DECREASED HOSPITALIZATIONS AT THE COST OF INCREASED EMERGENCY DEPARTMENT RETURNS? OUTCOMES OF A CLINICAL DECISION UNIT

• Published in: Paediatrics & child health Vol. 22; no. suppl_1; p. e36
• Main Authors: Karacabeyli, D, Park, D, Meckler, G, Doan, Q
• Format: Journal Article
• Language: English
• Published: US Oxford University Press 01-06-2017
• Subjects: Abstracts / Résumés; Clinical decision making; Clinics; Decision making; Effectiveness; Emergency medical care; Hospitalization; Pediatrics
• ISSN: 1205-7088; 1918-1485
• DOI: 10.1093/pch/pxx086.091

Abstract
BACKGROUND: Within emergency departments (EDs), clinical decision units (CDUs) allow for protocol-driven treatment and observation of patients who are not ready for discharge after initial assessment and care. CDUs can serve as an alternative to short stay inpatient admission, optimizing hospital resource utilization. A CDU was established at our institution in October 2014 to reduce hospitalizations. Preliminary administrative data review, however, revealed a return to ED (RTED) rate of 15% following a CDU stay, 2-3 times the RTED rate reported in the literature. Whether this is the expected cost of reducing hospitalizations remains unclear. Research exploring root causes of RTED following a CDU stay is limited.
OBJECTIVES: Following a CDU stay, to determine 1) the number of potentially averted hospitalizations, and 2) the proportion of potentially preventable RTED.
DESIGN/METHODS: Retrospective cohort study of all ED visits with a CDU stay from Jan 1, 2015 to Dec 31, 2015. Following administrative database review, health records data was extracted and entered into standardized online forms by trained research assistants, then blindly evaluated by two investigators to determine: a) the most probable cause of each RTED; and b) the number of RTED that were clinically unnecessary.
RESULTS: 1503 (89%) of the 1696 index CDU visits were discharged home. Of these visits, 653 had a total ED length of stay of 8 hours or greater, thus were considered averted hospitalizations attributable to a CDU stay. However, 139 (9%) of the 1503 visits had ≥1 associated RTED. Among these, 48 (35%) were deemed clinically unnecessary (89% agreement, Kappa = 0.79) and therefore potentially preventable. The most common reason (88%) for unnecessary RTED was mismatch between expected natural progression of disease (not requiring ED reassessment or treatment) and families’ understanding of disease symptom range and duration. In 90% of these cases, anticipatory guidance regarding natural progression of disease was not provided to parents upon discharge.
CONCLUSION: The CDU potentially prevented several inpatient admissions, positively impacting patients and the healthcare system. A relatively high RTED rate, however, was observed, with 35% of RTED being deemed clinically unnecessary and 27% lacking adequate discharge instructions. The CDU’s effectiveness may therefore be further optimized through quality improvement initiatives targeting the ED discharge process.