Harbor:Observation placement


  • 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]
  • Patients who would have been admitted but are pending a transfer that is delayed should NOT be placed on OBS just for that reason. These transfers often do not occur quickly. Only place such patients on OBS if they would have been OBS appropriate by their medical condition. [Peterson 2/2019]

Observation Service Guidelines

  • "Yes" to OBS
    • Placement: All patients requiring placement should go to OBS
    • 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
      • 2 specimen cups with 1ml and 5ml total expectorate
  • Do NOT Place on OBS (Admit instead)
    • COVID patients – take longer than two midnights, typically get admitted to medicine teams (Spiegel 11/2019)
    • Fever of unknown origin (FUO) – takes longer than two midnights to get cultures back (Spiegel 11/2019)
    • Coumadin bridging requiring heparin drip (Lewis - 7/2017)
    • Multi-drug resistant history requiring antibiotics while awaiting culture results (Lewis - 7/2017)
    • Patients needing first ever dialysis (Spiegel/Daar 1/2019)
    • Decompensated liver disease – if bleeding, SBP, or in need of diuresis, this will require at the very least two midnights (and typically at least 72 hours) for treatment (Spiegel 11/2019)
    • Surgical patients should go to their respective surgical service for admission; E.g., patients who are awaiting determination of if they will need surgical management (particularly those who come in overnight), with the statement in the chart “chief/specialty service to reassess in am”, etc. (Spiegel/Wu 11/2019)
    • Pancreatitis may be better served with admission, but may fly in OBS (~40% admission rate)
  • Patients that are OOP
    • For patients who are (1) not safe for discharge home; (2) stable for transfer or can be stabilized for transfer; and (3) empaneled to an outside system
      • Ask, via UR, that the patient be transferred for hospitalization within their empaneled system
      • Clearly document why the patient’s medical condition makes it impossible to safely discharge them from the ED, and why they need acute medical care or additional evaluation.
      • Ask, via UR, that the empaneled system grant approval for inpatient admission if they are unable to accept the patient in transfer.
      • If the empaneled system both refuses to accept their patient in transfer (e.g., they have no capacity) and refuses to give approval for inpatient admission (e.g., the patient doesn’t meet their own internal criteria for requiring admission), then UR will determine whether the patient should be admitted or placed on OBS/CORE, based on our internal assessment of the likelihood that we will be able to successfully appeal the initial denial for authorization. If we believe that a successful appeal is likely, we will admit the patient to an inpatient service to continue to preserve OBS/CORE capacity for DHS patients. (Dr. Lewis 9/2019)

Chappell, 12/2020

See Also