clinical unit in ed by saad al juma
DESCRIPTION
By Saad AL JumaTRANSCRIPT
By : Saad Al Juma R3
Introduction Objectives Terminology Rationale Pros and Cons Mechanics Evidence conclusion
risks, benefits, and requirements to develop an ED observation unit or clinical decision unit
Recognize what is required to develop and manage these units and programs
Recognize the conditions that can be better managed through these programs
ED Observation Unit (EDOBS) Clinical Decision Unit (CDU) Rapid Diagnostic Unit (RDU)
dedicated area within or directly adjacent to the ED
defined nursing and physician staffing. clearly defined written policies and
procedures for management of certain medical problems within specific time limits. It must be provided with equipment and supplies appropriate for the kinds of patients treated.
dedicated area within or directly adjacent to the ED
defined nursing and physician staffing. clearly defined written policies and
procedures for management of certainmedical problems within specific time limits. It must be provided with equipment and supplies appropriate for the kinds of patients treated.
dedicated area within or directly adjacent to the ED
defined nursing and physician staffing. clearly defined written policies and
procedures for management of certainmedical problems within specific time limits. It must be provided with equipment and supplies appropriate for the kinds of patients treated.
Clearly defined admission criteria Well planned policies and procedures Clear chain of command Proper staffing, location, and equipment Carefully developed programs for quality
assurance and utilization review.
What is the current context of Emergency Medicine?
Crowding / Increasing volume
Saturated inpatient bed capacity/ Decreasing access inpatient beds
EMS diversion
Problem with missed MIs, TIAs that return as a stroke, or door-to balloon times.
Increasing Length of Stay (LOS)
No
No
Services are an extension of ED evaluation and stabilization services beyond the traditional two-to three-hour limit
Benefit better definition of the patient's problem with
reduction in both costs and inappropriate dispositions.
Ultimate goal improve the quality of medical
reducing inappropriate admissions and health care costs.
PROS : Allow additional time , extensive ED care before
discharge
Enlarge the emergency physician's scope of practice providing a longer period of time to observe the effects of ED treatments and changes in the patient's clinical condition;
Add an educational experience for medical students and residents that is not available in the traditional outpatient setting;
PROS : (Cont’) Reduce hospitalization and health care costs for some
patients , while allowing a more comfortable area for patient care;
Reduce the ED workload and improve patient flow;
Reduce physicians' liability risks by allowing more time to make difficult disposition decisions and, thus, allow more certainty of diagnosis. While the patient is still in an observation setting, outpatient management strategies can be initiated and examined to ensure appropriateness.
CONS:
Lack of clearly defined admission criteria, policies and procedures, and direct lines of command may prolong decision making and disposition
Dumping Area
An inadequately staffed facility will overload the emergency staff
CONS : (cont’)
Carelessly organized and equipped unit will be unacceptable to the patient because of commotion and lack of privacy
Patient care may suffer from the lack of continuity of care as emergency physicians change from one shift to the next if signout procedures are not followed.
Lack of control/agreement over extent of work up
sensitivity vs. specificity in the ED/ The Drive for Specificity
Stop Counting Visits and start counting “BED HOURS” We must get paid for what we do Time increases diagnostic accuracy EP can no longer be forced into ‘home vs
admit’ dichotomy
EDOBS/Rationale Why is this maxim true? Because we know that certain patients will
benefit From
FURTHER TESTING
F URTHER TREATMENT
More time will allow us to apply more specificity to the decision yielding a benefit to the patient, the institution and the professional staff
What are the important design features? The unit should be contiguous to the Emergency
Department▪ resuscitate any person who is admitted to the unit.
▪ cardiac monitoring
▪ IVAC capabilities
▪ inhalation therapy equipment, depending upon the unit.
curtain vs. cubicles vs. Rooms
real hospital beds
some provision for food
TV
The number of beds range from four to 20 beds on the unit
equal to 10% to 40% of the ED bed capacity
Both Physicians and Nurses need to have broad-based knowledge and experience in the management of a wide variety of disease processes
The average staff is one registered nurse per four to six patients in monitored beds and one registered nurse per six to nine patients in non-monitored beds
Calculations of the physician staffing for the amount of additional services will be approximately one full-time equivalent for every 2000 patients observed per year
ancillary personnel:
depend on the size and type of services
Adequate secretarial and clerical staff
Basic Rules
Have to be able to walk
Stable condition
80% chance of going home
Safety reasons
Social/Financial reasons
Pt. Satisfaction reasons
Role of age
a focused goal of the period of observation.
Low probability but high mortality
▪ Chest pain
▪ RIF pain
short-term therapy for an emergency conditions
▪ asthma
▪ dehydration
The intensity of service needs should be limited and consistent with the staffing pattern of the unit
the patient's severity of illness should be limited
one organ system
must not preclude the expectation that the patient will be discharged within established time limits
The patient should have a clinical condition that is appropriate for observation
Diagnostic Evaluation Short Term Therapy Psychosocial Needs
Abdominal Pain Allergic reactions Alcohol intoxication
Vaginal bleeding, threatened abortion
Asthma Adjustment reaction
Chest pain (low probability of myocardial infarction)
Acute exacerbation of chronic CHF Depression
Syncope, negative initial evaluation Dehydration Psychosis
Flank pain, rule-out renal colic Hyperglycemia, mild to moderate Social disposition problems
GI bleed with initial evaluation Hypertensive urgencies
Chest trauma, normal initial evaluation and chest X-ray
Selected infections (e.g., pyelonephritis)
Abdominal trauma, normal initial evaluation and lavage
Seizure disorder requiring anticonvulsant loading
Drug overdose, clinically stable Sickle cell pain crisis
Transfusion of blood
Physician can not identify a goal of patient care that can reasonably be expected to be met within a time limit
unstable vital signs
myocardial infarction
comatose condition
Discrete end-point yields success When observation beds are permitted Written policies and procedures address the
type of patient use
the maximum time period of use
the mechanism for providing appropriate surveillance
the type of nurse/patient system to be used
A time limit is most important and should be carefully monitored and strictly enforced.
Many ED observation unit have time limits of 12 or 24 hours.
An admission note
the reason for the period of observation
working diagnosis
treatment plan
clearly defining the end point for patient disposition is mandatory.
The ED personnel (physician, nurse, PA, etc.) should examine the patient and write regular progress notes.
“OBS resets the attention clock” And Reduces exposure to hazard by short LOS
Good studies for
Asthma
Chest Pain
Unstable Angina
A Fib
Same conclusion
Faster, Better, Cheaper
Marx: Rosen's Emergency Medicine, 7th ed.
CHAPTER 196 – Observation Medicine and Clinical Decision Units
American College of Emergency Physicians, www.acep.org
National Library of Medicine–National Institutes of Health, www.nlm.nih.gov