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Who Should Be "Obs in the Zone"
Who Should Be "Obs in the Zone"
Any patient who will be in the ED for > 8 hours who cannot go to the CDU
The most common situations to trigger "Obs in the Zone" are
Sober Reevaluations
Behavioral Health Patients on suicide or elopment precautions
Because we do not have the nursing or safety resources to care for these patients in CDU, they should be kept in the main ED.
Should Every patient staying in main ED > 8 hours be considered "Obs in the Zone"?
Yes. After a patient has been in the ED for 8+ hours, we are able to bill for services related to their ongoing stay, including nursing, professional and facility fees. Patients staying in the ED are resource intensive, and we should make sure we are being paid for the care we are giving.
Initiate "Obs in Zone"
Initiate "Obs in Zone"
Once you have decided a patient will be obs in zone (they have either passed the 8 hour mark in the ED already or you know that they will prior to disposition), please let the nurse and charge know that you plan to "Obs in the zone" and then complete the following tasks:
1. Patient Status Order
In the Order entry area type "Obs".
This will give you lots of options. You want to choose the option from the Procedures: "Initiate Outpatient with Observation Services"
Once you open this order, you will be prompted with several fields that will need further information.
For "Service": choose or type "ED Observation"
For "Level of Care": choose "Observation Unit"
For "Estimated Length of Stay": choose 1 day
Make sure to sign the order. This Order must be placed by MD or DO
2. Notify Nursing Staff of "obs in zone" status
Initial ED provider should notify the nurse in the main zone of expected transfer
CDU provider should notify the CDU nursing staff of the admission
3. Complete Home Medication Reconciliation. With intoxicated patients, this is often impossible. Please just note this in your documentation. For Behavioral Health patients, please make an effort to ask about their home medications and if any will be needed while they await BHE evaluation and disposition. Many of our BH patients also suffer from seizure disorders etc, that have consequential medications need.
Between 11 am and 9 pm pharmacy can help using the "Medication Reconcilliation by Pharmacy" order.
if outside of pharmacy hours (11:00 - 21:00) you will have to do this yourself
5. Order any home medications needed while patient in the ED
6. Complete "ED Observation" order set in particular be sure to:
Order PRNs (Pain, Nausea, Sleep, Agitation, anxiety etc)
Order BHE and Care Management as appropriate
Order and specific tests or therapies for the particular patient
Any chemical or physical restraints have been documented and ordered per ED protocols
7. Obs in Zone Note
Please document the "Obs in zone" plan by including the dot phrase ".IESEDOBSERVATION" in your main ED Note.
If you are receiving the patient as a signout from a prior provider, you may use ".IESEDOBSERVATION" as your entire note for the patient if it has not already been completed by the prior provider
If you recieve the patient as a signout and they have already had the above documented, the patient will need a note with either ".IESEDOBSERVATIONPROGRESSNOTE" or ".IESEDOBSERVATIONDISCHARGE". During your shift. Both is OK too.
8. Signout the patient to oncoming team
When you sign out your acute zone patients, treat this patient as an acute signout and let the receiving physician know about any pending studies, issues and status of notes and orders as above
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