Concept: Observation Units & Admission Policies Across Winnipeg Hospitals and Emergency Departments

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Concept Description

Last Updated: 2004-10-22

Introduction
    In Winnipeg hospitals and emergency departments, patients sometimes wait on stretchers in the hallways. There are many questions regarding correctly capturing this patient group. Information received from Manitoba Health attempts to answer these difficult questions.
Bed Count
    Are beds in observation units counted as inpatient beds? The beds within observation units have not been counted since the bed map program was initiated. Prior to the bed map program, observation unit beds were counted. For related information on bed counts in Manitoba refer to the Bed Counts - Acute Care Hospital concept.
Non-Uniform Policies and Counting Inpatients
    There are no uniform policies among the seven acute care hospitals in Winnipeg regarding counting patients in observation units as inpatients.

    • 24-hour policy - adopted by some hospitals

    • 72-hour policy - (e.g. Seven Oaks Hospital) - the physician, after 72 hours must decide whether or not to admit the patient. If the patient is to be admitted, the service must be specified.

    • Counting inpatients - general rule seems to be that a patient is considered to be an inpatient when the physician writes the order to admit.

    • Patient days are counted from the time of admission.

    • Beds in the observation unit (and hallways) are not counted, but patient days can be counted after the order to admit has been written.

      Note: hospital occupancy is inflated when the patient remains in the observation unit or hallway until separation.
    • Each hospital has an independent system of counting days and therefore actual days may vary.

    • The rules regarding patients in the observation unit applies to patients on the stretchers in the hallway.

    Definitive policies must be obtained from each of the seven hospitals. Manitoba Health does not carry the policies but there are indications that admissions policies might be standardized by January 2000.
A. Hospital Admission Policy Trends
    The following table contains information obtained from each hospital to support documentation of the WHA Planning and Management Information System (July 1998).

    Table 1: Hospital Admission Policy Trends

    Hospital Definition/Coding Practice
    Grace General Hospital - Patients are abstracted when they have been admitted as inpatients after a 24 hour stay in hospital. This practice of abstracting has been more consistent in last 2-3 years. Also, patients may be admitted after 24 hours from the ER.
    Misericordia General Hospital (Note: as of 1998, LTC facility) - When the attending physician gives the order for admission, the case is abstracted upon discharge as an inpatient (even if the complete hospital stay is within the OU). There is no automatic admission criteria for OU patients.
    St. Boniface General Hospital - Considered inpatient admission when a physician has documented that an admission is required (i.e., admit when bed available). St. Boniface does not automatically admit after 24 hours in the observation unit.
    Victoria General Hospital - Patients in the observation unit become inpatients upon a physician's order to admit.
    Concordia Hospital - Patients are admitted after 24 hours although this practice is not always automatic if nursing staff are unsure. Prior to Oct. 1996, the time of admission for these patients was back dated to the time of admission to ER. This has since been changed to reflect time when inpatient admission occurred.
    Seven Oaks General Hospital - Patients are abstracted if an admit order is written. There is no established policy regarding the time frame that holding/reassess patient requires an admit order.
    Health Sciences Centre - Contact HSC directly.

    Further to this information from the Regional Director of Bed Utilization (WRHA) sent the following information dated June 23, 2000.

    "... there appears to be little or no policy regarding admissions, but each facility has a standard practice that is followed. A recently formed committee to standardize data elements will be looking at this issue from a regional perspective this fall (2000)."
B. Admission Coding Practices
    Hospital Definition/Coding Practice
    St. Boniface General Hospital Current practice is to admit the patient when an admission order is written. Patient can be admitted and remain in the ER when no beds are available.
    Seven Oaks General Hospital Patients are admitted after a written order for admission is left.
    Grace General Hospital Current practice is to admit a patient only when an admit order is written.
    Health Sciences Center practice varies slightly depending on the service the patient is being admitted to. Generally patients are admitted upon an order, but the admit date and time is generated once a patient is discharged from emergency and admitted to an inpatient bed.
    Victoria General Hospital Patients are admitted on a physician's order.
    Concordia Hospital Patients are admitted on a physician's order.

    This information has been updated with the following information received from Rosemary McDowell at Manitoba Health (August 24, 2004).

    The provision of health care is entrusted to the Regional Health Authorities (RHA). Policies and procedures regarding admission are the responsibility of each RHA. Following is the information from the Winnipeg Regional Health Authority:

    • there are 6 emergency rooms and 1 urgent care centre (no acute inpatient beds) in the WRHA.
    • prior to regionalization, some hospitals had automatic admit policies after a certain period of time. This no longer occurs.
    • there is no common definition or criteria for the observation units. The WRHA is currently working on standardization of the policies throughout the ABC (Achieving Benchmarks through Collaboration) project.
C. Current Observation Unit Admission Practices
    The following table describes the current Observation Unit admission practices of Winnipeg hospitals.

    Hospital Description of Practice
    St. Boniface General Hospital Patients are under the care of the emergency physician. Admitted patients may be cohorted in observation.
    Seven Oaks General Hospital Patients are admitted and under the care of a family physician / surgeon.
    Grace General Hospital Patients are admitted under the care of a family physician. Some patients may be under the care of the emergency physician.
    Health Sciences Center Patients are under the care of the emergency physician. Admitted patients may be cohorted in observation.
    Victoria General Hospital Patients are admitted under the care of the family physician. Admitted patients may be cohorted under the internal medicine or surgery program.
    Concordia Hospital Patients are admitted under the care of a family physician. Some patients may be under the care of the emergency physician.
Notes
  • Alternatives to Acute Care (1996) - After 24 hours in the hospital, patients must be admitted, whether they are still in the observation unit or not. However, at least one hospital, possibly Concordia, routinely admitted patients prior to the 24-hour time period. Neil Donen stated that Concordia routinely admits all medical and emergency surgical patients to the observation unit first, prior to going to the ward. As a result, the OU is filled with patients who are waiting for beds on the wards but they are not strictly patients under observation. Overall, patients who should be in the observation unit are in the hallways.[

  • Hospital Case Mixing Project (1994, 1995) - Patients who should be admitted but are not, due to a lack of beds, should at least be admitted on paper. In many instances, record of admission was overlooked as demonstrated by counting OU days. In regards to the costing study, lacking a record of admission was the issue for OU patients and hall patients especially at Concordia and, to a lesser degree, at the other hospitals excluding the HSC. For this study, Concordia posed the greatest concern by being off about 4000 days. The Winnipeg hospitals have since changed policy since the high numbers of hallway patients have been recognized.
More Information

  • McDowell R., Manitoba Health in email to Carolyn De Coster dated August 24, 2004.

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References 

  • Brownell M, Roos NP. Monitoring the Winnipeg Hospital System: The Update Report 1993/1994. Winnipeg, MB: Manitoba Centre for Health Policy and Evaluation, 1996. [Summary] [Full Report] (View)
  • De Coster C, Peterson S, Kasian P. Alternatives to Acute Care . Winnipeg, MB: Manitoba Centre for Health and Evaluation, 1996. [Summary] [Full Report] (View)
  • Harrison ML, Graff LA, Roos NP, Brownell MD. Discharging patients earlier from Winnipeg hospitals: does it adversely affect quality of care? CMAJ 1995;153(6):745-751. [Abstract] (View)
  • Kasian P, De Coster C, Peterson S, Carriere KC. Assessing the extent to which hospitals are used for acute care purposes. Med Care 1999;37 (6 Suppl):66-151.(View)
  • Lloyd M, Shanahan M, Brownell M, Roos NP. Hospital Case Mix Costing Project 1991/92: Methodological Appendix. Winnipeg, MB: Manitoba Centre for Health Policy and Evaluation, 1995. [Summary] [Full Report] (View)
  • Shanahan M, Lloyd M, Roos NP, Brownell M. Hospital Case Mix Costing Project 1991/92. Winnipeg, MB: Manitoba Centre for Health Policy and Evaluation, 1994. [Full Report] (View)