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The COVID Observation Protocol: Evaluating a nurse practitioner implementation in an Emergency Department Observation Unit


Background: To optimize patient outcomes and conserve limited inpatient bedspace, the University of California, Irvine Medical Center Emergency Department (UCIMC ED) developed the COVID Observation Protocol, designed to decompress ED overcrowding, inpatient hospital admissions, and 30-day ED revisitations by discharging patients home on home-oxygen therapy. Methods: A retrospective program evaluation was conducted to assess whether the COVID Observation Protocol reduced 30-day ED readmissions and hospital admissions. Data from the electronic health record (EHR) compared patients presenting to the UCIMC ED pre-and post-implementation. Chi-square tests were utilized to compare inpatient hospitalizations, 30-day ED revisitations, and discharge home with home-oxygen therapy. A thematic analysis was conducted based upon an anonymous online survey to assess the role NPs played during the implementation process. Results: 4,049 patients presented to the ED, 48% before December 29, 2020, and 52% after. Thematic analysis yielded four themes: (1) significant issues with overcrowding in the ED; (2) lack of evidence-based research to support the newly implemented protocol; (3) a general lack of resources; and (4) needing coping skills to manage patients during a pandemic. Inpatient hospitalizations and 30-day ED revisitations were lower before implementation, and more patients were discharged home with home-oxygen therapy before protocol implementation. 30-day revisitations were lower among those discharged home on home-oxygen therapy after protocol implementation. Discussion: The goal of this protocol was to decrease and decompress inpatient admissions and reduce 30-day ED revisitations by discharging them home on home-oxygen therapy. While it was hypothesized that the protocol would reduce the number of inpatient hospitalizations after implementation, this project demonstrated the opposite; however, those patients who were discharged on home-oxygen therapy were significantly less likely to return to the ED within a 30-day timeframe. Analysis of the NP interviews demonstrated a stressful environment in which decisions had to be made to prioritize the sickest of patients with access to limited resources and a challenging practice environment in the mobile field hospital. Conclusion: While, on the surface, it appears that the protocol was not successful, a closer examination of the cohort discharged home on home-oxygen therapy after December 29, 2020, demonstrated a significant reduction in 30-day ED revisitations. Despite the number of confounding items, this scholarly project has demonstrated that the updated protocol was successful in reducing revisitation rates and warrants further analysis.

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