Harbor:Observation placement

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  • Any OOP patients needing observation or CORE services should be transferred to an in-network hospital if they are stable - Peterson 5/2016
  • Only patients with internal medicine (or family medicine) covered illness can be placed on obs. All other services require admission (or transfer) - Lewis 5/2016
  • If the hospitalist is capped (cap is 20 if single overnight hospitalist coverage, which includes Obs and CORE leftover from dayshift, new Obs or CORE, and new admissions), and you have a patient you’d like to place in Observation, CORE, or an admission:
    • Do not place the order for obs placement, CORE, or the ‘request for admit’ order. This becomes confusing for nursing who is actually managing the patient. Only place this order when you have discussed the patient and the care officially transfers to the inpatient/obs/CORE physician.
    • Continue to manage the patient until the next hospitalist shift starts (typically 7:30am) or the next medicine slot is available.
    • Do put in an Attending Admit Note at the time of the actual admit decision but document in your notes that patient is being held in the ED due to lack of hospitalist/Medicine capacity.

Observation Placement Guidelines

  • There is no cap on observation patient numbers
  • Placement: All patients requiring placement at an extended care facility should go to OBS even if they require physical therapy assessment for placement
  • Patients should be placed on the most appropriate unit by the ED; if specialty services are not available in the desired timeframe (ie, GI, IR), the observation team may make the decision to admit such patients (Lewis - 10/2017)
  • TB rapid rule-out (GenExpert PCR) takes about 12 hours: order AFB bundle, saline chloride 10% for RT, and 2 specimen cups with 1ml and 5ml total expectorate
  • Coumadin Bridging requiring heparin drip (not low molecular weight heparin or NOAC candidates) - ADMIT (Lewis - 7/2017)
    • Please do your best to prescribe rivaroxaban (Xarelto) to avoid this as it is available on our DHS formulary.
  • Multi-drug resistant history requiring antibiotics while awaiting culture results - ADMIT (Lewis - 7/2017)
    • MDR infections such as ESBL, VRE, CRE, etc., admit to medicine if you are worried about a repeat MDR infection (ie.,: urine culture in pyelonephritis patient)


  • Admit for non-CHF edema, anasarca, or requiring significant diuresis (>10kg)
  • Psych can consult in CORE, or patient can be discharged from CORE to psych ED on patients requiring cardiac clearance

Chappell, 8/2017