Cambridge University Press

978-1-107-02234-8 — Observation Medicine

Edited by Sharon E. Mace
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Observation Medicine

Using sample clinical protocols, order sets, and administrative policies that
any hospital can use, this book gives a detailed account of how to set up and
run an observation unit (OU) and reviews conditions in which observational
medicine (OM) may be beneficial. In addition to clinical topics such as
improving patient outcomes and avoiding readmissions, it also includes
practical topics such as design, staffing, and daily operations; fiscal aspects
such as coding, billing, and reimbursement; regulatory concerns such as
aligning case management and utilization review with observation; nursing
considerations; and more. The future of OM, and how OM can help solve
the healthcare crisis from costs to access, is also discussed. Although based
on U.S. practices, this book is also applicable to an international audience,
and contains instructions for implementing observation in any setting or
locale and in any type of hospital or other appropriate facility.

Sharon E. Mace is Professor of Medicine at the Cleveland Clinic Lerner College of

Medicine of Case Western Reserve University; Director of Observation Unit, Director
of Research, and previously Director of Pediatric Education/Quality Improvement at
the Emergency Services Institute, Cleveland Clinic; and a member of the Faculty of
MetroHealth Medical Center/Cleveland Clinic Emergency Medicine Residency in
Cleveland, Ohio.

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Observation Medicine
Principles and Protocols
Edited by
Sharon E. Mace
Emergency Services Institute, Cleveland Clinic, Cleveland, OH

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Edited by Sharon E. Mace
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Names: Mace, Sharon E., editor.
Title: Observation medicine : principles and protocols /
edited by Sharon E. Mace.
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Identifiers: LCCN 2015048881 | ISBN 9781107022348
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Subjects: | MESH: Emergency Service, Hospital |
Diagnostic Techniques and Procedures | Emergency
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Contents
Advance Praise x
About the Editors xiii
Contributors xv
Foreword: Onward and Upward xx
Greg L. Henry
Preface xxiii
Sharon E. Mace

Part I Administration: Key 9 Metrics and Performance Improvement:

Patient Quality, Safety, and
Concepts of Observation Experience 48
Medicine, and Developing and Sharon E. Mace and Elaine Thallner
Maintaining an Observation Unit
1 Observation Medicine – Key Concepts:
Part II Observation Medicine: Clinical
How to Start (and Maintain) an Observation Setting and Education
Unit: What You Need to Know: Clinical
Issues 2 10 The Community Hospital Perspective in a
Suburban/Rural Setting 58
Sharon E. Mace
Ryan Prudoff and Stephen Sayles
2 Observation Medicine – Key
Concepts: How to Start (and Maintain) 11 The Urban Community Hospital 60
an Observation Unit: What You Robert S. Bennett
Need to Know: Administrative 12 The Tertiary Care Hospital and Academic
Issues 11 Setting 62
Sharon E. Mace Jonathan Glauser
3 Observation Medicine Development 13 Observation Medicine and the
Over Time 23 Hospitalist 64
Louis Graff IV David G. Paje and Peter Y. Watson
4 Observation Medicine Principles 27 14 Training and Education – Residents 66
Louis Graff IV Pawan Suri
5 Design 30 15 Training and Education – Medical
David Robinson Students/Fellows 68
6 Staffing Considerations 33 Margarita E. Pena
Christopher W. Baugh and
J. Stephen Bohan Part III New Developments in
7 Nursing 37 Observation Medicine
Sharon E. Mace and Karen Games
16 Extended and Complex
8 Risk Management 43 Observation 72
Gregory L. Henry L. Christine Gilmore and Bret A. Nicks

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Table of Contents

17 Extended Observation Services 76 Subpart IVC Clinical – Vascular

Catherine T. Puetz
Editor’s Comments: Venous
18 Hospital Readmissions 78 Thromboembolic Disease: Deep Vein
Sharon E. Mace Thrombosis and Pulmonary Emboli 158
19 Level of Care Determination: 31 Deep Vein Thrombosis (DVT) 159
Medical Necessity Risk Carol Lynn Clark and Michelle A. Wiener
Stratification 88
Louis Graff IV 32 Acute Pulmonary Embolism (PE) 165
David G. Paje
20 Accountable Care Organizations 92
Kayur V. Patel and Igor Kozunov 33 Anticoagulants 173
David G. Paje
21 Acute Medicine in the United
Kingdom 95
Louella Vaughan Subpart IVD Clinical – Neurologic
34 Transient Ischemic Attack (TIA) 180
Matthew Tabbut and Jonathan Glauser
Part IV Clinical
35 Headaches 189
Subpart IVA Clinical – Cardiac Sharon E. Mace
22 Chest Pain 98 36 Seizures 200
Tertius T. Tuy and W. Frank Peacock Sharon E. Mace
23 Heart Failure 107 37 Dizziness and Vertigo 211
Jieun Kim and W. Frank Peacock Saurin Bhatt
24 Atrial Fibrillation 114 38 Central Nervous System (CNS)
Catherine T. Puetz Shunts 222
25 Syncope 121 Mark G. Moseley and Miles P. Hawley
T. Andrew Windsor and Amal Mattu
26 Stress Testing 127
Subpart IVE Clinical – Metabolic,
Kami M. Hu and Amal Mattu Endocrine
39 Hyperglycemia 225
Pawan Suri and Taruna Aurora
Subpart IVB Clinical – Respiratory
40 Hypoglycemia 231
27 Asthma 138
Pawan Suri and Taruna Aurora
Eric Anderson
41 Electrolyte Abnormalities 235
28 Acute Exacerbation of Chronic
Kimberly A. Ressler and Jonathan Glauser
Obstructive Pulmonary Disease
and Bronchitis 143
Eric Anderson Subpart IVF Clinical – Hematologic
29 Community Acquired Pneumonia 149 42 Sickle Cell Disease 244
Eric Anderson Matt Lyon, Leah Taylor and
Robert W. Gibson
30 Primary Spontaneous
Pneumothorax 153 43 Transfusions 250
Chew Yian Chai Rokhsanna Sadeghi and Jonathan Glauser

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Subpart IVG Clinical – Infections Subpart IVL Clinical – Surgical

44 Skin and Soft Tissue Infections (SSTI) 257 Evaluation
Robert S. Bennett
56 Abdominal Pain 309
Mark G. Moseley and Miles P. Hawley
Subpart IVH Clinical –
Gastrointestinal Subpart IVM Clinical – Pain
45 Abdominal Pain 263 Management and Musculoskeletal
Louis Graff IV 57 Pain Management, Including
46 Upper Gastrointestinal (GI) Bleeding 267 Musculoskeletal and Low Back Pain 312
Abhinav Chandra Nathaniel L. Scott and James R. Miner

47 Dehydration, Gastroenteritis, and

Vomiting 271 Subpart IVN Clinical – Trauma
Elizabeth A. Rees and Bret A. Nicks
58 Trauma 318
Mark G. Moseley and Miles P. Hawley
Subpart IVI Clinical – Genitourinary
48 Urolithiasis 274 Subpart IVO Clinical – Toxicology
Claire Pearson and Robert D. Welch
59 Toxicology 323
49 Pyelonephritis and Urinary Tract Steven J. Walsh and Marsha Ford
Infections 280
Brian Kern and Robert D. Welch
Subpart IVP Clinical – Psychosocial
Subpart IVJ Clinical – Obstetrics and Editor’s Comments on Medical
Clearance 332
Gynecology
60 Psychiatric Patients 332
50 Pelvic Inflammatory Disease (PID) 284 Jonathan Glauser
Veronica Sikka and Renee Reid
51 Vaginal Bleeding 287 Subpart IVQ Clinical – Disasters
Veronica Sikka and Renee Reid
61 Disasters 339
52 Hyperemesis Gravidarum 289 Constance J. Doyle
Veronica Sikka and Harinder Dhindsa
Part V Financial
Subpart IVK Clinical – Pediatrics and Subpart VA Financial – Coding and
Geriatrics Reimbursement
53 Pediatric Observation Medicine 291
62 Physician Coding and
Sharon E. Mace
Reimbursement 348
54 Pediatric Observation Medicine at a Michael A. Granovsky and David
Children’s Hospital 300 A. McKenzie
Aderonke Ojo
63 Hospital Coding and Reimbursement 355
55 Geriatric Observation Medicine 304 Candace E. Shaeffer and Michael
Fredric M. Hustey A. Granovsky

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Subpart VB Financial – Case Subpart VIC International –

Management Australia/New Zealand
64 Determining the Correct Status 363 73 Australia 406
BK Kizziar John Burke
65 Case Management: Care 74 New Zealand 409
Coordination 366 Michael Ardagh
Nancy E. Skinner

Subpart VID International – Europe

Subpart VC Financial – Medical 75 France 411
Necessity, Denials, and Appeals Said Laribi and Patrick Plaisance
66 Medical Necessity 370 76 Germany 413
Robert H. Leviton Martin Mockel and Julia Searle
67 Denials and Appeals 378 77 Italy 417
Robert H. Leviton Salvatore Di Somma, Angelo Ianni, and
Cristina Bongiovanni

Subpart VD Financial – The Business 78 United Kingdom 421

Louella Vaughan and Dylan Jenkins
of Observation Medicine
68 Ensuring Financial Viability: The Business
Case for Observation Units 382 Subpart VIE International – South
Christopher W. Baugh and America
J. Stephen Bohan
79 Colombia 424
69 Observation Services in the Eyes of the Carlos-Hernan Camargo-Mila
Payers 386
Sandra Sieck
70 The Business of Observation
Part VII Evidence Basis for
Medicine 391 Observation Medicine
Sandra Sieck
80 The Evidence Basis for Observation
Medicine in Adults Based on Diagnosis/
Clinical Condition 430
Part VI International Christopher W. Baugh, Sharon E. Mace,
Subpart VIA International – Africa Margarita E. Pena, and J. Stephen Bohan

71 South Africa 398 81 The Evidence Basis for Age-Related

Heather Tuffin and LA Wallis Observation Care 478
Sharon E. Mace, Christopher W. Baugh,
and Madeline Joseph
Subpart VIB International – Asia
72 Singapore 403 Part VIII Clinical Protocols
Malcolm Mahadevan and Chew Author’s and Editor’s Comments:
Yian Chai Protocols and Order Sets 511

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82 Clinical Protocols 514 90 Adult Order Sets: Electrolyte

Sharon E. Mace Abnormalities 705
Sharon E. Mace and Matthew J. Campbell
Specialized Clinical Protocols 547
83 Spontaneous Pneumothorax 548 91 Adult Order Sets: Trauma 713
Chew Yian Chai Sharon E. Mace

84 Snakebites: Rattlesnake Bites 556 92 Adult Order Sets: Intravenous Fluids,

Sean Bush Laboratory, Radiology, and Special
Studies 729
85 Snakebites: North American Crotalid
Sharon E. Mace and Matthew J. Campbell
Snake (Pit Viper) 560
Bret A. Nicks 93 Adult Order Sets: Medications 733
86 Dengue 565 Sharon E. Mace and Matthew J. Campbell
Chew Yian Chai 94 Adult Order Sets: Generic or General
87 Low-Risk Pulmonary Embolism (PE) 567 Order Set 748
David G. Paje Sharon E. Mace

Part IX Administrative Policies Subpart XB Order Sets – Pediatrics

88 Administrative Policies 570 95 Pediatric Order Sets: Medications 752
Sharon E. Mace Sharon E. Mace and Matthew J. Campbell
96 Pediatric Order Sets: Generic or General
Order Set 762
Part X Order Sets Sharon E. Mace
Subpart XA Order Sets – Adult
89 Medical Center Department
of Emergency Medicine
Observation Unit Manual: Adult Prologue: Observation Medicine Is Not the
Order Sets by Diagnosis/Clinical Same as Observation Status 766
Condition 602 Sharon E. Mace and Robert E. O’Connor
Sharon E. Mace Index 769

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Advance Praise

This is a wonderful, much needed book by a practice. The included clinical protocols, alone,
wonderful, much learned author. Dr. Mace has are worth their weight in gold; they will give you
decades of experience in observation medicine an excellent basis for the wide range of problems
and even more in emergency medicine leadership. we can safely deal with through observation medi-
This book not only includes the best summary to cine. I just wish we had access to the knowledge
date of what EM observation medicine has been and wisdom contained in this book when we
but also provides a road map to the future. If your started our observation unit in 1979!
practice includes observation medicine, you need
Stephen V. Cantrill, MD, FACEP
this book. Rock on, Dr. Mace.
Denver Health Medical Center
Nick Jouriles, MD, FACEP Chair, EM, Cleveland University of Colorado School of Medicine
Clinic Akron General: Professor & Chair, EM,
Northeast Ohio Medical University; President, Observation medicine is the perfect tool for pro-
ED Benchmarking Alliance; Past President, gressive emergency physicians to leverage
American College of Emergency Physicians improvements in cost, quality and patient satis-
faction. I have seen physician groups and hos-
“Observation Medicine: Principles and Proto- pitals struggle to collect all the information
cols” edited by Dr. Sharon E. Mace is a relevant necessary to build and run an observation medi-
and timely textbook to Emergency Medicine. It cine service effectively, sometimes taking years to
has unique content as it relates to the development get it right. We have needed this book for a long
of both adult and pediatric observation medicine. time, and now it’s here – a single source for the
The book is written in an easy to read format with best information on what, why and how to
many outstanding ideas on how to implement develop an observation service that lasts and adds
observation medicine in the emergency depart- value to your hospital partner.
ment. This is an indispensable resource! James R. Blakeman
Isabel A. Barata, MS, MD, MBA, FACP, FAAP, Executive Vice President
FACEP Emergency Group’s Office, San Dimas, CA
Associate Professor of Pediatrics and Emergency
Medicine, Hofstra Northwell School of Medicine; Dr. Mace’s Observation Medicine is a must have
Pediatric Emergency Medicine Service Line Qual- for all physicians and administrators who have or
ity Director, Emergency Medicine and Pediatrics would like to start an observation unit. Jammed
Service Line; Director of Pediatric Emergency with helpful tips, useful clinical protocols and
Medicine, North Shore University Hospital administrative guidelines, it will guarantee the
success of your program!!
Finally! After decades, an up-to-date authority Ann M Dietrich, MD, FAAP, FACEP
on observation units and observation medicine. If Associate Professor Ohio University Heritage
you are in any way involved in this dynamic College of Medicine
aspect of emergency medicine, this book is for Medical Director of Education Ohio ACEP
you. From the clinical to the administrative to
the convoluted billing and regulatory issues, this As a longstanding residency director, it is diffi-
book is a wealth of information that will help you cult to provide the training needed to keep up with
navigate this complex area of emergency medical the advancements in emergency care. Observation

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Advance Praise

medicine is proving to be an extremely valuable Chair, Department of Emergency Medicine,

addition to emergency care, and emergency medi- Michigan State University Grand Rapids,
cine residents need to be exposed and trained in Michigan
this facet of emergency care. Dr. Mace’s textbook,
Observation Medicine, provides a valuable training The Textbook Observation Medicine: Prin-
resource useful to all emergency medicine residen- ciples and Protocols edited by Sharon E. Mace is
cies. This textbook provides the background a must have in your Emergency Medicine Library.
needed to not only work within an emergency Dr. Mace, an experienced Emergency Physician
department that has an Observation unit, but practicing Observation Medicine for Adults
potentially to develop one. This is a great resource and Children at the Cleveland Clinic Hospital
for training in Observation Medicine. System for decades, has assembled a team of con-
tributors representing the best and brightest of
Michael S. Beeson, M.D., MBA
Emergency Medicine. In the ninety-six (96)
Program Director of Emergency Medicine
Chapters of this book, the reader will learn every-
Professor | EM | Northeast Ohio Medical
thing you need in implementing an Observation
University
Unit for your Emergency Department and your
Director | American Board of Emergency
hospital. The breath of this book is exhaustive.
Medicine
The chapters are organized into multiple sections.
Cleveland Clinic Akron General
They include: “Administration, Clinical Setting
The face of health care is changing and that is a and Education, New Developments, Financial
good thing. However, we are a stubborn group and (including coding and reimbursement), Clinical
change is difficult. Dr. Mace’s book describes Protocols, Administrative Policies, Order Sets
observation care in a manner that is easily under- for Adults and Pediatrics, and much more.”
stood by all healthcare providers and administra- Economics and the desire to provide optimal
tors. What we are unfamiliar with We are afraid care for Emergency patients who needed just a
of. . . Dr. Mace’s book will provide the knowledge little bit more time to stabilize their care, arrive at
you need to embrace the change and leverage the a definitive answer, or prepare patients for safe
observation services you deliver. As a nurse, we discharge home without a hospital admission,
continue to care for our patients the same as we helped to drive the development of this special-
always have but in a shorter span of time, this book ized area of Emergency Medicine.
shares invaluable information in resource manage- As written, in the forward by Greg Henry,
ment, time management and expedited care man- MD, FACEP, (Past President of the American
agement. This book is a MUST HAVE for success College of Emergency Physicians), “Remember
in our evolving health care environment. the goals: cost-effective care, time-efficient care,
the best patient outcomes, and more compassion-
Ethel Games, RN ate human-centered care. Observation medicine
Emergency Room Nurse can achieve these goals.”
Fountain Valley Regional Hospital This book can help establish an Observation
Fountain Valley, California Unit as part of your Emergency Department
through its guidance of Administration, Proto-
This text will serve as the “go to" resource for cols, exploring the types of Clinical Problems that
health care providers managing patients in an would best be served by these units. They also
observation unit. The book is well organized with bring in the experts of reimbursement to help
chapters that focus on the content most relevant you pay for the services you provide. If you
to contemporary observation medicine. There is already have an Observation Unit, this book is
no doubt it will become required reading for the essential to operating that unit correctly and at a
observation medicine curriculum in EM resi- higher level. If it is your responsibility, as an
dency programs. Emergency Department Leader (Director, Associ-
Michael Brown, MD, MSc ate Director, or responsible for medical or nurs-
Professor, Michigan State University College of ing education), the protocols and educational
Human Medicine modules will make your life easier.

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Edited by Sharon E. Mace
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Advance Praise

Do yourself a favor and purchase this book for symptom-driven approaches and disease specific
yourself and your department. You will be glad care. Rather than searching through many texts or
you made the investment. sites, Dr. Mace and her team created a singular
source that uses a clear and accessible format
Andrew I. Bern, MD, FACEP to aid those wanting to start or improve their
Past Member, ACEP Board of Directors observation unit.
Past, Chairman of the ACEP Board of Directors
Donald M. Yealy, MD
We currently sit amidst one of the most trans-
formational periods in healthcare, with a rise Chair, Department of Emergency Medicine,
in consumer based value assessments that are University of Pittsburgh / University of Pitts-
driving care. For those with new or worsened burgh Physicians; Senior Medical Director,
illness or injury, observation care is a key tool Health Services Division, and Vice President of
after emergency department care to optimize Emergency and Urgent Care Services, UPMC;
outcomes and enhance value. This Observation Professor of Emergency Medicine, Medicine, and
Medicine text assembles the knowledge needed, Clinical and Translational Sciences, University of
from organization and oversight through Pittsburgh School of Medicine

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About the Editors

National Science Foundation Research Fellowship,

Editor Academic Residency Science Day Award, National
Sharon E. Mace, MD, FACEP, FAAP is board Chapter Project Award, State Emergency Medical
certified in emergency medicine and pediatrics. Services Council Award for Leadership and Excel-
She is a Professor of Medicine at the Cleveland lence in Emergency Medical Services, the Ameri-
Clinic Lerner College of Medicine at Case Western can Association of Women Emergency Physicians
Reserve University and is full time faculty in emer- Research and Education Award, and Who’s Who
gency medicine for the MetroHealth Medical in America and Who’s Who in the World. She has
Center/Cleveland Clinic Emergency Medicine served as a course director for numerous medical
Residency Program in Cleveland, Ohio. She has courses including many national conferences on
over 37 years of administrative and clinical experi- Observation Medicine and has even been a
ence in emergency medicine in academic and com- member of the Pediatric Medical Care Subcommit-
munity hospital settings including nearly a decade tee for the National Presidential Commission on
as a Director of the Emergency Department in a Children and Disasters.
Community Hospital. She is currently an attending
physician in the Emergency Services Institute at the
Cleveland Clinic. She is the Director of Research Section Editors
and has been the first and only Director of the Matthew J. Campbell, Pharm.D., BCPS obtained
Observation Unit at the Cleveland Clinic for the his Doctor of Pharmacy degree from Ohio North-
past 23 years since the inception of the “Clinical ern University and subsequently completed a
Decision Unit” in 1994, where she has been able to Pharmacy Practice Residency at MetroHealth
mentor medical students, residents and even sev- Medical Center in Cleveland, Ohio. He is a
eral international fellows in observation medicine. licensed pharmacist in the state of Ohio and is a
The observation unit at the Cleveland Clinic is a Board Certified Pharmacotherapy Specialist
20 bed unit that places about 6,000 patients a year (BCPS). He has received numerous honors and
in the Observation Unit. She has also been Director awards including the Ohio Northern University
of Pediatric Education and Quality Improvement Presidential Merit Scholarship, Institutional Pre-
for the Cleveland Clinic Emergency Services Insti- ceptor of the Year at the College of Pharmacy at
tute. She has lectured nationally and internation- Lake Erie College of Osteopathic Medicine,
ally on emergency medicine especially observation Pharmacist Mission Award at Cleveland Clinic,
medicine. She has served as the Chairman of the and the Promoting the Profession Award at
Section of Observation Medicine for the American Cleveland Clinic. He has had numerous presenta-
College of Emergency Physicians and on the tions locally and nationally and is actively
Observation Medicine Committee for the Society involved with pharmacy resident education at
of Hospital Medicine that authored a white paper Cleveland Clinic. He practiced as a Clinical Phar-
on observation medicine. She has authored over macy Specialist in the surgical ICU of a commu-
200 articles in the medical literature, over 60 text- nity hospital for several years and is currently the
book chapters (excluding this textbook) and edited Lead Pharmacist in the Emergency Services Insti-
a previous medical textbook and now this second tute at the Cleveland Clinic in Cleveland, Ohio.
authoritative and comprehensive textbook on He is the Section Editor for the Section IX: 1
observation medicine. She has been the recipient Adult Order Sets and Section IX: 2 Pediatric
of numerous grants and awards including a Order Sets.

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About the Editors

Karen Games, RN, has over 40 years of Specialty Certification. He has been a member of
experience as a registered nurse and as a case the American College of Emergency Physicians
manager. She received her nursing degree from (ACEP) for 20 years, a member of the AAPC for
South Surburban College in Illinois, and com- 15 years and has served for nearly 15 years on the
pleted a Critical Care Specialty Nursing Course ACEP Physicians Coding and Nomenclature
at Good Samaritan Hospital in Los Angeles. Her Advisory Committee (CNAC), including three
academic credentials include the following years as the CNAC National Chairman. He has
training and certifications: FHP Management spoken nationally at numerous conferences and
Training – Quality Education System, HFMA has been the author of many articles in profes-
Billing Compliance and a five year Certification sional publications dealing with reimbursement,
Program in Case Management (CCM). She is also practice management issues, CPT, ICD–9, CMS
an InterQual Certified Trainer. She has been a issues and ICD–10. He has served as the course
consultant and a national speaker on Case Man- director for the ACEP Coding and Reimburse-
agement. With her extensive nursing, case man- ment Conference for over a decade. He has been
agement, and administrative experience, she has on the editorial board and served as the editor for
had an opportunity to develop multiple programs, ED Coding Alert. He is the Technical Editor of
policies and procedures related to nursing, case the AAPC ED specialized CPC–CEDC Emer-
management, and observation medicine. Her gency Department Coding Specialty Certification.
various administrative positions include serving He is the subject matter expert on the ED
as a Regional Case Management Director, a PMI Specialty Exam and Study Guide for the AAPC.
Case Management Specialist, the Director of Case His service on national committees includes
Management Education and Informatics for the immediate past chairman ACEP National
Tenet Health System. She has also been the Dir- Coding Advisory Committee, Work Group Chair
ector of Risk Management and Patient Safety for ICD–10 – ACEP Quality and Performance Com-
Desert Regional Medical Center in California and mittee, ACEP Expert Technical Panel for Quality
most recently, Administrative Director of Collab- Measure Development, ACEP Registry Task
orative Care at Los Alamitos Medical Center, also Force and the ACEP Reimbursement Committee
in California. She is the Section Editor for – Fair Payment Work Group Chair. Dr. Gran-
Chapter 7: Nursing, Chapter 64: Determining ovsky is currently the Chairman of the ACEP
the Correct Status and Chapter 65: Care Reimbursement Committee. As the President,
Coordination. Division of Coding for Logix Health; he is respon-
Michael Granovsky, MD, CPC, CEDC, sible for health policy, coding, education, and
FACEP is board certified in emergency medicine. regulatory processes with oversight of seven mil-
His certifications in coding include the American lion annual emergency department claims. He is
Academy of Professional Coders (AAPC) – Certi- the Section Editor for Section V: Financial Coding
fied Professional Coder and AAPC – CEDC ED and Reimbursement and Chapters 1 and 2.

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Contributors

Sharon E. Mace, MD, FACEP, FAAP Karen Games, RN

Professor of Medicine, Cleveland Clinic Lerner Director of Process Improvement, Los Alamitos
College of Medicine at Case Western Reserve Medical Center
University, Faculty, MetroHealth/Cleveland
Gregory L. Henry, MD, FACEP
Clinic Emergency Medicine Residency
Director, Observation Unit and Director, Clinical Professor Department of Emergency
Research Cleveland Clinic Cleveland, OH Medicine, University of Michigan Medical School,
Ann Arbor, MI, Past President, American College
Robert E. O’Connor, MD, MPH, FACEP of Emergency Physicians
Chair, Physician-in-Chief, Department of
Elaine Thallner, MD, MS
Emergency Medicine, University of Virginia
Organizational Development and Change
Health System, Charlottesville, Va. Chair, Board
Management
of Directors, American College of Physicians
Staff Physician, Emergency Services Institute,
Louis Graff MD FACEP FACP FACC. Cleveland Clinic Foundation, Cleveland, OH
Professor Surgery and Emergency Medicine.
Ryan Prudoff, DO, MS, FACEP
Clinical Professor Medicine.
Staff Emergency Physician, Cleveland Clinic
University of Connecticut School of Medicine.
Foundation
Chair Utilization Review Committee.
Clinical Associate Professor Emergency Medicine
Hartford Healthcare Corporation Central Region
Ohio University Heritage College of Osteopathic
Hospitals
Medicine
Farmington, CT
Cleveland, OH
David Robinson, MD, MS, MMM, FACEP
Stephen Sayles, MD, FACEP
Professor and Vice-Chairman of
Director Cleveland Clinic Brunswick Emergency
Emergency Medicine, University of Texas
Department, Cleveland Clinic Foundation,
Medical School at Houston;
Cleveland, OH
Chief of Emergency Services, Lyndon B. Johnson
Hospital, Harris Health System Houston, TX Robert S. Bennett, MD
Director, Observation Unit, Highland Hospital
Christopher W. Baugh, MD,MBA, FACEP
Rochester, NY
Medical Director of Clinical Operations and
Observation Medicine Jonathan Glauser, MD, FACEP
Department of Emergency Medicine | Brigham & Professor Emergency Medicine Case Western
Women’s Hospital Reserve University.
Assistant Professor Harvard Medical School Faculty Emergency Medicine Residency
Boston, MA MetroHealth/Cleveland Clinic Cleveland, OH
J. Stephen Bohan, MD, MS, FACEP, FACP David J. Paje, FACP, SFHM
Executive Vice Chair, Emergency Medicine Assistant Professor at University of Michigan
Brigham and Women’s Hospital Medical School
Associate Professor, Harvard Medical School Associate Director, Medical Short Stay Unit,
Boston, MA University of Michigan Health System

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Contributors

Staff Physician, Ann Arbor VA Healthcare Senior Clinical Research Fellow, Northwest
System London CLAHRC
Ann Arbor, MI London, UK
Peter Y. Watson, MD, FACP, SFHM Tertius T. Tuy, MD
Division Head of Hospital Medicine Singapore General Hospital, Singapore, Former
Henry Ford Hospital Detroit, MI Research Fellow, Cleveland Clinic Foundation,
Emergency Services Institute, Cleveland, OH
Pawan Suri, MD
Chair, Division of Observation Medicine W. Frank Peacock, MD, FACEP, FACC
Program Director, Combined EM/IM Residency Professor, Emergency Medicine
Program Associate Chair and Research Director
Department of Emergency Medicine Baylor College of Medicine
Assistant Professor in Emergency Medicine and Houston, Texas
Internal Medicine
Virginia Commonwealth University Medical Jieun Kim, MD
Center Medical Officer, Singapore General Hospital,
Richmond, VA Singapore Former Research Fellow, Cleveland
Clinic Foundation, Emergency Services Institute,
Margarita Pena, MD, FACEP Cleveland, OH
Medical Director, Clinical Decision Unit
Associate Program Director, Emergency T. Andrew Windsor, MD, RDMS, FAAEM
Medicine Assistant Professor, Department of Emergency
St. John Hospital and Medical Center Medicine
Detroit, MI University of Maryland School of Medicine
Baltimore, MD
L. Christine Gilmore, MD
Physician, Wake Forest Baptist Medical Center Amal Mattu, MD, FACEP, FAAEM
Department of Emergency Medicine Winston- Professor and Vice-Chair, Emergency Medicine,
Salem, NC University of Maryland, Baltimore, MD

Bret A. Nicks, MD, MHA, FACEP Kami M. Hu, MD

Chief Medical Officer, Wake Forest Baptist Critical Care Medicine Fellow, University of
Health - Davie Medical Center Maryland Medical Center
Emergency Medicine Winston-Salem, NC Departments of Internal and Emergency
Medicine
Catherine T. Puetz, MD, FACEP Baltimore, MD
Attending Physician Department of Emergency
Medicine Eric Anderson MD, MBA, FACEP, FAAEM
Grand Rapids, MI Faculty Cleveland Clinic – MetroHealth
Emergency Medicine Residency
Kayur V. Patel MD, FACP, FACPE, FACHE, FACEP Faculty Emergency Medicine Cleveland Clinic
Chairman, Access2MD Terre Haute, Indiana Lerner College of Medicine
Cleveland, OH
Igor Kozunov, MBA, MHA
Chief Executive Officer, Wellness For Life Chew Yian Chai, MD, MCEM, FAMS
Medical, LLC Consultant/ EDTU Director, National University
Indianapolis, IN Hospital Emergency Medicine Department,
Singapore
Louella Vaughan, MBBS, MPhil, DPhil, FRACP
Consultant Physician in Acute Medicine, The Carol L Clark MDMBA FACEP
Royal London Hospital Professor, Oakland University William Beaumont
Senior Clinical Research Fellow, The Nuffield School of Medicine
Trust, Associate Director of Research

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Department of Emergency Medicine Director, Center of Ultrasound Education and

Beaumont Health Systems- Royal Oak, MI Research
Department of Emergency Medicine and
Michelle A. Wiener, MD, MS Hospitalist Services
Clinical Faculty, Wayne State University School Medical College of Georgia, Augusta University
of Medicine
St. John Medical Center, Detroit , MI Leah S. Taylor, MA
Instructor, Augusta University
Matthew Tabbut, MD, FACEP Augusta, GA
Attending Physician, Department of Emergency
Medicine, MetroHealth Medical Center Robert W. Gibson, PhD, MSOTR/L FAOTA
Assistant Professor of Emergency Medicine, Professor, Director of Research
Case Western Reserve University School of Department of Emergency Medicine
Medicine Medical College of Georgia
Cleveland, OH Augusta University, Augusta, GA
Saurin Bhatt, MD, MBA Rokhsanna Sadeghi, MD, MPH
Faculty Cleveland Clinic – MetroHealth Finger Lakes Health, Attending Physician Geneva,
Emergency Medicine Residency NY
Faculty Emergency Medicine Cleveland Clinic
Lerner College of Medicine, Cleveland, OH Abhinav Chandra, MD, FACEP
Kaiser Permanente Senior Clinician Physician in
Mark G. Moseley MD, MHA, FACEP Emergency Medicine,
Vice Chairman for Clinical Affairs Director of Emergency Observation Medicine,
The OSU Department of Emergency Medicine Kaiser Permanente South Sacramento, CA
Medical Director for Utilization Management
The Ohio State University Health System Elizabeth A. Rees, MD
Columbus, OH Attending Physician, Methodist Medical Center
Oak Ridge, TN. (formerly Wake Forest Baptist
Miles P. Hawley, MD, MBA Health Medical Center, Winston-Salem, NC)
Senior Medical Director, System Hospitalist and
Observation Services Claire Pearson MD, MPH
Director, Physician Advisor Services Assistant Professor, Department of Emergency
OhioHealth Columbus, OH Medicine
Division of Clinical Research, Wayne State
Taruna Aurora, MD University School of Medicine
Assistant Professor, Departments of Emergency &
Internal Medicine Robert D. Welch, MD, MS, FACEP
Director, Clinical Decision Unit, Emergency Professor , Wayne State University School of
Department Medicine
Medical Director, Department of Care Director of Clinical Research, Department of
Coordination and Utilization Management Emergency Medicine
Virginia Commonwealth University Health Detroit Receiving Hospital, Detroit, MI
Systems
Richmond, VA Brian Kern, MD
Attending Physician, Detroit Medical Center,
Kimberly A. Ressler, MD, MSN Clinical Assistant Professor, Department of
Attending Physician Emergency Medicine, Wayne State University
Rochester General Hospital Rochester, NY School of Medicine
Matt Lyon, MD, FACEP Veronica Sikka MD, Phd, MHA, MPH, FACEP
Professor and Vice Chairman Veronica Sikka, MD, PhD, MHA, MPH, FAAEM,
Director, Emergency Department Observation FACEP
Unit Chief, Emergency Medicine

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Contributors

Orlando VA Medical Center St Joseph Mercy Hospital Emergency Medicine,

Associate Professor, Emergency Medicine Ann Arbor, MI
UCF School of Medicine Orlando, FL
Michael A. Granovsky, MD, CPC, CEDC, FACEP
Renee Reid, MD, FACEP President, Coding for Logix Health
Assistant Professor, Virginia Commonwealth Chair, ACEP Physicians Coding and
University Richmond, VA Nomenclature Advisory
Committee (CNAC)
Harinder Dhindsa, MD, MBA, MPH
Associate Professor, Attending David A. McKenzie, CAE
Physician, Virginia Commonwealth University Reimbursement Director, American College of
School of Medicine, Chief of Emergency Emergency Physicians Dallas, TX
Medicine, Richmond, VA
Candace E. Schaeffer, RN, MBA, RHIA
Aderonke Ojo, MBBS Compliance Officer, Optum360
Associate Professor of Pediatrics
Baylor College of Medicine BK Kizziar, RN-BC, CCM
Attending ED Physician, Texas Children’s Member Case Management Society of America,
Hospital, Houston, TX Owner, BK Associates Grandbury, TX

Fredric M. Hustey, MD, FACEP Nancy E. Skinner, RN-BC, CCM

Attending Physician Cleveland Clinic President, Riverside HealthCare Consulting
Associate Professor, Cleveland Clinic Lerner Whitwell, TN
College of Medicine
Robert L. Leviton, MD, MPH, CI, FACEP
Case Western Reserve University, Cleveland, OH
Chief Medical Information Officer - Physician
Nathaniel L. Scott, MD, FACEP Advisor
Program Director, EM / IM Combined Residency Bronx Lebanon Hospital Center, Bronx, NY
Program
Staff Physician, Emergency Medicine and Sandra Sieck, RN, MBA
Hospital Medicine, Hennepin County Medical Chief Executive Officer, Sieck HealthCare
Center Mobile, Al
Assistant Professor, University of Minnesota
Heather Tuffin, MBChB (UCT), DipPEC (CMSA)
Medical School Minneapolis, MN
Improvement Advisor, Western
James R. Miner, MD, FACEP Cape Department of Health, Capetown,
Chief of Emergency Medicine South Africa
Hennepin County Medical Center
LA Wallis, MBChB, FRCS, DIMCRCS, Dip Sport
Professor of Emergency Medicine
Med, FCEM, FIFEM
University of Minnesota, Minneapolis, MN
Professor and Head of Emergency Medicine,
Steven J. Walsh, MD Stellenbosch University
Fellow, Carolinas Poison Center, Chapel Hill, NC Head of Emergency Medicine, Western Cape
Government
Marsha Ford, MD, FACEP President, International Federation for
Former President, American Association Poison Emergency Medicine
Control Centers, Adjunct Professor UNC-Chapel Professor and Head of Emergency Medicine,
Hill School of Medicine, Toxicoligist/Attending University of Cape Town, South Africa
Physician Carolinas Healthcare System Charlotte,
NC Malcolm Mahadevan MD, FRCS, MRCP, FAMS
Associate Professor, National University of
Constance J. Doyle, MD, FACEP Singapore
Clinical Instructor Emergency Medicine Head and Senior Consultant, National University
University of Michigan, Attending Physician Hospital System, Singapore

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Contributors

John Burke, FACEM Angelo Ianni, MD

Deputy Director, Emergency Department Department of Emergency Medicine
Royal Brisbane & Women’s Hospital Sant’Andrea Hospital, Rome, Italy
Brisbane, Australia
Christina Bongiovanni , MD
Michael Ardagh, ONZM, PhD, MbChB, DCH, Department of Emergency Medicine
FACEM Sant’Andrea Hospital, Rome, Italy
Professor of Emergency Medicine, University of Dylan Jenkins, MBBS
Otago, Christchurch, New Zealand Consultant, Doncaster Royal Infirmary
Said Laribi, MD, PhD Doncaster, United Kingdom
Professor of Emergency Medicine, University of Carlos-Hernan Camargo-Mila, M.D., E.A.E.S., A.C.E.P.
Tours, France Professor of Surgery and Emergency Medicine
Chair of the Emergency Medicine Department, Colegio Mayor del Rosario University
Tours University Hospital, France Chairman of the Emergency Department
Fundación CardioInfantil - Instituto de
Patrick Plaisance, MD, PhD
Cardiología
Professor of Emergency Medicine, University
Bogotá D.C. - COLOMBIA
Paris Diderot, France
Chair of the Emergency Room, Lariboisière Madeline Joseph, MD, FACEP, FAAP
University Hospital, Paris, France Professor of Emergency Medicine and Pediatrics
Assistant Chair of Pediatric Emergency Medicine
Martin Mockel, MD, PhD, FESC, FAHA
Quality Improvement, Department of Emergency
Charité – Universitätsmedizin Berlin, Berlin,
Medicine
Germany
University of Florida College of Medicine-
Julia Searle, MD, MPH Jacksonville, FL
Charité – Universitätsmedizin Berlin, Berlin, Sean Bush, MD, FACEP
Germany Professor of Emergency Medicine Brody School
Salvatore Di Somma, MD, PhD of Medicine East Carolina University, Attending
Physician Vidant Medical Center Greenville, NC
Department of Emergency Medicine
Sant’Andrea Hospital, Rome, Italy Matthew J. Campbell, Pharm. D., BCPS
Department of Medical and Surgery Science and Lead Pharmacist Emergency Department,
Translational Medicine Cleveland Clinic.
University “Sapienza”, Rome, Italy Cleveland, OH

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Foreword: Onward and Upward

Science in many ways has become an inter- computer for the word machines and you have
national bully. It expects everyone to stop their our own age.
day-to-day life as “we scientists” prod and probe Fourth, there is no controlled governor on the
the human body doing everything we can to belit- current system. Dr. John Rogers once comment-
tle human life and reduce the patient to a soulless ing on medicine said, “They gave us an unlimited
heart-lung preparation without value, virtue, and budget, and we over spent it.” Will the useless
the essence of humanity removed. The more time CPR ever stop?
the patients spend in the giant monolith known With these thoughts in mind, let’s predict
as the tertiary care hospital, the less real patient’s where medicine will be and why this book should
lives become. be extremely useful. The emergency departments
Enter this book and more importantly the of America have become centers of clinical deci-
field of observation medicine. First things first. sion making. The ED is where all important deci-
Most books don’t need a foreword! Get on with it, sions of inpatient v. outpatient care are now being
but in the best traditions of foreword writing I’m made. Observation medicine is the new third
going to set forth a framework as to where medi- pathway which allows a good alternative to pro-
cine is to go if we are to have any economic tect inpatient populations and yet recognize that
viability as a profession and still meaningfully time is the only reliable test of therapy. Not all
improve outcomes. care fits into the neat four hour maximum of
Let’s draw some quick conclusions as to where standard emergency department visits.
medicine stands at the year 2016. What have we Hopefully with new opportunities to control
learned from the past? First, most things that overall costs, we will take this opportunity and
happen in hospitals have unintended conse- seize the day. The real question is, are we going to
quences, i.e. “Bad things happen; even with the be able to move the current system to “buy into” a
best of intentions.” The sooner we get you out of healthcare product mode which addresses indi-
the hospital, the less likely you are to pick up an vidual charges but can concentrate on actual
infection we can’t cure or fall and break your hip. costs? No economist would confuse these con-
This is a change from my early life in medicine cepts. The bulk purchase of service will require
where we assumed that the death rate was lower honesty about what needs to be done for patients
inside these huge structures of science than out on as opposed to what can be charged for when
the streets or at home. dealing with the government and third party
Second, costs count! You can die at home for payers.
free and if we can’t make a real contribution to a Just conclude that if the days of big money
meaningful life, what are we doing, and why are and “spend at all costs” isn’t over with, it shortly
we charging so much money for it? Human flour- will be. Observation medicine should be ready to
ishing is not equivalent to having a heartbeat. offer the cost effective alternative. If we can’t do
Third, Charlie Chaplin’s classic film, that than just burn this book and admit everyone.
“Modern Times” was made during the machine Lost somewhere in ICD–10 coding, (and what
age when there was a wide spread fear that tech- isn’t lost in ICD–10 coding) is the concept of
nology was setting the agenda for human life. making life better. Getting patients closer to their
“Taylorism” as the Marxist used to put it, was families and friends and out of rooms where the
putting rigid unvarying thought before actions mattresses are covered in plastic and the only
or consideration of outcomes. Substitute people who touch you wear gloves and masks.

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Foreword: Onward and Upward

The new world for providers looks much from 5,700 to slightly less than 4,000. What is the
different than the old. It is no accident that organ- correct number of such hospitals which are
ized medicine has not asked serious questions needed? What is the number of free standing
concerning workforce issues. 75% to 80% of the ERs and urgent care centers which are needed?
healthcare costs in America are workforce. There All of these will depend on the blossoming of
is almost no real research as to who should be observation medicine. So as you proceed through
doing just what. This is as true in urban areas as this book, don’t lose the forest in the ventilators.
in rural outposts. It is an embarrassment that we Remember the goals; cost effective care, time effi-
do not have these answers which are needed if cient care, the best patient outcomes, and more
cost control is to be achieved. Even the simplest compassionate human centered care. Observation
questions as to how many facilities do we need per medicine can achieve these goals.
population, hinges on the questions of utilization Ars longa vita brevis.
and cost. The number of hospital based emer-
gency departments in the last 40 years has gone Greg Henry, MD

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Preface

The purpose of this textbook is to provide a medicine operating with a patient/family centered
resource for anyone interested in observation focus can help provide the highest quality of
medicine and to be a practical education for patient care with optimal patient outcomes and
“how to” do observation in any setting or loca- be cost-effective.
tion, even internationally. Currently, there is no I hope that everyone: clinicians, administra-
one source that you can reference to learn about tors, nursing, case managers, reimbursement spe-
not just the clinical aspects of observation with cialists, utilization review experts, and the many
information including protocols and order sets; others involved in any aspect of observation
but also the administrative, business, fiscal, nurs- medicine; will find this textbook a valuable
ing, case management, utilization review, design, resource in their clinical practice and daily oper-
reimbursement, regulatory/governmental, and ations that can provide a useful toolkit for under-
other facets of observation medicine. Monumen- standing the many complex issues with
tal changes are occurring in health care not just in observation medicine and healthcare, and offer
the United States but throughout the world and insights into recent developments and the future.
observation medicine can be on the frontlines in With any endeavor, there are many contribu-
solving the complex issues facing healthcare now tors. I could not have accomplished this textbook
and in the future. without the numerous authors and editors, as well
This text is intended to be a practicum for as the individuals at Cambridge University Press.
anyone interested in setting up or maintaining a I have had the honor and pleasure of serving as
successful Observation Unit (OU). To quote a the Director of the Clinical Decision Unit at the
colleague and friend, this textbook is “one stop Cleveland Clinic since its beginning in 1994, more
shopping” for observation medicine. Much of the than twenty years ago. The CDU is one of the
information in this textbook is not readily avail- oldest OUs in existence. The 20 bed unit has
able elsewhere. Some of the Chapters, such as the averaged about 6,000 patients a year and has been
protocols and order sets are detailed enough to in operation with the same director since its
serve as a “hands on’ manual for observation inception. Indeed, we may have the longest con-
medicine. The intent was to provide a concise, tinuously in operation OU with the same OU
useful overview of all aspects of observation medi- director anywhere. I would like to acknowledge
cine starting with the clinical and expanding to the numerous contributions of my colleagues and
the organizational and administrative aspects coworkers over these two decades including the
from set-up and staffing; to the regulatory/gov- many outstanding physicians, the exceptional
ernmental, the business and financial, and reim- nurses and other personal in the OU and the
bursement. This “real world” information should emergency department and the hospital staff/per-
be applicable to any given practice setting; sonnel. Thank you for allowing me to work with
whether urban, suburban or rural; community- you and improve care for our patients. To my
based or academic, in the United States or world- students, residents and fellows, thank you for
wide. In the 21st century, medicine including allowing me to participate in your education and
observation medicine is an art, a science and a research. May all our patients benefit. Finally,
business. This text is intended to address these thank you to my family and friends for their
three topics; while detailing how observation encouragement and love.

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