Our Clinical Decision Unit works to cut time in the ER, save money and reduce hospital admissions
By Kristy Bleizeffer Jan 26, 2017
Scenario: A man reports to the Emergency Room with mild chest pain. ER docs determine he is not suffering a full heart attack, but want to watch him for several hours to run more tests.
In the meantime, several more people report to the ER with injuries and illnesses with varying degrees of seriousness. Critical care beds in the ER fill up, and doctors and nurses work to save patients with life-threatening conditions.
What happens to the man with mild chest pain?
In many hospitals, the man waits for his tests, sometimes for hours, in one of the most expensive beds.
At Wyoming Medical Center, that man now may be sent to the Clinical Decision Unit. There he can wait for his test results in a room that is quieter and less expensive while receiving more individualized care.
Our CDU is a designated unit providing an alternative to discharge or hospital admission. It is for patients who may benefit from an extended period of testing, evaluation, treatment and/or observation (not more 24 hours).
“I call it medical purgatory,” said Andy Dunn, M.D., medical director. “It’s for people in the ER who need a little bit more time for evaluation or treatment. They can come to the CDU and we can prepare them for discharge or admittance to the hospital. Overall, it leads to shorter stays in the hospital and, actually, fewer admissions.”
What was the need for this kind of unit?
The CDU relieves pressure on staff and resources during high-volume periods in the ER while also reducing lengths of stay in the ER for many patients.
“We have protocols for falls and some medications, for example, that require 14 to 16 hours of observation,” Dunn said. “If that observation is done in the ER, the patient is taking a critical care bed that is both more expensive and resource intensive.”
What are the advantages?
“A lot of larger hospitals in the country have established CDUs and found that they reduce bounce backs and readmission rates,” Dunn said. (“Bounce back” refers to patients who are discharged and report back to the ER within a day or two for the same issue.)
Other advantages include:
- The CDU is designed to reduce unnecessary hospital admissions while avoiding premature discharges. For example, chest pain observation units have been shown to reduce the number of patients admitted to the hospital by 17 percent while reducing patients discharged with acute coronary syndrome by 8 percent.
- CDUs have been shown to reduce healthcare costs by reducing unnecessary admissions, cutting readmissions and cutting the amount of unnecessary tests and treatments.
- It also takes some non-critical patients out of the Emergency Room, one of the hospital’s most expensive units, for diagnosis in a lower-cost setting. This saves money for the patient.
- The CDU frees up Emergency Department nurses, physicians, staff and beds for patients who are critically injured or ill.
What patients qualify for the CDU?
Patients may be admitted to the CDU from the Emergency Department, as a direct admit from their primary care provider’s office, following a surgical procedure or after a cardiac catheterization.
For example, your primary care doctor could admit you directly to the CDU for a quick treatment that would allow you to bypass the ER altogether.
Good candidates include patients who require more time for a test to come back or a period of observation and/or treatment to determine if their condition is improving or getting worse. These include patients with the following diagnoses:
- allergic reaction
- chest pain/possible acute coronary syndrome
- COPD exacerbation
- deep vein thrombosis
- dehydration or vomiting/diarrhea
- other conditions
How does it affect patient outcomes?
About 80 percent of the patients seen on the CDU go home within the 24-hour period. Only a small set of those are admitted to the hospital. “That percentage is drastically different than what we see in the emergency room,” Dunn said. “From that aspect, patient outcomes improve because they get to go home and people just heal better at home.”
The CDU is able to provide fast, efficient care for a set diagnosis list. It’s also a more comfortable room for patients and families.
“The bed alone in the ER is not very comfortable. It can be very chaotic. The sooner they can go to their own, more private room, it’s better for stress,” Dunn said.
“It’s easier for the nurses too. The nurses in the ER are flying. You have someone coming in with a full cardiac arrest or a traumatic injury, and it’s hard for them to make individual time for a patient who is under observation or with less emergent needs.”
Who cares for patients on the CDU?
The care team on the CDU – including registered nurses, certified nursing assistants, case managers and other care staff – are under the supervision of unit physicians or family nurse practitioners. These are mainly providers from Mesa Primary Care who manage many of these same conditions in their regular patient panel.
“A lot of them did their training at Wyoming Medical Center or worked here for many years, so they enjoy being back in the hospital setting for a few shifts,” Dunn said. (Dunn is also medical director of both Mesa and Sage Primary Care.)
This is especially beneficial for continuity of care and getting patients to the right specialists for follow-up care, if needed.
Dr. Andy Dunn is board certified in family medicine, and is medical director of Mesa Primary Care and Sage Primary Care.
After working as a Wyoming Medical Center hospitalist for several years, Dr. Dunn transitioned to family practice to form deeper, more long-term relationships with his patients.
Dr. Dunn grew up in Denver and became interested in medicine after completing a semester of EMT training as part of a volunteer fire department EMS team. He relished the chance to really help people in need.
“This sounds corny, but I love the Norman Rockwell approach to medicine. There is a painting where the doctor is listening to a young child’s doll with his stethoscope, and that has always kind of stuck with me,” he said. “I feel very fortunate to be in that kind of setting, to help someone when they need it.”
As a medical student, he completed a four-week rotation at Wyoming Medical Center and fell in love with the hospital and the community. He completed his residency in Casper and stayed here as a WMC hospitalist. He is excited to help establish primary care practices focused on preventative medicine for the whole community.
“I love treating families,” he said. “I love kids. I love grandparents and everyone in between. To treat a family is a huge honor and a huge blessing.”
Dr. Dunn is married and has two children.