Short stay units

Introduction

• Response to ED physician’s desire not to be forced into a dichotomous decision to admit or discharge
• Provide a third option for medically complex patients who require further diagnosis or treatment in a short time-frame
• Defined by:
  • Discrete wards of 4-20 beds, located adjacent to main departemnt
  • Capacity to care for 5-10% of total ED volume
  • Staffed and run by ED staff
  • Provide an area for further diagnostics/treatment before discharge
  • Average LOS 10 hours and 80% discharge rate

• Provide a degree of control and flexibility to extend beyond 4 hour targets
• Benefits include:
  • Allowing access to investigations prior to discharge to ensure accurate diagnosis and formulation of a comprehensive discharge plan
  • Admission to correct inpatient service once accurate diagnosis made
  • Alternative to inpatient care to improve efficiency, clinical care and patient satisfaction while minimising the costs
  • Reducing inpatient admissions
  • Temporary holding areas for access blocked patients
  • Temporary accommodations for patients e.g. elderly, situational crisis until daylight hours
  • Safeguard for junior medical staff who require assistance with disposition planning
  • Shorter LOS and cost compared to inpatient stay

Policies

• Admission process
  • Clear medical governance and responsibility for patient at all times
  • Minimising handovers reduces errors
  • Senior clinicians making key decisions, minimising handovers and ensuring nursing staff know who to contact with issues
  • Treatment plan, defined objectives for admission and conditions to be met prior to discharge documented on admission
• Admission criteria
  • Time-limited intensive treatment or single system problems with clear treatment and follow-up guidelines
  • Should have pre-negotiated referral pathways for failed short stay cases
  • Usually expectation is discharge <24 hours
  • Examples
    • Renal colic
    • Mild/moderate asthma
    • Gastroenteritis
    • Migraines
    • Analgesia and mobilisation after soft-tissue injury
    • Cellulitis
    • Investigations before discharge planning
    • Post-procedure observation e.g. Bier’s block/procedural sedation
    • Alcohol or drug intoxication
    • Minor head injury observation
    • Envenoming requiring period of observation

Exclusion criteria

• >24 hours expected admission
  • More than one or complex medical issues
  • No clear treatment plan
  • Intensive nursing cares e.g. immobile
  • Violent/psychotic/disruptive
• Some patients will be admitted pending inpatient review if the expectation is that the patient can be discharged but it is important not to delay inpatient therapy unnecessarily

Improving efficiency

• Senior clinician input for rapid decision making and referral as required
• Negotiated pathways for common presentations to facilitate patient disposition
  • E.g. renal colic, imaging, urology follow-up guidelines
• Access to allied health staff
• Negotiate priority admission to inpatient wards for patients who fail SSW admission so as not to impact on efficiency of the ward

Audit and feedback

• Key performance indicators include
  • Number of patients transferred to inpatient teams (ie. Failed SSW) – 10-20% acceptable
  • Occupancy rates
  • Length of stay
  • Discharge to home rate
  • Representation rates within 48 hours
  • Adverse events and outcomes
  • Complaints

Evidence

• Proven reduced LOS and cost compared to inpatient care for:
  • Chest pain
  • Asthma
  • TIA
  • Croup
  • Infections
• The true cost benefit is unclear as the presence of a SSW may reduce the likelihood of discharge from ED in the first place
• Short-stay medicine is becoming an area of interest/subspeciality with blurred lines between observation units, clinical decision units and chest pain units

Hazards of short stay

• Unnecessary delay to admission
• Deferral of decision making
• Failure to exclude serious diagnoses
• Optimism of staff is common i.e. elderly will get better quickly
• Access block if admitted patient has no allocated bed

Predictors of SSU admission failure

• Referral for inpatient admission prior to SSU admit – LR + 6.2
• Inability to weight bear or walk, when previously able to do so LR +4.8
• Need for ongoing active treatment LR + 1.6
• More than one active problem
• Multiple medical comorbidities
• Progressive deterioration prior to presentation despite optimal treatment and minimal change in therapy on admission

Last Updated on October 6, 2021 by Andrew Crofton