Implementing a Second-Level Observation Unit at a Large Academic Medical Center

Authors: Padageshwar R. Sunkara, MD, MMCi, William C. Lippert, MD, MPH, Gary E. Rosenthal, MD, Brian C. Hiestand, MD, John Blalock, MHA, Chi C. Huang, MD


This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.


1. Centers for Medicare & Medicaid Services. Fact sheet: two-midnight rule. Published October 30, 2015. Accessed February 21, 2021.
2. Feng Z, Wright B, Mor V. Sharp rise in Medicare enrollees being held in hospitals for observation raises concerns about causes and consequences. Health Aff (Millwood) 2012;31:1251–1259.
3. Vincenzo D, Pignataro F, Sero A, et al. [Observation unit]. Recenti Prog Med 2009;100:259–260.
4. Leykum LK, Huerta V, Mortensen E. Implementation of a hospitalist-run observation unit and impact on length of stay (LOS): a brief report. J Hosp Med 2010;5:E2–E5.
5. Nahab F, Leach G, Kingston C, et al. Impact of an emergency department observation unit transient ischemic attack protocol on length of stay and cost. J Stroke Cerebrovasc Dis 2012;21:673–678.
6. Ross MA, Hockenberry JM, Mutter R, et al. Protocol-driven emergency department observation units offer savings, shorter stays, and reduced admissions. Health Aff (Millwood) 2013;32:2149–2156.
7. Osborne AD, Farrah H, Wheatley M, et al. There's another observation unit? A case series survey of second level observation units. Crit Pathw Cardiol 2016;15:26–28.
8. Conley J, Bohan JS, Baugh CW. The establishment and management of an observation unit. Emerg Med Clin North Am 2017;35:519–533.
9. The Define, Measure, Analyze, Improve and Control (DMAIC) Process. American Society for Quality. Milwaukee, Wisconsin. Accessed 19 November 2019.
10. Gordon MB, Melvin P, Graham D, et al. Unit-based care teams and the frequency and quality of physician-nurse communications. Arch Pediatr Adolesc Med 2011;165:424–428.
11. Bhamidipati VS, Elliott DJ, Justice EM, et al. Structure and outcomes of interdisciplinary rounds in hospitalized medicine patients: a systematic review and suggested taxonomy. J Hosp Med 2016;11:513–523.
12. Yoo JW, Kim S, Seol H, et al. Effects of an internal medicine floor interdisciplinary team on hospital and clinical outcomes of seniors with acute medical illness. Geriatr Gerontol Int 2013;13:942–948.
13. O'Mahony S, Mazur E, Charney P, et al. Use of multidisciplinary rounds to simultaneously improve quality outcomes, enhance resident education, and shorten length of stay. J Gen Intern Med 2007;22:1073–1079.
14. Sunkara PR, Islam T, Bose A, et al. Impact of structured interdisciplinary bedside rounding on patient outcomes at a large academic health centre. BMJ Qual Saf 2020;29:569–575.
15. O'Leary KJ, Creden AJ, Slade ME, et al. Implementation of unit-based interventions to improve teamwork and patient safety on a medical service. Am J Med Qual 2015;30:409–416.
16. Boulain T, Malet A, Maitre O. Association between long boarding time in the emergency department and hospital mortality: a single-center propensity score-based analysis. Intern Emerg Med 2020;15:479–489.
17. Singer AJ, Thode HC, Viccellio P, et al. The association between length of emergency department boarding and mortality. Acad Emerg Med 2011;18:1324–1329.
18. McChesney C, Huling J, Covey S. The 4 Disciplines of Execution. Salt Lake City, UT: Franklin Covey; 2014.
19. Haddad LM, Annamaraju P, Toney-Butler TJ. Nursing shortage. Updated December 14, 2020. Accessed February 21, 2021.
20. Milliman Care Guidelines. Milliman Care Gu idelines, LLC. Seattle, Washington.