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"It was set up and lo and behold, we got the length of stay down to 12 hours."
To Admit or Not to Admit
With emergency departments across the country seeing record numbers of patients, creative approaches are buying valuable evaluation time.

Howard County General Hospital's chest pain unit, says nurse manager Colleen Thornton, has significantly reduced unnecessary and expensive hospital admissions. The same is true at Hopkins Bayview, where a similar unit set up four years ago as part of the medical center's extended-stay unit means patients can be admitted without taking up scarce acute-care inpatient beds. "One of the biggest advantages," says Bayview ED Director Edward Bessman, "is that it allows us to identify individuals who you might not think have acute coronary syndrome, but in fact do."
When someone would come into the Emergency Department at Howard County General Hospital and say "chest pain," the word that followed was usually admission-as in admission to the hospital's intensive care or intermediate care unit. But many such patients, says Colleen Thornton, nurse manager for intermediate care, suffer symptoms that mimic cardiac chest pain, including muscular and respiratory problems. They need to be monitored, and not necessarily admitted to an expensive ICU.

"Not only were these admissions adding unnecessary costs to health care, but they were also taking up valuable intensive care space in the hospital," says Thornton, noting that fewer than half of the chest-pain admissions through the ED were actual cardiac-pain patients.

Looking at the numbers, Thornton and other Howard County staff came up with the idea for a short-stay unit that would give borderline chest-pain patients access to some of the high-tech monitoring found in an ICU. Should early tests show their chest pain was related to a problem not requiring hospitalization, they could be released within 12 hours. Thornton helped design and staff the 13-bed unit, producing a ratio of one nurse to every five or six patients, compared with the ICU ratio of one nurse for every two patients.

Initially, the lengths of stay were longer than Thornton had expected. Then she figured out that many patients were ready to go home earlier, but had to hang around because the cardiologists waited until after their clinic hours before reading patients' stress tests and releasing them. The solution? An improvement team suggested a computer link between the chest unit and the cardiologists' offices that would allow them to read test results.

"It was set up and lo and behold, we got the length of stay down to 12 hours," says Thornton. Of the 90 patients sent to the unit in one recent month, only 10 were admitted to the hospital; four patients were transferred to a higher-acuity hospital. On average, Thornton says, about 16 percent of chest pain patients in the short-stay unit are admitted to the hospital.

Because the chest-pain unit is usually only half full, other potential medical and surgical patients are sent to the unit from the ED for short-term management. Often, explains Thornton, patients may just need to be hydrated or nebulized, not admitted to the hospital.

"We had beds open so we thought, Why not deal with other diagnoses like abdominal pain, asthma, TIA?" says Thornton. She adds, "The unit works. Patients are happy, physicians are happy, staff love it. It's really exciting."

-Gary Logan



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