Introduction: A clinical decision unit (CDU) is an area within the emergency department (ED) that allows for protocol-driven treatment & observation of patients who may not require hospital admission, but are not ready for discharge after initial assessment & treatment. A CDU was established at BC Children’s Hospital in 2014 as a means to optimize hospital resource utilization. Preliminary administrative data review revealed a return to ED (RTED) rate of 15% following a CDU stay, 2-3 times the RTED rate reported in the literature. Whether this is the expected cost of reducing hospital admissions remains unclear. Research exploring the underlying reasons for RTED following a CDU stay is limited. Objectives: Following a CDU stay, to describe 1) disposition outcome distribution; 2) underlying reasons for RTED; and 3) the proportion of potentially preventable RTED. Methods: Retrospective cohort study of all ED visits with a CDU stay from Jan 1, 2015 to Dec 31, 2015. Health records data was extracted & entered into standardized online forms by trained research assistants, then blindly reviewed by two investigators to determine a) the most probable cause of each RTED & b) the number of RTED that were clinically unnecessary. Results: Of the 1696 index CDU visits, 1503 (89%) were discharged home. However, 139 (9%) had ≥1 associated RTED. Among these, 48 (35%) were deemed clinically unnecessary (89% agreement, Kappa=0.79) & therefore potentially preventable. The most common reason (88%) for unnecessary RTED was mismatch between expected natural progression of disease (not requiring further medical assessment or treatment) & families’ understanding of disease symptom range & duration. In 90% of these cases, anticipatory guidance regarding natural progression of disease was not communicated to parents upon discharge. Among the remaining 1364 (91%) that did not return, 750 had an initial visit total ED length of stay of >8 hours, thus were considered averted hospitalizations attributable to the CDU. Conclusion: The CDU has had a positive impact on patient & system outcomes through the prevention of several inpatient admissions. However, we observed a relatively large proportion of RTED, 35% of which were clinically unnecessary & 27% of which had inadequate discharge instructions. This highlights opportunities to further optimize the effectiveness of the CDU through quality improvement initiatives focusing on the ED discharge process.
Undiagnosed Diabetes in Patients Admitted to a Clinical Decision Unit from the Emergency Department: A Retrospective Review
