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Background: The benefit of virtual emergency department observation unit (EDOU) care relative to traditional observation care in an inpatient bed is unknown., Objective: To determine if virtual observation care in an EDOU is associated with improved length of stay, cost, inpatient admission rate, and adverse events relative to traditional observation care in non-observation unit (NOU) inpatient bed., Methods: This is a retrospective observational cohort study of observation patients managed over 24 months in two urban teaching hospitals. Following an ED visit, observation care occurred in a virtual-EDOU or NOU inpatient setting based on bed availability, physician discretion, and observation guidelines. Primary outcomes were length of stay, total cost, inpatient admission rate, and adverse events (death or ICU admission). Hospital cost and clinical databases were used. Analysis with a doubly-robust regression with entropy balancing and propensity scores was used to control for subgroup differences., Results: 30,191 observation patients were divided into 13,753 NOU patients and 16,438 EDOU patients with similar distributions for age and gender, and differences in health insurance and diagnosis. For both discharged and admitted patients, the mean cost was higher in the NOU setting at $7989 than the virtual-EDOU setting at $4876 with an adjusted difference of $1951 (95% CI: $1762-$2133). The mean total length of stay was higher in the NOU setting (60.5 h) than the virtual-EDOU setting (36.4 h) with an adjusted difference of 20.4 h (95% CI: 19.2 h - 21.3 h). NOU inpatient admission rates were higher (25.3% vs 18.4%). Cost and length of stays were lower in discharged observation patients, with differences favoring the virtual-EDOU group. Adverse events were higher in the NOU setting (2.1% vs 0.8%). 30-day ED recidivism did not differ significantly between NOU and virtual-EDOU study groups. The virtual-EDOU saved the two hospitals $16,036,913 and 6986 bed-days annually., Conclusion: Management of observation patients in a virtual-EDOU setting is superior to care in a traditional inpatient setting in terms of costs, length of stays, inpatient admission and adverse events rates., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To describe the feasibility of managing hyponatremia patients under outpatient observation status in an academic medical center, and compare outcomes based on the use of an emergency department observation unit (EDOU)., Methods: This is a retrospective cohort study of emergency department hyponatremic patients managed in four hospitals within a large urban academic medical center over 27 months. All patients had an admit-to-observation order, ICD-10 codes for hyponatremia, and mild (130-135 mmol/L) to moderate (121-129 mmol/L) hyponatremia. Observation settings were divided into two groups: EDOU and Non-Observation Unit (NOU) inpatient beds. Severe hyponatremia (≤120 mmol/L) was excluded. Primary clinical outcomes were inpatient admit rate, length of stay (LOS), total direct cost, the rate of adverse events and 30-day recidivism., Results: 188 patients were managed as an observation patient, with 64 managed in an EDOU setting (age 74.0 yr, 70.3% female) and 124 managed in a NOU setting (age 71.5 yr, 64.5% female). Patient subgroups were similar in terms of presenting complaints, comorbidities, and medication histories. Initial and final sodium levels were similar between settings: EDOU (125.1 to 132.6 mmol/L) vs NOU (123.5 to 132.0 mmol/L). However, outcomes differed by setting for observation to inpatient admit rate (EDOU 28.1% vs NOU 37.9%, adjusted effect 0.70), overall length of stay (EDOU 19.2 h vs NOU 31.9 h; adjusted effect -10.5 h and total direct cost ($1230 vs $1531; adjusted effect -$167). EDOU sodium correction rates were faster (EDOU 0.44 mmol/L/h vs 0.24 mmol/L/h; adjusted effect 0.15 mmol/L/h) and 30-day recidivism rate was similar (EDOU 13% vs NOU 15%). There were no index visit deaths or intensive care unit admissions., Conclusion: Management of selected hyponatremia patients under observation status is feasible, with the EDOU setting demonstrating lower admit rates, shorter length of stay, and lower total direct costs with similar clinical outcomes., Competing Interests: Declaration of competing interest No conflicts of interest for all authors., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Physicians dedicate substantial time to documentation. Scribes are sometimes used to improve efficiency by performing documentation tasks, although their impacts have not been prospectively evaluated. Our objective was to assess a scribe program's impact on emergency department (ED) throughput, physician time utilization, and job satisfaction in a large academic emergency medicine practice., Methods: We evaluated the intervention using pre- and post-intervention surveys and administrative data. All site physicians were included. Pre- and post-intervention data were collected in four-month periods one year apart. Primary outcomes included changes in monthly average ED length of stay (LOS), provider-specific average relative value units (RVUs) per hour (raw and normalized to volume), self-reported estimates of time spent teaching, self-reported estimates of time spent documenting, and job satisfaction. We analyzed data using descriptive statistics and appropriate tests for paired pre-post differences in continuous, categorical, and ranked variables., Results: Pre- and post-survey response rates were 76.1% and 69.0%, respectively. Most responded positively to the intervention, although 9.5% reported negative impressions. There was a 36% reduction (25%-50%; p<0.01) in time spent documenting and a 30% increase (11%-46%, p<0.01) in time spent in direct patient contact. No statistically significant changes were seen in job satisfaction or perception of time spent teaching. ED volume increased by 88 patients per day (32-146, p=0.04) pre- to post- and LOS was unchanged; rates of patients leaving against medical advice dropped, and rates of patients leaving without being seen increased. RVUs per hour increased 5.5% and per patient 5.3%; both were statistically significant. No statistically significant changes were seen in patients seen per hour. There was moderate correlation between changes in ED volume and changes in productivity metrics., Conclusion: Scribes were well received in our practice. Documentation time was substantially reduced and redirected primarily to patient care. Despite an ED volume increase, LOS was maintained, with fewer patients leaving against medical advice but more leaving without being seen. RVUs per hour and per patient both increased.