Emergency department short stay units

Introduction

Emergency department (ED) short stay units have evolved to become an integral part of modern emergency medicine service provision. The exact function and benefit to patient care varies according to hospital demand and patient needs, but in general ED short stay units allow for safe decision making and management whilst a final disposition decision is reached. It provides a further option for medically complex patients who require more diagnostic testing and therapeutic intervention in a short time frame, and also facilitates effective patient flow through emergency departments.

ED short stay units augment hospital bed access through prevention of hospital admissions for <24 hours and have proved to be a safe and cost-effective alternative to hospital admission for various conditions including chest pain, asthma, syncope, atrial fibrillation, dehydration, infection and other conditions requiring initial work up and stabilization.

Terminology around short stay units is inconsistent and these wards are sometimes referred to as observation wards or clinical decision units (CDUs). The emergency short stay unit is characterized by specific admission and discharge criteria, whereas the term of ‘observation ward’ can be considered for patients with more undefined clinical presentations. In contrast to these, some units are referred to as CDUs, implying that patients require a period of medical management prior to a final disposition decision being reached. The CDU has defined admission and discharge criteria, but generally, the focus is on medically unwell patients, potentially for admission, as opposed to patients being discharged home with potentially surgical conditions. No consensus definitions exist.

In contrast to the above the concept of a medical assessment and planning unit (MAPU) has also emerged over the past years. These units are short stay medical inpatient wards with an expected length of stay <72 hours.

Emergency short stay units are defined by the following general characteristics :

• discrete wards with 4 to 20 beds, located adjacent to or in close proximity to the main body of the emergency department (ED)

• designed for short term observation or stay <24 hours

• staffed and run by ED personnel

• specific admission and discharge criteria and policies

These wards provide evidence-based short-term observation and treatment for specific patients as clinically indicated. The average length of stay is dependent on a variety of factors unique to each facility, but a length of stay of 10 to 15 hours is common. Any length of stay for >24 hours should be the exception. In the era of focus on patient flow and time targets (e.g. 4-hour rule or National Emergency Access Target [NEAT]), the emergency short stay unit provides a degree of control and flexibility to emergency physicians to extend investigation and care beyond the 4-hour targets.

The benefits of having a short stay unit as part of the emergency department include :

• allowing patients to access investigations before leaving the emergency department, ensuring accurate diagnosis and formulation of a discharge plan;

• admission to the correct inpatient service once an accurate diagnosis has been made;

• provides an alternative to inpatient hospital admission as a way to improve efficiency, clinical care and patient satisfaction, while minimizing costs ;

• reducing inpatient admissions ;

• temporary accommodation for patients (e.g. elderly or those with acute situational crisis) where immediate discharge, especially after hours, would place the person at risk;

• safeguard for junior medical staff who require assistance;

• shorter length of stay and cost compared to inpatient stay ( Table 29.6.1 ).

  Table 29.6.1

  Cost and length of stay comparisons for observation ward versus inpatient care

  Modified from Baugh C, Venkatesh A, Bohan J. Emergency department observation units: a clinical and financial benefit from hospitals. Health Care Manag Rev . 2011;36:28–37, with permission.

  Diagnosis	Observation ward cost (A$)	Inpatient cost of care (A$)	EDOU LOS (h)	Inpatient LOS (h)	References
  Chest pain	844	987			2
  Chest pain	1450	1989	33	45	3
  Chest pain (UK)	450	638			4
  Asthma	1141	2133			5
  TIA	820	1451	26	61	6
  Croup	1259	1599	21	27	7
  Infections	1506	2643	44	88	8

  EDOU , Emergency department observation units; LOS , length of stay; TIA , transient ischaemic attack.

Observation ward policies and protocols

The general function of the observation ward varies depending on the needs of the individual hospital and department; nonetheless, there are some common characteristics that are essential to the efficient functioning of these wards.

These include guidelines around leadership, criteria for admission and discharge, responsibility of care and escalation of concerns, and documentation and transfer of care upon discharge from the unit whether that be to an inpatient unit or community-based service. Operational and clinical protocols, a policy manual and a quality improvement program with measures that evaluate performance are essential to the safe and efficient functioning of these units.