Short Term Observation: 2008-2015 Activity Report And Data Analysis

A. Simone¹, D. Livoli², V. Valeriano², F.R. Pugliese³

MD Director Short Term observation
Medical Doctor
Director of Department of Emergency PErtini Hospital in Roma

Introduction

The Short Term Observation (STO) section was instituted at Sandro Pertini Hospital of the ASL RMB in Rome on January the 1st 2008, following a regional administration’s decision but most of all in order to meet some of the patients’ real need for a 1 or 2 days hospitalization with non-clinical DRG. This identifies the Short Term Observation section as a form of assistance that with no hospitalization guarantees the treatment of moderately complex clinical situations, looking to improve the quality of assistance in the emergency room and to reduce the number of inappropriate hospitalizations using criteria based on clinic and time (max 36h).

The object of this study is to demonstrate very important rule of STO in filter function in proper hospitalitazion theme and to give patients better proper paths

Over the first two years the unit was equipped with 19 beds; from 2010 on the number of beds was cut down to 10, following the application of the decree 80.

According to the American College of Emergency Physicians Short Term Observation Section (USA), these observation areas have the following goals:

To allow an early risk stratification with a reduction of the number of inappropriate hospitalizations
To determine the risk reduction through early EBM protocols that ensure an effective health care
To mprove the care process with a reduction of the means used and the consequent cost optimization.

These last few years experience showed that the Short Term Observation Section represented for the hospital and the territory of the ASL RMB the answer to the emergency physician’s dilemma: potentially dangerous diseases not to be underestimated, averagely serious patients that are too serious to be discharged but not enough to be admitted, psycho-social needs to fulfill, the constant increase in number of those fragile patients that are under the poverty line whose only answer sometimes are the always open doors of the emergency room.

Over the last few years the regional plans, with the necessity to optimize the care and the costs in order to meet the increasingly strict European standards, cut down the availability of beds for severe patients, without a contemporary potentiation of the role of the territorial structures in the management of chronicities. The inapproprite timing of realization between the number of beds reduction and the territory potentiation resulted in the overcrowding of the Emergency Departments, which was worsened by the population ageing

These issues, shared by other countries in Europe and the world, lead to the need for a care modality that can be used as an alternative to hospitalization and that allows to maintain the required diagnostic accuracy and the outcomes of the treatment.

Clinical trials and multicenter studies confirmed that the pathologies that surely cause an increase of improper hospitalizations are:

Chest Pain
Asthma
Abdominal pain
Very old patients with multiple pathologies
Deep Vein Thrombosis

Matherials and Methods

Thoughout the years we used the following criteria:

A precise diagnostic-therapeutic goal to reach in the 70% of cases with subsequent discharge over 36 hrs
A limited cure intensity, otherwise hospitalization was ordered
A proper use of the physician/nurse-patient time

The clinical methodology was perfectioned over the years but always sticking to the clinical EBM guidelines, according to which cures and diagnostic tests have to be delivered rapidly and regardless of the weekdays, discharging patients even on Saturdays and Sundays.

Short Term Observation section at Sandro Pertini Hospital

It is a dedicated area, endowed with the proper equipment: monitoring technologies, medical gases, adjoining toilet rooms and attentive and trained personnel.

The term “intensive” refers to the organization and management features and it doesn’t refer to structural and technological requirments that are part of the so called intensive care.

The STO section is located next to the emergency room operative area, which allowed an increasing integration of the unit that often represented the only source of available beds seen the rapid turn over ( see graphics and tables).

When it was instituted and until 2010, the STO section was provided with 19 beds and a personnel of 2 phisicians 12 hrs a day (director included), 4 nurses 12 hrs, 2 nurses 24 hrs, an auxiliary 12 hrs.

Afterwards, in compliance to the decree 80/100, the number of beds was cut down to 10 with a reduction of the dedicated personnel down to 1 physician, 2 nurses and an auxiliary for 12 hrs a day.

The bed places are all equiped with wireless internet connection, medical gases and every needed technology and comfort like any other ward (closet, bedside table, chair and table). They are reclining beds with safety rails and they can be disassembled when necessary.

The STO section has always operated independently from the Complex Operative Unit (COU), this being a crucial feature to guarantee the efficiency of the system. There has always been a great mediation effort in the otherwise conflictual relationship with other hospital services specialists, often withstanding the sometimes even improper pressure to assign a bed to a difficult patient or to a “too well known” one.

Since its institution there’s been a person in charge of the unit that answers solely to the COU director. This figure is a clinical decision making expert, that represented the point of reference in all the STO unit activities.

The specialist consulting as well as the laboratory exams request and the medication use have always been as focused as possible, never dictated by routine.

The specialist valuation as well as a comfortable access to the specialistic and instrumental follow up pathways have always been carried out within the DEA time limit.

Methodology.

The every day activity in the Short Term Observation unit has the following characteristics:

The clinical record has a dedicated electronic form in the regional system called GIPSE
All the medical and nursing activities are recorded on the electronic form
The medical examination is carried out with two laptops (one for the physician and another one for the nurse manager/nurse) linked through wifi connection to the hospital network which allows both of them to assess every variable and issue concerning each patient
The only paper items, at the moment, are hemogasabalysis and electrocardiogram that are collected in dedicated charts in which just the front page of the record is printed
After the examination and the valuation, the short term observation unit physician comunicates to the patient the outcome and the decision about discharge or the continuation of the hospitalization. In case of old, fragile and/or disabled patients, families are reached by phone and summoned for an interview
At the end of the interview with the family and considering the overall family issues, a pathway is activated: discharge; patient return to their recidence by ambulance transport, CAD and ADI activation, transfer to other internal medicine or specialist care structures; hospitalization continuation in other wards inside the same hospital
Discharge from the STO section has to be seen through over the morning
The STO form allows to discharge the patient during the examination since notes and prescriptions can be filled through a few steps in the GIPSE form, that can be printed and handed to the patient and the family.

At the end of the morning check up the STO physician fills a list of the patients that have to be hospitalized. It comprehends patients presenting high complexity clinical situations that have to be admitted to wards inside the hospital as well as those patients who have to continue the hospitalization but can be safely looked after in healthcare facilities accredited by the SSR, presenting an avarage-low complexity clinical situation.

The STO section beds are reintegrated in real time thanks to a dedicated team so that the emergency room can clear the observation areas as soon as possible.

As soon as the STO bed is restored, the emergency room observation area (holding area) or, in particular cases of overcrowding, the red-code area, sends the patient to the STO upon prior phone call to the nurse manager.

The holding area physician edits the destination in the electronic form and assigns the bed in the STO.

Upon their arrival in the unit, the patient is examined by the STO physician that revaluates them (anamnesis, objective examination, therapy) and traces a pathway to reach the decisional goal (hospitalization or discharge).

Within the 36 hours stay at the unit, the patient is assessed and reassessed multiple times (EBM) so as to allow a precise clinical risk stratification in order to define in a short time the patient’s clinical pathway.

In the present study we considered the data concercing the STO input/output streams in the period of time that goes from January the 1st 2008 to December the 31st 2015, analyzing them as follows:

Admittance in sto for triage color code
Admittance in sto for diagnosis in the emergency room
Admittance in sto for pathology (code ICD10)
Discharged for pathology (code ICD10)
Hospitalized for pathology
Hospitalized for age and gender
Transferred to other structures
Readmission within the 72 hours
Deaths

Results

Data analysis shows that for a mean of 1800 observed patients for year about the 65% was discharged and the 35% hospitalized with a percentage of readmission within 72 hours, over the considered period, of about the 7%.

The total number of transfers to external structures in the considered period was of about 200 patients. The analysis also dealt with the single pathologies; in particular it was found that some of the pathologies like TIA, COPD and heart failure kept a constant percentage over the years, whereas some clinical conditions connected to the fragility of the old age (management difficulty of patients affected by dementia, electrolyte imbalance, dehydration, etc…) are increasing and often require hospitalizations at other facilities.

Table 1: Analysis patients for year with a percentage of discharged

Table 2: Readmissions within 72 hrs for year/total admission STO

Graphic 1: Total discharges from STO and readmissions over 72 hrs/year

Graphic 2: Discharged/readmitted within 72 hours report STO 2008-2015

Regarding the priority codes, in the STO section there’s a prevalence of green and yellow codes, with a trend that remained more or less constant over the years.

Table 3: Priority codes

The hospitalization analysis by age range showed a prevalence of patients over 75 years of age, confirming the role of the STO section in managing the clinical conditions connected to the fragility of old age.

Table 4: Admissions STO/year for age range

The total number of deaths in the considered period was of 135 patients, with a significant decrease over the years.

Table 5: Number of deaths per year

Among the pathologies in the considered period the following prevailed :

Transient Ischemic Attack
Chest pain
Acute exacerbation of chronic bronchitis
Syncope

Table 6: Prevailing pathologies outcome 2008/2015

It’s important to point out that over the course of the considered years there was a variation in the users demand that resulted in modifications of the organization of the Emergency Room.
For example the number of admissions in STO with “chest pain” as main symptom decreased with the institution of clinical pathways that allowed the discharge of that category already from the Emergency Room. On the contrary, there was an increase of the admissions in the STO of patients with social fragility and patients over 75 years of age, for an increase of these categories of the population.

Table 7: Analysis of prevailing pathologies

Conclusions

These last few years experience made us grow and encouraged us in the research of an increasingly better appropriateness of the care delivered, paying great attention to our patients’ social and welfare issues. Our experience has identified the main focus of activity dell’OBI in the interview with the patient and his family, a real centerpiece for the management and the appropriateness of both hospital locations on the territory.
to achieve the objective that we set (70% resignations and 30% admissions) was possible in large part thanks to the alignment of all staff behavior, that has formed on field, and daily membership and filed with the method of work.
It is most important for this purpose an increasing integration of the territory with the emergency departments.