CLINICIAN’S CAPSULE
What is known about the topic?
Clinical decision units (CDUs) may reduce short-stay hospitalizations (<48 hours), which are associated with longer lengths of stay, increased staffing needs and higher costs.
What did this study ask?
What are the disposition outcomes and emergency department (ED) return rates following CDU care? Has CDU implementation changed short-stay hospitalization rates?
What did this study find?
Most CDU patients were discharged, and short-stay hospitalization rate significantly decreased by 0.39% with CDU implementation.
Why does this study matter to clinicians?
The CDU may reduce short-stay hospitalizations, and is a safe care option for pediatric patients requiring prolonged ED care.
INTRODUCTION
Approximately one-third of inpatient admissions from the pediatric emergency department (PED) result in a short hospitalization (<48 hours in duration).Reference Macy, Stanley and Lozon 1 Inpatient admission is associated with a longer length of stay (LOS) and increased staffing needs and costs compared to PED observation.Reference Macy, Stanley and Lozon 1 Alternative care settings may reduce the number of short-stay inpatient admissions,Reference Macy, Stanley and Lozon 1 and one such setting is a clinical decision unit (CDU).Reference Barata, Brown and Fitzmaurice 2 CDUs are special care areas within the PED that provide protocol-driven treatment and observation for up to 24 hours for patients who may not require hospital admission but are not ready for discharge.Reference Zebrack, Kadish and Nelson 3 We established a CDU at the BC Children’s Hospital (BCCH) PED in October 2014 as a quality improvement initiative. Given the paucity of Canadian pediatric CDU data, we conducted a descriptive analysis to describe disposition decisions and ED return (EDR) rates following CDU care and changes in short-stay (<48 hour) hospitalization rates after CDU implementation.
METHODS
Study design, setting, and population
This retrospective cohort study of all PED visits with a CDU stay was performed at the BCCH PED, the only quaternary care pediatric referral centre in British Columbia. Our four-bed CDU is open 24 hours daily and functions as a separate unit within our PED. It is staffed by one nurse and one nurse practitioner (when available) or a pediatric emergency physician who oversees disposition decisions. CDU admissions are limited to patients who require prolonged ED LOS and are expected to be safe for discharge within 24 hours, the maximum allowed LOS. CDU admission is accompanied by a pre-printed order sheet completed by the admitting ED provider. A CDU option is integrated into certain care paths such as our PED asthma pathway that have standardized reassessment periods. Our CDU does not accept PED overflow or boarded patients awaiting admission. We reviewed all PED visits from January 1, 2015, to December 31, 2015. The study protocol was approved by the University of British Columbia, Children’s and Women’s Health Centre Research Ethics Board.
Study protocol
We collated the administrative data that summarized the patient demographics, triage acuity, chief complaint, discharge diagnosis, disposition, total PED LOS, and CDU LOS for all CDU admissions and then identified patients who had EDR within seven days. Trained research assistants performed the chart review and entered the visit characteristics, physician findings, management, and personalized discharge instructions into an online research electronic data capture (REDCap) database.Reference Harris, Taylor and Thielke 4
Two trained investigators reviewed the clinical information to determine if the return visits were clinically related to their index CDU visit by assessing whether the revisit presentation fell within the spectrum of illness that was diagnosed on the index visit or if new health care needs arose partly or wholly because of care received during the index visit. All cases were reviewed in duplicate, and disagreements were settled by a third investigator.
Measures
Primary outcome measures were patient disposition following CDU stay and EDR rate. Secondary outcomes included PED utilization (total PED and CDU LOS), CDU diagnostic case mix, and rates of short-stay hospitalization (LOS <48 hours) before and after CDU implementation (2013 v. 2015). Total PED LOS was defined as the time from triage to PED disposition (discharge, admit, or other). CDU LOS was defined as the time from CDU admission to PED disposition and was included within total PED LOS.
RESULTS
Of the 46,706 PED visits in 2015, 1,696 (3.6%) received CDU care. The median CDU occupancy was 25%, and 1,503 (89%) patients were discharged, with 190 (11%) admitted and 3 (0.2%) who left against medical advice. Of the 1,503 discharged patients, 157 had return ED visits within seven days, and 139 of the 157 revisits were clinically related to their index CDU visit (inter-rater agreement 97%, kappa 0.85), yielding an EDR rate of 9.2%. The CDU patient and visit characteristics are shown in Table 1.
Table 1. CDU index visit characteristics by disposition outcomes
CDU=clinical decision unit; CDU LOS=CDU admission time to the pediatric emergency department disposition time; CTAS=Canadian Triage and Acuity Scale; EDR=a clinically related return visit to the pediatric emergency department within seven days of the index visit; IQR=interquartile range; SD=standard deviation; PED LOS (CDU LOS-inclusive)=pediatric emergency department triage time to pediatric emergency department disposition time.
* Three patients left against medical advice from the CDU (1,503 discharged + 190 admitted + 3 left AMA=1,696 disposition outcomes).
The median (IQR) CDU LOS was 4.4 hours (2.7–7.8), and the total PED LOS including CDU was 7.8 hours (5.4–12.0) (Table 1). Asthma was the most common condition in our CDU, representing 31.3% of all diagnoses (Table 1). The short-stay (<48 hour) hospitalization rate fell from 3.62% in 2013 to 3.23% in 2015, a difference of 0.39% (95% CI 0.15–0.63, p=0.001).
DISCUSSION
We found that 89% of our CDU population was discharged, with an EDR rate of 9.2%, which is consistent with EDR rates reported elsewhereReference O'Brien, Hein and Sly 5 - Reference Cator, Weber, Lozon and Macy 8 but higher than the 7.3% EDR rate for our PED overall. Nearly one-half of our CDU population had asthma, allergy/anaphylaxis, or concussion/traumatic brain injury. Each of these conditions has protocol-driven observation periods from two to six hoursReference Ortiz-Alvarez and Mikrogianakis 9 – Reference Kuppermann, Holmes and Dayan 11 that may explain our median CDU LOS of 4.4 hours, which is shorter than previous reports.Reference Macy, Kim, Sasson, Lozon and Davis 12 Short-stay inpatient admissions fell significantly after CDU implementation; however, the difference was small, and other factors may have contributed.
CONCLUSION
CDU is a safe care option for PED patients requiring prolonged ED care; however, the cost-effectiveness and impact on other hospital operations are unclear based on this retrospective study of one site.
Acknowledgements
We would like to acknowledge the contribution of the trained research assistants, Vivian Lee, Paula Gosse, and Ally Slattery, and the research coordinators, Karly Stillwell and Greg Georgio.
Competing interests
This research received no specific grant from any funding agency, commercial, or not-for-profit sectors. QD is supported by a Michael Smith Foundation for Health Sciences Scholars salary award. The authors have no conflicts of interest.
