Utilization of Nurse Practitioners in a Hospital-Based Observation Unit

Article Outline

• Clinical Topic
• Implementation
• Outcomes
• Recommendations
• Copyright

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Clinical Topic 

The purpose of this project was to describe how utilization of emergency department (ED) nurse practitioners could provide an alternative to medical management of observation-unit patients. Observation units can be extensions of the emergency department, designed to decrease inpatient bed use and promote safe, expedient patient care. In most settings, physicians manage ED patients while also providing ongoing care for observation patients. A new model of ED observation care management was developed utilizing nurse practitioners independently to manage observation-unit patients. Observation patients have acute problems that are anticipated to resolve or improve within 24 to 48 hours of treatment.

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Implementation 

In July 1997, our Level I University Hospital Emergency Department opened a 10-bed observation unit. Initially, a staff emergency physician and nurse practitioner or resident provided patient care management in the observation unit. After one year, a new model was developed so that nurse practitioners could be solely responsible for managing the observation-unit patients from 7:00 a.m. to 1:00 a.m. A staff physician was assigned to the observation unit from 8:00 a.m. to 11:00 a.m. to assist with final patient disposition. Also from1:00 a.m. to 7:00 a.m., the night shift staff physicians were responsible for admitting patients to the unit and providing ongoing patient management. The nurse practitioners conducted history and physical exams, developed differential diagnoses, and determined the need for additional testing, pharmacological management, consultation, and disposition of the observation patients.

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Outcomes 

Over the last seven years, the observation unit census has doubled, with an average census of seven patients per day. The average length of stay is 16 hours, and 84 % of the patients are discharged home. The majority of complaints admitted to the observation unit include minor closed head injury, blunt chest and abdominal trauma, low-risk chest pain, dehydration, cellulitis, bronchiolitis, asthma, and chronic obstructive disease exacerbation. Critically ill or complex patient-care problems and children less than 8 weeks of age are excluded. Utilizing nurse practitioners in this ED observation unit has provided more physician satisfaction, decreased overcrowding, and increased efficiency in the emergency department.

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Recommendations 

Recommendations for furthering this work include: