While ED physicians can be admitted to the SSU without approval of a unit-assigned physician, Cook County’s departments of medicine and emergency medicine have promoted five guidelines for admission, although none are statutory:
- Patients should have anticipated stays of less than 72 hours;
- Patients should not be expected to require traditional inpatient services;
- Patients with provisional cardiovascular diagnoses should be preferentially admitted to the SSU over general medical units;
- No patients should be admitted with a risk level higher than intermediate; and
- Patients shouldn’t require advanced ancillary services, including bedside procedures, time-intensive nursing, and complex social services.
Once the study began, attending physician investigators would interview, examine, and review the health records of enrolled patients within 12 hours of admission to the unit. When diagnoses included possible acute coronary syndrome (ACS) or decompensated heart failure, additional data was gathered. ACS and decompensated heart failure are two of the most common provisional diagnoses admitted to the SSU, in large part because the unit is equipped with continuous telemetry monitors, a treadmill testing laboratory, and other reserved cardiac tests.
“We built an online database that allowed the physicians to enter the data on all of their patients in real time,” Dr. Lucas explains. “We didn’t have any research assistants. We gathered all the data ourselves.”
Length of Stay
Of the 21% of unsuccessful stays, the most common reason was a hospital length of stay (LOS) longer than 72 hours (71% of 156 patients), although the median LOS was 42 hours. Sixty-six patients eventually required traditional inpatient services, nearly half of those after a specialty consult. The study concluded that the types of services patients received during their SSU stays were stronger predictors of success than the patients’ characteristics upon admission.
“I was surprised by some of the findings, in the sense that I’ve worked and I’ve seen the kind of patients that are admitted into ED-run short-stay units … and for the most part, that is observation medicine,” Dr. Lucas says. “I got the immediate sense in our unit you’re actively managing sick patients. They’re just discharged within 72 hours.
“One of the whole reasons to have hospitalists run this unit, as opposed to ED docs, is because the hospital should be able to handle any diagnoses that come their way because they’re handling any diagnoses that come their way upstairs. But the ED doctors are more limited in what they’re able to do.”
Dr. Kumpaley adds that the hospitalist-run SSU works best when there is open communication between ED physicians who are doing the admitting and SSU physicians who must deal with the repercussions of those decisions.
In the case of a hospitalist-run unit, the earlier the two departments start a dialogue, the more successful the unit will be in determining whether patients should be admitted to the SSU in the first place, Dr. Lucas says.
“Every time you have to hand off a patient to a new doctor, there’s risk involved,” he says. “One of the ideas of HM right now is how transitions should be improved upon. The best way to improve on care transitions is to make them unnecessary altogether.” TH