To Admit or Not to Admit
With emergency departments across the country seeing record numbers of patients, creative approaches are buying valuable evaluation time.
"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."