When the hospitalist-run short-stay unit (SSU) debuted at Cook County Hospital in Chicago seven years ago, a dearth of clinical research made it difficult to show the efficacy of such programs. Only a handful of such studies existed, and none had been conducted in the U.S. So while the hospitalists behind the nascent Cook County SSU thought their approach worked, Brian Lucas, MD, FHM, MS, wanted more evidentiary proof.
“We accept patients the emergency department sends to us without argument,” says Dr. Lucas, a hospitalist in the Department of Medicine at Cook County. “We wanted to be able to convey to the ED docs with data what kind of patients actually are best suited for the short-stay. We didn’t want it to be anecdotal or based on hunches a couple of us had. … We thought it would be nice to contribute something to the literature.”
Now they have.
Their prospective, observational, cohort study, “A Hospitalist-Run Short Stay Unit: Features that Predict Length-of-Stay and Eventual Admission to Traditional Inpatient Services,” can be found in the May-June Journal of Hospital Medicine. The study found that 79% of 738 eligible patients had successful SSU stays. Success was defined as discharge from the unit within 72 hours without admission to a general hospital unit.
The authors also found that in a multivariable model, the provisional diagnosis of heart failure predicted stays of longer than 72 hours (P=0.007), but risk assessments were unimportant. Patients who received specialty consultations were most likely to need eventual admission, and the likelihood of long stays was inversely proportional to the accessibility of diagnostic tests.
“In our hospital-run SSU, the inaccessibility of diagnostic tests and the need for specialty consultations were the most important predictors of unsuccessful stays,” the authors concluded. “Designs for other SSUs that care for mostly low-risk patients should focus on matching patients’ diagnostic and consultative needs with readily accessible services.”
—Brian Lucas, MD, FHM, MS, hospitalist, Cook County Hospital, Chicago
Dr. Lucas thinks the study could help HM groups establish or refine hospitalist-led SSUs and understand the best way to administer programs. He also points out that minimal funding was needed to complete the review, as the study mostly required the time of participating hospitalists to record their own data.
“Hospitalists are increasingly involved with quality-improvement projects at their hospitals,” Dr. Lucas says. “In order to actually decide whether it’s working right, you need data, and usually data costs a lot of money. In this case, it was free.”
Cook County’s 14-bed SSU was formed in 2002, when the hospital moved into new facilities and reduced its bed count from about 650 to 500. The decreased number of beds led to the short-term unit approach to handle potential overflows and diagnoses that required shorter lengths of stay. Dr. Lucas ran the unit at inception and later handed it off to Rudolf Kumapley, MBChB, its current medical director.
But questions on the operational parameters of the unit arose quickly. What types of admissions should the SSU allow? What risk levels would it focus on? And because one of the main benefits of an SSU is to alleviate pressure and backlogs in the ED, how should the wants of ED physicians be balanced against the success rate of the SSU?
“This was an extremely useful unit,” Dr. Kumapley says, and he thought, “Why don’t we get ourselves some data?”