最终未入院的患者确定为OU候选者，同时遗漏了许多可能适合作为OU候选者的入院患者。应解决过度使用和使用不足的问题，以最大程度提高OU的效能。
