Long ED stays for intoxicated patients highlights need for dedicated observation units

A recent study published by the American College of Emergency Physicians (ACEP) found that psychiatric patients spend an average of 11.5 hours in the emergency department (ED). The patient’s age and insurance coverage contributed to the increased length of stay; however, the most significant factor was intoxication. Patients with a positive toxicology screen for alcohol stayed an average of 6.2 hours longer than others. “The presence of alcohol had a dramatic effect in lengthening overall length of stay, with a particular influence on the time before and during psychiatric evaluation,” according to the report’s authors. The delay is due to the fact that ED staff cannot complete an accurate psychiatric evaluation on patient whose cognitive abilities are compromised by alcohol. Until they sober up, intoxicated patients wait in the ED, occupying valuable ED beds. According to best practices, simply expediting the patient’s sobriety is not an appropriate solution. The authors cite a previous study that found “the patient’s cognitive abilities, rather than a specific blood alcohol level, should be the basis on which clinicians begin the psychiatric assessment.” Instead, the authors suggest developing dedicated observation units for monitoring intoxicated patients until they become sober. Doing so would keep intoxicated patients out of the ED and free up valuable ED resources for patients that need specialized psychiatric evaluation. The idea of dedicated observation units for certain patient populations is becoming a more popular idea. Several peer-reviewed studies have found that these units provide cost-effective, quality care. One such paper, “ Emergency department observation units: A clinical and financial benefit for hospitals“, concluded that dedicated observation units “provide high-quality and efficient care to patients with common complaints seen in the emergency department.” Furthermore, dedicated observation units have also been shown to reduce the number of unnecessary inpatient admissions, which is a favorite target for government auditors. Some facilities have found success using dedicated hospitalists on a rotating schedule to staff their observation units. University Hospital, a 604-bed public teaching hospital affiliated with the University of Texas Health Science Center at San Antonio, staffs its observation unit with a hospitalist and a physician assistant who work together in 12-hour shifts to provide 24/7 coverage. Facilities interested in creating a dedicated observation unit, but concerned about strain on their hospitalist staff may want to explore using locum tenens hospitalists or hospitalist nurse practitioners to ensure adequate coverage.