2. • Full service health system
• 851 bed, not for profit medical center
• 5th largest hospital in the state of Florida
• Busiest single-site Emergency Department in
the state, approximately 200,000 visits per
year
• Approximately 1400 surgical cases per month
3. Outline:
• Opportunity Statement
• Goals
• Design
• Who Qualifies?
• Standardized Protocols
• Current Performance
• Barriers & Lessons Learned
• Next Steps
4. Opportunity Statement
• Opportunity exists to reduce our observation
length of stay (LOS) and increase our bed
capacity
• Baseline average observation LOS: 33.6 hours
5. Goals:
• Reduce observation Length of Stay (LOS)
• Reduce health care costs
• Increase bed capacity
• Provide efficient assessment and treatment
through standardized protocols
6. Project Team:
• Interdisciplinary Project Team
– Senior Chief Quality and Informatics Officer
– Chief Quality and Informatics Officer
– Chief of Medicine
– IT Analysts
– Nursing Leadership
– AVP Medical Staff
– ARNPs
– Director of Quality
– Director of Emergency Department
– Director of Radiology
– Data Science Analyst
– Industrial Engineer
7. Design:
• CDU = “Extension of ED”
• Discharges expected throughout the 24 hour
continuum
• 18 bed unit
• ARNP assigned to unit
• Standardized Protocols
8. Who Qualifies?
• Main diagnoses appropriate for CDU:
–Chest Pain Observation (low-risk)
–CHF
–COPD/Asthma
–Anemia
–Dehydration
–Allergic Reaction
–General
9. Example of Standardized Protocol:
Chest Pain Observation
1.0,3,6 hr Troponin
2.No IV Dilaudid (narcotic pain reliever)
3.NPO until after discharge (nothing to eat or drink)
4.No Caffeinated Beverages
5.Vital Signs – Q4hrs
6.EKG 0,6 hr (PRN change in condition)
7.Physician’s protocol is to default to CCTA test and
if patient does not qualify to utilize Nuclear
Stress Test or GXT Treadmill Test
8.Education
10. • Patient presents to ED with chest pain
• ED physician determines patient has low-risk
chest pain and qualifies to be admitted to the
Clinical Decision Unit
• Admitting Physician visits patients and chooses
CDU Chest Pain Power Plan (standardized
protocol)
• ARNP assigned to unit responsible for ensuring
timely treatment path and completes discharge
for patient if test result is negative
Sample Patient with Low-Risk Chest Pain
15. Barriers & Lessons Learned:
• Access to same-day testing for Nuclear
Studies
• Staffing
– Current productivity model used for clinicians
– Physician assignment
• Current reimbursement model for
observation patients
16. Next Steps:
• Increase capacity for access to same day testing
for Nuclear Studies
• Collaborate with finance to increase observation
base rate so that becoming more efficient does
not have a negative revenue impact
• Reduce process variation and assign one
physician or one physician per group to unit
• Revise nursing productivity model to be volume
driven and not based on midnight census ratios
