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Observation units address certain shortcomings of traditional emergency department (ED) patient evaluation and management. Failure to diagnose and treat serious dangerous disease is an important problem with many patients inadvertently discharged home. Based on their initial evaluation alone, emergency physicians may miss 2% to 5% of acute myocardial infarctions (MI), 10% to 20% of acute appendicitis, and 20% to 40% of ectopic pregnancies.1-4 In addition, many patients admitted to the hospital are found to have no serious dangerous disease. To avoid the problem of inadvertently missing the diagnosis of acute serious disease, emergency physicians often must lower their threshold for admitted patients which results in many patients being found to have no serious disease during hospitalization. For example, of patients admitted for a chief complaint of chest pain, over two-thirds are found to have no serious coronary artery disease.1 On the other hand, of patients who are actually suffering an MI, one-third will present without chest pain and half will have a nondiagnostic ECG.5,6 Atypical symptoms for acute MI becomes a growing problem as the population ages.

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Yet in the present age of soaring healthcare costs, the use of acute care hospitalization to evaluate patients with low probability of serious disease has become unacceptable to payors and the public. Decreasing avoidable admissions, while maintaining quality, continues to be a central issue in controlling national healthcare costs through programs such as accountable care organizations.7,8 Patients and third-party payors expect as many patients as possible to be managed on an outpatient basis with acute care hospitalization only for patients with acute serious dangerous disease.

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ED observation units are a tool which clinicians may use to decrease diagnostic uncertainty for serious conditions such as chest pain, syncope, transient ischemic attacks, and abdominal pain—while remaining cost-effective by avoiding unnecessary admissions.2,9-11 The unit can also be used to extend the treatment window of acute conditions, again avoiding admission and decreasing costs. This has been shown for conditions such as asthma, atrial fibrillation, and congestive heart failure.12-14 There has been a growth in these units in the United States from 19% of US hospitals in 2003 to 36% in 2007 with more than half managed by emergency medicine.15,16

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Observation medicine has developed over the past several decades to address these issues. With ED observation units, emergency physicians have improved their diagnostic accuracy.3,8 Patients with a difficult diagnostic condition (eg, abdominal pain, chest pain, or grand mal seizure) are not discharged home until the physician has a high degree of certainty that they do not have a serious disease. With ED observation units, emergency physicians have also improved their therapeutic success rate. Most patients who fail an acute trial of clinical therapy (such as those with asthma or acute congestive heart failure) can be successfully managed with the use of ED observation beds. With the evolution of these units, emergency physicians have ...

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