ED throughput too slow? A short-stay unit may help

Key takeaways:

• How a short-stay unit differs from an observation unit
• How a hospitalist-run short-stay unit can improve ED throughput
• What diagnoses can be treated in an SSU

CHANCES ARE, YOUR ED is over-crowded and even swamped with “boarders,” patients who’ve been admitted but who can’t yet access a bed. That chronic condition, studies show, is associated with worse patient outcomes and more hospital diversions.

So how can you improve ED throughput? One idea at Atlanta’s Grady Memorial Hospital, which is staffed by Emory School of Medicine faculty, was to create a short-stay unit that hospitalists would staff to treat medically complex patients who come in with relatively simple acute medical issues. First floated in 2021, the short-stay unit (SSU) opened in October 2022.

In a write-up published last fall in the Journal of Hospital Medicine, authors from Grady posted the following unit results: Compared to non-SSU medicine patients, the median time for patients admitted to the short-stay unit from admission order placement to the patient leaving the ED (or checking into a unit) fell from 720 minutes to 207 minutes—a 71% gain in efficiency. Moreover, the average length of stay for patients with acute kidney failure who aren’t admitted to the SSU is 3.8 days, while patients with the same condition treated in that unit had an LOS of only 1.4 days.

“The idea was we really need to improve ED throughput as well as patient progression,” says hospitalist Jung Mi Park, MD, medical director of the short-stay unit. “We succeeded with both those goals.”

Unit origin

For years, Grady has maintained an observation unit it calls a clinical decision unit (CDU), which is staffed by the ED. Like many ED-run observation units, the Grady CDU has strict inclusion and exclusion criteria, a limited range of diagnoses to be treated and highly protocolized care.

“You need to enjoy fast turnover.” 

Jung Mi Park, MD
Grady Memorial Hospital

But in 2021, the idea began brewing among Grady leadership that the hospital needed another unit for patients with relatively simple acute medical needs who were expected to be discharged within 48 hours.

That short-stay unit would also accelerate ED throughput by providing care to medically complex patients—the rationale behind staffing the SSU with hospitalists. The SSU also differs from the CDU in that it treats both admitted patients and those with observation status.

“Our patients now are getting older and more medically complex, so many of them are not quite fitting the CDU observation protocols,” says Dr. Park. Unlike the CDU, the short-stay unit accepts a very broad range of diagnoses that includes patients who may need medical/surgical-level or intermediate-level (not ICU-level) care.

Examples of SSU-appropriate diagnoses include syncope/stroke work-up, diabetic ketoacidosis, hypertensive crisis, mild alcohol withdrawal, seizures, and COPD/asthma/CHF exacerbation with a history of not needing more than a two-day stay. Patients excluded from the SSU—because their length of stay could be more than 48 hours—include those with high illness severity, patients at high risk of self-harm, those needing a new malignancy workup or a multi-step evaluation, and patients who need enteric or airborne precautions.

Another key feature that contributes to the success of Grady short-stay unit: All the ancillary services—imaging, nursing, phlebotomy, therapy services, care coordination, social work—agreed to give orders from the SSU priority, even on weekends.

“Because the vision for the short-stay unit originated from Grady leadership,” Dr. Park points out, “it was easier to gain stakeholder involvement in prioritizing SSU patients.”

A different workflow

Staffed by a dedicated hospitalist/APP team, the unit contains 10 beds. To accommodate the new unit, the hospital medicine department did budget to hire two additional physicians and three more APPs.

All of the nearly 50 day-time physicians in the hospitalist group can rotate through the SSU. Those who enjoy the position can request to work there more often, while others who prefer the wards can opt out.

For Dr. Park, the work is a big satisfier. “You see a very wide range of diagnoses in this unit, which speaks to hospitalists’ strengths and holds our interests,” she says. At the same time, she adds, “it’s a different workflow, one with a lot of churn. You need to enjoy fast turnover.”

Turnover is so fast, in fact, that the short-stay unit has put a cap of 15 on the number of daily encounters the hospitalist/APP team working the unit can see. Beyond that cap, patients keep being admitted to the SSU, but they will be seen by the rest of the group’s admitters and rounders.

Different triage methods?

Hospitalists and APPs working in the SSU also need to be able to maintain good relationships with the ED. It is ED personnel who decide to refer patients to the short-stay unit, calling the SSU triage line to run prospective patients past the hospitalist-APP team. The hospitalist has the final say in whether or not a particular patient is appropriate for the unit or should be admitted instead to the floors or to the ED’s CDU.

Talks are now underway to consider other ways to triage SSU patients.

“We’re looking into whether we should have an overall admissions coordinator, which is something other hospitals have,” Dr. Park notes. “Or we may decide to have one hospitalist who works closely with the ED to do disposition for all patients in medicine, including those admitted to the SSU.”

Another work in progress related to the SSU is night coverage. The hospitalist-APP teams work 12-hour day shifts. After hours, a dedicated SSU APP processes unit admissions and provides cross coverage.

A nocturnist used to hold onto the SSU triage phone, speaking directly to the ED about admissions that would then be passed onto the unit’s APP—but that process became too involved because volume was so variable. Currently, SSU admissions at night are filtered through either the nocturnist or one of the resident teams. “We’re looking into,” says Dr. Park, “whether there’s a better way to streamline that night-time admission process.”

Phyllis Maguire has been Executive Editor of Today’s Hospitalist since 2006. Based in Bucks County, Pa., her health care interests are hospital medicine and long-term care options. She also likes zydeco, hiking, and reading memoirs and romances.