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Emergency Department Clinical Decision Unit (48.5)

Emergency Department Clinical Decision Unit (48.5) - Policies, Clinical, UWHC Clinical, Department Specific, Emergency Department

48.5





Effective Date:
Month 11/1/2016

ED Policy Manual

Policy #:
_48.5_____

X Original
Revision

Page
1
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Title: Emergency Department
Clinical Decision Unit


1

Emergency Department Clinical Decision Unit


I. Outline of Policy
a. Purpose of the Clinical Decision Unit (CDU)
b. CDU Patient Selection
c. Patient Admission and Management In The CDU
d. CDU Staffing
e. CDU Documentation
f. CDU Quality Management and Utilization Review

Appendix A: Approved Protocols for the CDU

II. Purpose of the Clinical Decision Unit (CDU)
Emergency Department (ED) patients often require services beyond their initial
ED course. This includes, but is not limited to, further testing, additional treatment,
and continued observation and re-evaluation. The Clinical Decision Unit is an ED
managed unit that may provide additional services to actively manage patients
following their initial ED care. Patient care is expected to be largely protocol driven
(See section for Approved Protocols for the CDU).
Patients’ admission to the CDU will be determined by the ED Attending physician
based on clinical needs and resource availability. The goal is to provide
continuation of care while decreasing inappropriate discharges or inpatient
admissions. The CDU will not be a holding area for patients awaiting disposition to
an inpatient care unit or transfer to another facility (i.e. boarded patients).

III. CDU Patient Selection

CDU patient selection will be based on the clinical judgment of the ED Attending
caring for the patient and the assigned CDU Emergency Medicine (EM) Physician. It
is the expectation that the patient will be discharged within 18 hours from
admission to the CDU. If a patient is not discharged within 18 hours, inpatient
admission will need to be pursued.

a. The plan of care should be focused, defined, and with a clear end point
stated. Patients should have only one acute problem with a well-defined
plan to address this problem (See Appendix A for CDU Protocols).
b. Patients to be generally excluded from the CDU will include those listed
below:





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i. Patients who are at risk of self harm or are disruptive. This may
include patients who are suicidal, acutely psychotic or inebriated
due to drugs or alcohol
ii. Patients who are high risk for acute deterioration.
iii. Patients with anticipated CDU length of stay less than 4 hours or
greater than 24 hours.
iv. Patients with an acute gait disturbance or inability to ambulate to
the bathroom.
c. The CDU EM Physician ultimately makes patient eligibility final
determination for CDU admissions.

IV. Patient Admission and Management in CDU

The following is a stepwise approach to the process by which patients are
admitted to the CDU:

a. ED Attendings are responsible for first identifying specific patients in the
ED for admission to the CDU.
b. When a patient is deemed appropriate for a CDU admission, the ED
Attending caring for the patient will contact the CDU EM Physician to
confirm eligibility. The ED Attending will also contact the advanced
practice provider (CDU APP) and the nurse staffing the CDU to aid in
transitioning care from the ED to the CDU.
c. Following notification to the CDU APP, the ED Attending will place an
“admit to observation” order.
d. The ED nurse will transition care to the CDU nurse at the time of transfer
to the CDU.
e. ED physician documentation indicating the need for admission to the CDU
is to be completed prior to transferring patient to assigned CDU room.
f. The CDU care team ensures treatment plans for the patients in the CDU
are carried out.
g. The CDU RN will keep CDU Attending informed of significant patient
management issues and changes in condition.
h. In the event should a patient become unresponsive and in a life
threatening circumstance initiate the following procedure: Call 262-0000
for Code Blue and give location of individual. The response team will be
paged overhead with chimes and on pager as appropriate, as “Adult Code
Blue to Emergency Department CDU Room ( )on the second floor.”
This process will provide additional resources as well as alert the house
supervisor for expediting an ICU bed placement, as appropriate.





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Title: Emergency Department
Clinical Decision Unit


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i. The CDU care team will be responsible for assessing and reassessing
patients in the CDU and, as dictated by patient care needs, determining
disposition of patients following completion of patient care, further
treatment, results of further testing, prolonged observation, or change in
the patient’s condition.
j. The CDU care team will facilitate hospital admissions for patients
requiring further inpatient treatment.


V. CDU Staffing
a. The CDU EM Physician assigned to the CDU will be the South Side
Attending. Any ED Attending may admit patients to the CDU. The ED
Attending who makes the decision to admit their patient to the CDU will
be responsible for the care of that patient in the CDU up to the completion
of his/her shift. At end of shift, ED Attendings who have admitted
patients to the CDU will hand off care of these CDU patient to the CDU EM
Physician.
I. The CDU EM Physician is responsible for rounding in the CDU as
detailed below:
1. The South Side Day Attending scheduled for the 7am-4pm
shift will present to the CDU at 7am to round on all patients
in the CDU with the assistance CDU APP.
2. The South Side Evening Attending scheduled for the 3pm –
12am will round on the CDU at 3pm with the CDU APP and
also with the 3pm-12am Senior EM Resident.
3. The South Side Overnight Attending scheduled from 12am
– 9am will receive handoff from the Evening Attending
during board rounds.
b. CDU APP’s will work under direct supervision of the appropriate
attending and facilitate patient care, often as detailed by specific,
predetermined protocols. APP’s will also be responsible for facilitating
discharge and documentation of discharge for patients at the completion
of their CDU stay.
I. There will be two CDU APP shifts daily as detailed below. APP’s
will have oversight for the CDU daily from 6am to 12pm.
1. The CDU APP Day shift will be from 6am-3pm. The APP on
this shift will be responsible for pre-rounding on CDU
patients in preparation for the South Side Day Attending
rounds at 7am.





Effective Date:
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ED Policy Manual

Policy #:
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2. The CDU APP Evening shift will be from 3pm-12pm. The
CDU Evening APP will receive handoff of the CDU from the
CDU Day APP and during afternoon rounds with the South
Side Evening Attending and Senior, 3pm-12am, EM
Resident. At end of his/her shift, the CDU APP will handoff
care of patients in the CDU to the South Side Overnight
Attending.
c. CDU Nurses will be assigned to the CDU as patient census dictates and as
determined by nursing managers.


VI. CDU Documentation
A. Medical Providers documentation

i. ED Provider Note:
Documentation, which details the reason for CDU admission, must be completed
prior to patient transfer to the CDU. Progress notes should be written based on
patient need for intervention changes in condition, or at times of handoff/transition
of care. All CDU patients must also have a Discharge Summary. Guidelines for these
three forms of documentation are as follows:
a. History of Present Illness (HPI) – should include all
medically necessary characteristics/modifiers (i.e. –
location, quality, severity, duration, timing, context,
modifying factors, and associated signs and symptoms).
b. Past Medical, Family, and Social History (PFSH) – for
observation services findings from all three of these
components must be documented when medically
necessary.
c. Review of Systems (ROS) –all medically necessary
components of ROS should be reviewed and documented.
d. Physical Exam – should be comprehensive and all medically
necessary elements of the examination should be
performed and documented.
ii. Progress notes - Progress notes may be entered separately or as
an addendum to the initial observation note.
a. Patients in the CDU 18 hours after acceptance must have a
progress note addressing the course of action for admission
to inpatient or discharge to home.





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iii. Discharge (DC) Summary – A complete H&P similar to the initial
observation H&P should not be repeated however, the DC
summary should contain the following:
a. Final examination
b. A description of clinical care provided while under
observation.
c. Medical decision-making and final diagnosis.
d. Plans for ongoing/next step care.
e. Length of time in observation
B. Nursing Documentation
i. A Hand-off will occur between the ED nurse and the CDU nurse, as
care is transitioned to the CDU and the CDU nurse will perform a
focused assessment for the patient based on their chief complaint
and medical condition.
ii. Patient condition and status updates will be documented by the
CDU nurse as needed. Documentation will be a continuation of
the ED visit. Ongoing nursing documentation and progress notes
in the medical record must include patient assessments related to
the diagnosis upon assignment to observation Status.
iii. Assessment of patient status is required and documented for each
2-hour period the patient is in observation Status.
iv. Appropriate and timely interventions and therapeutic services ,
based upon patient condition, are documented by the CDU nurse.
v. CDU Patients’ medication administration record and medication
history is documented by CDU nurse
vi. The CDU nurse will notify the CDU APP or CDU physician of
patient condition changes including abnormal vital signs in
accordance with the ED vital sign policy.
vii. The CDU nurse will round with the ED physician and CDU APP.
viii. The CDU nurse will request disposition when protocol endpoint is
reached, when patient needs to be admitted or discharged, or
when length of stay (LOS) reaches 18 hour.
ix. If the patient is admitted to inpatient services, the CDU nurse will
complete the SBAR transfer note for general care patients or
verbally communicate the hand-off report for intermediate or ICU
patients


VII. CDU Quality Management and Utilization





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Policy #:
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To ensure appropriate usage of the CDU, careful monitoring of utilization will be
conducted on a regular basis.
i. Utilization review will include the following:
a. Review of the utilization of the specific protocols under
which patients are admitted to the CDU.
b. Measure of the arrival and departure volumes by hour of
the day.
c. Measure of CDU occupancy by hour of the day.
d. Measure of average length of stay for each specific protocol.
e. Time of arrival and departure will be collected
f. Data will be reviewed at the monthly data reporting
sessions with ED Leadership
ii. The following flags will trigger independent quality management
reviews:
a. Cases raised as specific concerns by patients, staff, and
consultants.
b. Cases in which a patient admitted to the CDU, is discharged
home, and returns to ED with subsequent admission to an
inpatient service or CDU within 7 days of initial discharge.
c. Any case in which CDU length of stay exceeds 24 hours.
d. Any case in which a patient admitted to the CDU is
subsequently admitted to the hospital.
e.
Appendix A (attached): Approved Protocols for the CDU

References

Brigham and Women’s Hospital, Department of Emergency Medicine, Emergency
Department Observation Units Policy and Procedure Manual. – Mar, 2014

Emergency Nurses Association position statement: Observation units/clinical
decision units. Developed 1989; latest update 2011

Graff, LG. Observation Medicine, The Healthcare System’s Tincture of Time. www.
acep.org, 2011

Ross, M et al. Emory University School of Medicine, Department of Emergency
Medicine, Clinical Decision Unit Manual – 2012






Effective Date:
Month 11/1/2016

ED Policy Manual

Policy #:
_48.5_____

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Title: Emergency Department
Clinical Decision Unit


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Ross, M et al. “State of the Art: Observation Units in the Emergency Department.”
Polciy Resource and Education Paper. www.acep.org – 2011

UWHC Administrative policy: Emergency Response Teams, Policy # 7.36. Accessed
October 10, 2016

UWHC Administrative policy: Patient status and observation patient management #
1.03. Accessed October 19, 2016

Turturro, M. “Documentation Guidelines for Emergency Physicians Providing
Observation Services.” www.acep.org

Reviewed by:

ED CDU Workgroup
ED Clinical Nurse Specialist
ED Clinical Operations committee
ED Co-Managers
ED Medical Director



SIGNED BY:

Joshua Ross, MD
Associate Vice Chair
Department of Emergency
Medicine
Mike Safa, MD
Medical Director
Emergency Department
Anne Rifleman, RN, MSN,
Interim Director
Emergency Department

















Effective Date:
Month 11/1/2016

ED Policy Manual

Policy #:
_48.5_____

X Original
Revision

Page
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of
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Title: Emergency Department
Clinical Decision Unit


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Appendix A: Approved Protocols for the CDU


1. Chest pain
2. Asthma/COPD
3. Cellulitis
4. Vomiting/Dehydration
5. Pyelonephritis
6. Abdominal Pain
7. Pneumonia
8. Syncope
9. Minor Head Trauma
10. TIA
11. DKA
12. Allergic Reaction/Angioedema