Emergency Medicine has made significant contributions to the proliferation of Observation Medicine, an attractive alternative to admission for patients with low- and moderate-risk chest pain. Selecting the right patient, identifying appropriate interventions, and documenting appropriately are just some of the challenges discussed in the latest ACEP E-QUAL Network podcast, a partnership with ALiEM to promote clinical practice improvements. We review highlights from a podcast with experts Dr. Anwar Osborne (Emory University) and Dr. Michael Granovsky (LogixHealth).

3 Key Components to an Observation Protocol

Chest pain is one of several chief complaints conducive to an observation protocol, which has 3 key components:

1. Patient selection
2. Intervention
3. Decision

For example, a patient with known coronary artery disease, reproducible chest pain, and a negative first troponin may be the correct patient for observation. The intervention, will be telemetry and a second ECG and troponin. The decision, will be “discharge if second ECG and troponin are negative.”

General Documentation Requirements

1. Date and timed order to place in observation
2. A short treatment plan regarding the goals of the observation
3. A clinically appropriate progress note
4. A short discharge summary note including a follow-up plan

There are more specific requirements for each level of patient, including those who are considered moderate and high severity patients, detailed in the podcast.

Financial Considerations

As observation medicine becomes more prevalent, several financial considerations continue to evolve:

1. Requirements to discharge to a skilled nursing facility
2. Self-administered medications
3. Facility payments
4. Medicare Part A versus Part D, and the cost of care associated with inpatient versus outpatient status

Learn more about the E-QUAL Network Chest Pain Initiative to review the webinar associated with this podcast.

Author information

Derek Monette, MD

ALiEM Deputy Editor-in-Chief
Medical Education Research Fellow
Department of Emergency Medicine
Massachusetts General Hospital

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