How to put a patient in ED Obs
Work Prior to Admitting to ED Obs
Who Decides to put a patient in Obs?
Patients that are candidates for ED obs are identified by the initial acute care physician or mid-level. Most ED Obs patients come from the main SJH ED, but a significant portion come from Urgent Care, other outside Emergency Departments and occasionally even clinics, facilities or home.
What should be done before placing patient in ED obs?
SJH Main ED - When patients are identified as ED Obs candidates in the SJH Main ED, the provider should order a “Medication Reconciliation by Pharmacy”. There is a pharmacist available to do medication reconciliation from 11 am to 9 pm. In most cases ordering a CBC and BMP should be ordered as well, although exceptions to this are possible.
From Outside Venues - For patients being referred to ED Obs from outside of SJH ED, once the patient is identified as a good ED Observation Candidate, the provider should contact the TMC, who will further triage the patient to either the SJH ED, ED Obs or another venue as appropriate. If the TMC feels the patient is good for ED Obs, they will contact the ED Observation doctor on the initial provider’s behalf.
Discuss the Patient with the ED Obs Provider
If you think you have a good patient for ED Obs you will need to tell the ED Obs provider about the patient and plan. It is ultimately up to the Obs provider to decide whether to “accept” or “decline” the patient. Outside of hours covered by the ED Obs physician, this judgment call will be on the referring provider - as they will be the ones writing the admission orders and note as well. Often the ED Obs provider will ask to see the patient before committing to accepting the patient. There will occasionally be patients for whom there is disagreement on the appropriateness of ED Obs. In these cases, the ED Obs physician has the final say.
Admit Patient to ED Obs
A printable "Checklist" to aid in completing an ED Observation admission can be found here.
Once the patient has been accepted to ED obs, and if there is capacity in the unit for the patient then the patient can be admitted to ED Obs. The process for actually doing the admission is below. As a general rule from noon to 5 pm,the ED Observation physician is expected to do the work of the admission. Outside of these hours, the provider in the main zone, including PAs and residents are expected to complete these steps.
Med Rec Order - If not already ordered, please order "Medication Reconciliation by Pharmacy"
2. Patient Status Order - NEW
As part of the new "ADT" process, the patient status order has changed. It is more difficult, and has several redundant steps. I have communicated this to the folks doing the Epic "Upgrade". Hopefully it will get simpler in the future, They've actually alreday incorporated some feedback to make this easier than it initially was. For now, please follow the steps below to put a patient in ED Obs.
In the Order entry area type "Obs".
This will give you lots of options. You want to choose the option from the Procedures: "Initiate Outpatient with Observation Services"
I've asked for these fields to be autopopulated with ED Observation and Observation Unit, which I've been told can probably happen but I have not been told when. For unclear reasons the Estimated Length of Stay Field cannot auto populate.
Once you open this order, you will be prompted with several fields that will need further information.
For "Service": choose or type "ED Observation"
For "Level of Care": choose "Observation Unit"
For "Estimated Length of Stay": choose 1 day
Make sure to sign the order. This Order must be placed by MD or DO
3. Notify Nursing Staff of ED Obs Admission
Initial ED provider should notify the nurse in the main zone of expected transfer
ED Observation provider should notify the ED obs nursing staff of the admission
4. Complete Home Medication Reconciliation if outside of pharmacy hours (11:00 - 21:00) you will have to do this yourself
Please be sure to "Mark as Reviewed" during Med Rec, otherwise the Discharge Med Rec cannot be completed
5. Order any home medications needed while patient is in ED Obs
6. Complete ED Observation Order set in particular be sure to:
Order PRNs (Pain, Nausea, Sleep, etc)
Order PT and Care Management as appropriate
Order and specific tests or therapies for the particular patient
7. Complete ED Observation Admission Note
For Patients seen in main zone use the dot phrase ".sjhedobsadmitnote"
For Patients who are coming directly from any other location (like Urgent Care)p1 use ".sjhedobsadmitnote" as above, even for direct admits.
8. Alert Crosscover Physician of Admission and Add Patient to Signout Sheet (only if admission done outside of Obs Physician Coverage Hours (0800-1800)