Clinical Unit In Ed By Saad AL Juma
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Clinical Unit In Ed By Saad AL Juma

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By Saad AL Juma

By Saad AL Juma

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    Clinical Unit In Ed By Saad AL Juma Clinical Unit In Ed By Saad AL Juma Presentation Transcript

    • By : Saad Al Juma R3
    •  Introduction  Objectives  Terminology  Rationale  Pros and Cons  Mechanics  Evidence  conclusion
    •  risks, benefits, and requirements to develop an ED observation unit or clinical decision unit  Recognize what is required to develop and manage these units and programs  Recognize the conditions that can be better managed through these programs
    •  ED Observation Unit (EDOBS)  Clinical Decision Unit (CDU)  Rapid Diagnostic Unit (RDU)
    •  dedicated area within or directly adjacent to the ED  defined nursing and physician staffing.  clearly defined written policies and procedures for management of certain medical problems within specific time limits. It must be provided with equipment and supplies appropriate for the kinds of patients treated.
    •  dedicated area within or directly adjacent to the ED  defined nursing and physician staffing.  clearly defined written policies and procedures for management of certain medical problems within specific time limits. It must be provided with equipment and supplies appropriate for the kinds of patients treated.
    •  dedicated area within or directly adjacent to the ED  defined nursing and physician staffing.  clearly defined written policies and procedures for management of certain medical problems within specific time limits. It must be provided with equipment and supplies appropriate for the kinds of patients treated.
    •  Clearly defined admission criteria  Well planned policies and procedures  Clear chain of command  Proper staffing, location, and equipment  Carefully developed programs for quality assurance and utilization review.
    •  What is the current context of Emergency Medicine?  Crowding / Increasing volume  Saturated inpatient bed capacity/ Decreasing access inpatient beds  EMS diversion  Problem with missed MIs, TIAs that return as a stroke, or door-to balloon times.  Increasing Length of Stay (LOS)
    •  No
    •  No
    •  Services are an extension of ED evaluation and stabilization services beyond the traditional two- to three-hour limit  Benefit  better definition of the patient's problem with reduction in both costs and inappropriate dispositions.  Ultimate goal  improve the quality of medical  reducing inappropriate admissions and health care costs.
    •  PROS :  Allow additional time , extensive ED care before discharge  Enlarge the emergency physician's scope of practice providing a longer period of time to observe the effects of ED treatments and changes in the patient's clinical condition;  Add an educational experience for medical students and residents that is not available in the traditional outpatient setting;
    •  PROS : (Cont’)  Reduce hospitalization and health care costs for some patients , while allowing a more comfortable area for patient care;  Reduce the ED workload and improve patient flow;  Reduce physicians' liability risks by allowing more time to make difficult disposition decisions and, thus, allow more certainty of diagnosis. While the patient is still in an observation setting, outpatient management strategies can be initiated and examined to ensure appropriateness.
    •  CONS:  Lack of clearly defined admission criteria, policies and procedures, and direct lines of command may prolong decision making and disposition  Dumping Area  An inadequately staffed facility will overload the emergency staff
    •  CONS : (cont’)  Carelessly organized and equipped unit will be unacceptable to the patient because of commotion and lack of privacy  Patient care may suffer from the lack of continuity of care as emergency physicians change from one shift to the next if signout procedures are not followed.  Lack of control/agreement over extent of work up  sensitivity vs. specificity in the ED/ The Drive for Specificity
    •  Stop Counting Visits and start counting  “BED HOURS”  We must get paid for what we do  Time increases diagnostic accuracy  EP can no longer be forced into ‘home vs admit’ dichotomy
    •  EDOBS/Rationale  Why is this maxim true?  Because we know that certain patients will benefit From  FURTHER TESTING  F URTHER TREATMENT  More time will allow us to apply more specificity to the decision yielding a benefit to the patient, the institution and the professional staff
    •  What are the important design features?  The unit should be contiguous to the Emergency Department ▪ resuscitate any person who is admitted to the unit. ▪ cardiac monitoring ▪ IVAC capabilities ▪ inhalation therapy equipment, depending upon the unit.  curtain vs. cubicles vs. Rooms  real hospital beds  some provision for food  TV
    •  The number of beds range from four to 20 beds on the unit  equal to 10% to 40% of the ED bed capacity
    •  Both Physicians and Nurses need to have broad-based knowledge and experience in the management of a wide variety of disease processes
    •  The average staff is one registered nurse per four to six patients in monitored beds and one registered nurse per six to nine patients in non-monitored beds  Calculations of the physician staffing for the amount of additional services will be approximately one full-time equivalent for every 2000 patients observed per year
    •  ancillary personnel:  depend on the size and type of services  Adequate secretarial and clerical staff
    •  Basic Rules  Have to be able to walk  Stable condition  80% chance of going home  Safety reasons  Social/Financial reasons  Pt. Satisfaction reasons  Role of age
    •  a focused goal of the period of observation.  Low probability but high mortality ▪ Chest pain ▪ RIF pain  short-term therapy for an emergency conditions ▪ asthma ▪ dehydration
    •  The intensity of service needs should be limited and consistent with the staffing pattern of the unit
    •  the patient's severity of illness should be limited  one organ system  must not preclude the expectation that the patient will be discharged within established time limits
    •  The patient should have a clinical condition that is appropriate for observation
    • Diagnostic Evaluation Short Term Therapy Psychosocial Needs Abdominal Pain Allergic reactions Alcohol intoxication Vaginal bleeding, threatened Asthma Adjustment reaction abortion Chest pain (low probability of Acute exacerbation of chronic CHF Depression myocardial infarction) Syncope, negative initial evaluation Dehydration Psychosis Flank pain, rule-out renal colic Hyperglycemia, mild to moderate Social disposition problems GI bleed with initial evaluation Hypertensive urgencies Chest trauma, normal initial Selected infections (e.g., evaluation and chest X-ray pyelonephritis) Abdominal trauma, normal initial Seizure disorder requiring evaluation and lavage anticonvulsant loading Drug overdose, clinically stable Sickle cell pain crisis Transfusion of blood
    •  Physician can not identify a goal of patient care that can reasonably be expected to be met within a time limit  unstable vital signs  myocardial infarction  comatose condition
    •  Discrete end-point yields success  When observation beds are permitted  Written policies and procedures address the  type of patient use  the maximum time period of use  the mechanism for providing appropriate surveillance  the type of nurse/patient system to be used
    •  A time limit is most important and should be carefully monitored and strictly enforced.  Many ED observation unit have time limits of 12 or 24 hours.
    •  An admission note  the reason for the period of observation  working diagnosis  treatment plan  clearly defining the end point for patient disposition is mandatory.  The ED personnel (physician, nurse, PA, etc.) should examine the patient and write regular progress notes.
    •  “OBS resets the attention clock” And Reduces exposure to hazard by short LOS
    •  Good studies for  Asthma  Chest Pain  Unstable Angina  A Fib  Same conclusion  Faster, Better, Cheaper
    •  Marx: Rosen's Emergency Medicine, 7th ed.  CHAPTER 196 – Observation Medicine and Clinical Decision Units  American College of Emergency Physicians, www.acep.org  National Library of Medicine–National Institutes of Health, www.nlm.nih.gov