SUMMARY: Observation Units (EDOUs) provide a cost-effective method of preventing Emergency Department misdiagnoses that are commonly litigated. For myocardial infarction, standard history, examination and investigations miss atypical cases that up to 24 hours' observation identify. Repeat examination every few hours for acute appendicitis prevents perforation and unnecessary surgery. For unexplained loss of consciousness, those with cardiac causes and high mortality can be selected for hospitalisation within 12 hours' observation.
Observation Units (EDOUs) provide a cost-effective method of preventing Emergency Department misdiagnoses that are commonly litigated. For potentially serious acute medical problems, the management options historically have been either a) 2-6 hour Emergency Department assessment and treatment followed by discharge or b) hospitalisation for a few days. However, a few hours of assessment is insufficient to confirm or refute diagnosis of many of the emergency conditions that commonly generate medical malpractice Actions.
To address the need for an intermediate service, Observation Units evolved. Since 1988 Emergency Department Observation Units (EDOUs) have been officially recognised and management guidelines developed1. They have been shown to be cost-effective2.
Of the 3 functions of EDOUs - diagnostic evaluation, short-term treatment and psychosocial management - it is misdiagnosis that most commonly results in medical malpractice litigation.
Practice PointLook for Emergency Department Observation Unit admission in misdiagnosis of
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The commonest causes of medical malpractice claims against emergency department physicians are misdiagnoses3 of chest pain, abdominal pain, wounds, fractures, pediatric fever/ meningitis, epiglottitis, central nervous system bleeding, and abdominal aortic aneurysm.
For myocardial infarction, standard history, examination and investigations miss atypical cases that up to 24 hours' observation identify. Failure to diagnose myocardial infarction accounts for about a quarter of indemnity paid on behalf of emergency department physicians3. A common clinical error is to place too much emphasis on typical characteristics of the chest pain, and too little on risk factors for coronary pain.
Because the short-term mortality of missed myocardial infarction is about 25%4, those patients with moderate to high probability of heart-attack or unstable angina should be admitted to hospital. Only patients with low probability should be evaluated in the EDOU5.
Initial ElectroCardioGraphy (ECG) and cardiac enzymes are poor at excluding myocardial infarction so a key part of the management should be repeats of these investigations over the <24-hour observation period5a.
Practice PointEmergency Department Observation Unit admission is appropriate for patients with chest pain who have a LOW probability of myocardial infarction |
Repeat examination every few hours for acute appendicitis prevents perforation and unnecessary surgery. Acute appendicitis is the most common surgical cause of acute abdominalpain6, and abdominal pain is the most common chief complaint for emergency department patients7. However, only 1-3% have acute appendicitis. It has long been known8 that 8-hourly re-examination is safer and more effective than traditional daily ward-rounds in diagnosing or ruling out appendicitis. The majority of patients could be discharged within 12 hours of observation, and the rate of normal appendix removal was significantly reduced9.
Recent evaluation7 of EDOUs showed a trend towards improvement in making and excluding the diagnosis, and preventing both perforation and unnecessary surgery, though the study was too small for the results to be statistically significant.
Practice PointIf an initial diagnosis of acute appendicitis cannot be made, re-examination every few hours is effective at preventing perforation and reducing rates of removal of a normal appendix |
For unexplained loss of consciousness, those with cardiac causes and high mortality can be selected for hospitalisation within 12 hours' observation. Syncope accounts for 3% of Emergency Department visits and 6% of hospital admissions10. Although half will remain unexplained after extensive investigation, up to a third of patients with unexplained transient loss of consciousness will prove to have a cardiac cause, with mortality rates of 20-30%11. The EDOU is a cost-efficient means of determining who needs to be hospitalised and who can safely be discharged home12.
Practice PointPatients with unexplained loss of consciousness should, if not hospitalised, be observed and investigated in the EDOU |
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