LO27: System outcomes associated with an emergency department clinical decision unit. (15th May 2017)

• Record Type: Journal Article
• Authors: Karacabeyli, D.; Park, D.K.; Meckler, G.; Doan, Q.
• Is Part Of: CJEM. Volume 19(2017:May)Supplement 1
• Page Start: S36
• Page End: S37
• Publication Date: 2017-05-15
• Subjects: clinical decision unit, -- return emergency visits, -- resource utilization; Emergency Treatment -- Periodicals; Emergency Medicine -- Periodicals; Emergency medical services -- Canada -- Periodicals; Medical emergencies -- Canada -- Periodicals; Emergency medical services; Medical emergencies; Canada; Periodicals; 616.02505
• DOI: 10.1017/cem.2017.89
• Languages: English
• ISSNs: 1481-8035

Abstract

Abstract : Introduction: A clinical decision unit (CDU) is an area within the emergency department (ED) that allows for protocol-driven treatment & observation of patients who may not require hospital admission, but are not ready for discharge after initial assessment & treatment. A CDU was established at BC Children's Hospital in 2014 as a means to optimize hospital resource utilization. Preliminary administrative data review revealed a return to ED (RTED) rate of 15% following a CDU stay, 2-3 times the RTED rate reported in the literature. Whether this is the expected cost of reducing hospital admissions remains unclear. Research exploring the underlying reasons for RTED following a CDU stay is limited. Objectives: Following a CDU stay, to describe 1) disposition outcome distribution; 2) underlying reasons for RTED; and 3) the proportion of potentially preventable RTED.Methods: Retrospective cohort study of all ED visits with a CDU stay from Jan 1, 2015 to Dec 31, 2015. Health records data was extracted & entered into standardized online forms by trained research assistants, then blindly reviewed by two investigators to determine a) the most probable cause of each RTED & b) the number of RTED that were clinically unnecessary.Results: Of the 1696 index CDU visits, 1503 (89%) were discharged home. However, 139 (9%) had ≥1 associated RTED. Among these, 48 (35%) were deemed clinically unnecessary (89% agreement, Kappa=0.79) & therefore potentially preventable. The most common reason (88%) for unnecessary RTED was mismatch between expected natural progression of disease (not requiring further medical assessment or treatment) & families' understanding of disease symptom range & duration. In 90% of these cases, anticipatory guidance regarding natural progression of disease was not communicated to parents upon discharge. Among the remaining 1364 (91%) that did not return, 750 had an initial visit total ED length of stay of >8 hours, thus were considered averted hospitalizations attributable to the CDU.Conclusion: The CDU has had a positive impact on patient & system outcomes through the prevention of several inpatient admissions. However, we observed a relatively large proportion of RTED, 35% of which were clinically unnecessary & 27% of which had inadequate discharge instructions. This highlights opportunities to further optimize the effectiveness of the CDU through quality improvement initiatives focusing on the ED discharge process.