Exclusion Criteria

ED Observation Exclusions and Admission Guidelines


These are guidelines. It is alway ultimately up to the judgment of the admitting physician to decide if a patient can come to ED Obs. So use good judgment.


General Exclusions:


  1. Hemodynamically unstable, anticipated clinical deterioration or need for ICU level care.

  2. Patients anticipated to need surgery. e.g. A confirmed septic joint should not be placed in ED obs for consultant to see them. One notable exception is patients going for a Urologic procedure and then home. These patients can go to ED obs, but otherwise patients going for surgery need to be admitted to the appropriate surgical or medical service.

  3. Patients who are anticipated to need < 8 hours of observation care or more than two midnights. (Greater than 20% likelihood that they will not be discharged the following day).

  4. Titratable medication drip (diltiazem, esmolol, octreotide, vasopressors).

  5. Age < 16 years old. SJH does not have pediatric inpatient capabilities (except the NICU). Age 16 is the minimum age to be admitted to medicine or to undergo surgery at SJH.

  6. Patients with end-stage renal disease who will require dialysis during their hospitalization.

  7. Patients requiring chemotherapy infusions as this medication needs to be administered by a certified nurse. These patients should be admitted to the Oncology Unit (or IMC, ICU as appropriate).

  8. Patients who need a PCA

  9. Psychiatric patients who require a mental health hold/security watch and suicide proofed room.

  10. Alcohol or drug intoxicated patients without other reasons for observation (e.g., possible GI bleed, or cardiac workup).

  11. Patients with alcohol withdrawal syndrome (AWS) or who are at very high risk for developing severe AWS, history of DTs, Seizures or severe withdrawal in the past. This is due to the potential need for frequent assessments, escalating medications, and our nursing ratios, particularly at night. See ED Observation AWS Algorithm.

  12. Patients who are likely to need procedural sedation, except for stable patients awaiting EGD/Colonoscopy (e.g. for food impaction) in the morning.

  13. Patients requiring multi-step evaluations (e.g., a patient with a headache who will need MRI, EEG, lumbar puncture, and then neurology and ophthalmology consultations).

  14. Admissions to facilitate an outpatient workup as this does not meet observation criteria (i.e., care provided to determine the need for admission).

  15. No clear diagnosis or endpoint (e.g., chronic abdominal pain of unclear etiology).


Diagnosis-Specific Exclusions:


  1. We don’t care for acute Strokes in ED Obs

  2. Acute kidney injury with creatinine >3 times baseline or >3.0 if no baseline.

  3. Asthma/COPD exacerbation with an O2 Sat < 87% RA (or on home FiO2), BiPAP, concomitant pneumonia

  4. Cellulitis with high risk for Necrotizing soft tissue infection, or who are anticipated to need antibiotics only available in IV formulations (Vancomycin)

  5. Chest pain with ischemic EKG changes, likely to need the cath lab, a positive troponin (>120). An elevated troponin in the absence of chest pain is not necessarily an exclusion from ED Obs if the provider feels there is a reasonable explanation for the elevated troponin and is not related to an Acute Coronary Syndrome.

  6. CHF that is new onset and needs an admission. CHF exacerbation with an O2 Sat <89% RA, creatinine>2.6 or 2 times baseline, or >10 pound weight gain, or thought to be due to ischemic heart disease should be admitted to an inpatient service.

  7. DKA or HHNS, on insulin drip

  8. Electrolyte Abnormality: Hyponatremia without an obvious cause. E.g. HCTZ. Generally < 124 should be admitted. Potassium <2.5 or >6.2.

  9. GI Bleed that is potentially unstable: on full dose anticoagulation, active hematemesis, persistent hypotension despite IVF, needing transfusion with an unclear source.

  10. Palliative Care: Patients who need to have an comprehensive Palliative Care consult and or organized family meeting with the Palliative care team should be admitted upstairs. A simple medication recommendation or titration question for the palliative care team can still go to ED Obs.

  11. Pulmonary Embolism with signs of right heart failure, elevated troponin, hypoxia, renal failure, heparin drip, or pregnant.

  12. Pyelonephritis with an altered mental status, obstruction, immunosuppression, anatomic urologic abnormality, or poorly controlled DM.

  13. Syncope with high suspicion for cardiac/arrhythmia:

    • Hx of CHF, CAD, structural heart disease (EF < 40%)

    • Associated CP or SOB

    • Syncope during exercise or when supine

    • Pacemaker or ICD malfunction

    • High-risk EKG abnormalities

  • New bifascicular block or other intraventricular conduction abnormality with QRS>120ms

  • Second degree heart block type II

  • Third degree heart block

  • Sinus pauses > 3 seconds

  • Non-sustained VT > 5 seconds

  • Pre-excitation QRS syndromes (WPW or LGL syndromes)

  • Findings suggestive of hypertrophic cardiomyopathy (consider with localized or widespread repolarization changes, high voltage, deep narrow qs in inferior/lateral leads, p wave abnormality suggesting LAE or biatrial enlargement, LAD, deep inverted T waves V2-V4)

  • Long or short QT intervals (> 500 ms or < 360 ms)

  • Brugada pattern (incomplete RBBB with STE in V1-V2)

  • Arrhythmogenic RV cardiomyopathy (negative T waves in R precordial leads, and epsilon waves)

TIA/CVA, Vertigo with high concern for central etiology.