The feasibility of emergency department observation units in the management of mild to moderate hyponatremia

Jamal J Taha; George B Hughes; Matthew T Keadey; Douglas W Chesson; Tim P Moran; Qasim Kazmi; Michael A Ross

doi:10.1016/j.ajem.2024.02.037

The feasibility of emergency department observation units in the management of mild to moderate hyponatremia

Am J Emerg Med. 2024 Mar 5:80:11-17. doi: 10.1016/j.ajem.2024.02.037. Online ahead of print.

Authors

Jamal J Taha¹, George B Hughes¹, Matthew T Keadey¹, Douglas W Chesson¹, Tim P Moran¹, Qasim Kazmi¹, Michael A Ross²

Affiliations

¹ Department of Emergency Medicine, Emory University School of Medicine, 531 Asbury Circle - Annex, Suite N340, Atlanta, Georgia.
² Department of Emergency Medicine, Emory University School of Medicine, 531 Asbury Circle - Annex, Suite N340, Atlanta, Georgia. Electronic address: maross@emory.edu.

PMID: 38471375
DOI: 10.1016/j.ajem.2024.02.037

Abstract

Objective: To describe the feasibility of managing hyponatremia patients under outpatient observation status in an academic medical center, and compare outcomes based on the use of an emergency department observation unit (EDOU).

Methods: This is a retrospective cohort study of emergency department hyponatremic patients managed in four hospitals within a large urban academic medical center over 27 months. All patients had an admit-to-observation order, ICD-10 codes for hyponatremia, and mild (130-135 mmol/L) to moderate (121-129 mmol/L) hyponatremia. Observation settings were divided into two groups: EDOU and Non-Observation Unit (NOU) inpatient beds. Severe hyponatremia (≤120 mmol/L) was excluded. Primary clinical outcomes were inpatient admit rate, length of stay (LOS), total direct cost, the rate of adverse events and 30-day recidivism.

Results: 188 patients were managed as an observation patient, with 64 managed in an EDOU setting (age 74.0 yr, 70.3% female) and 124 managed in a NOU setting (age 71.5 yr, 64.5% female). Patient subgroups were similar in terms of presenting complaints, comorbidities, and medication histories. Initial and final sodium levels were similar between settings: EDOU (125.1 to 132.6 mmol/L) vs NOU (123.5 to 132.0 mmol/L). However, outcomes differed by setting for observation to inpatient admit rate (EDOU 28.1% vs NOU 37.9%, adjusted effect 0.70), overall length of stay (EDOU 19.2 h vs NOU 31.9 h; adjusted effect -10.5 h and total direct cost ($1230 vs $1531; adjusted effect -$167). EDOU sodium correction rates were faster (EDOU 0.44 mmol/L/h vs 0.24 mmol/L/h; adjusted effect 0.15 mmol/L/h) and 30-day recidivism rate was similar (EDOU 13% vs NOU 15%). There were no index visit deaths or intensive care unit admissions.

Conclusion: Management of selected hyponatremia patients under observation status is feasible, with the EDOU setting demonstrating lower admit rates, shorter length of stay, and lower total direct costs with similar clinical outcomes.

Keywords: Electrolyte abnormalities; Emergency department; Health services research; Observation units.