March 4, 2013
CDU: Clinical Decision Unit
January 2013 - M O N T H January 2013 - F Y T D
Actual Budget Pr Yr Bud Var Actual Budget Pr Yr Bud Var
Acute Admits 1,575 1,474 1,489 101 10,653 10,645 10,752 8
Obs Admits 597 477 496 120 4,256 3,224 3,110 1,032
Obs ALOS 1.41 1.82 1.82
(0.41) 1.39 1.59 1.59 (0.20)
Total Acute Admits + Obs 2,172 1,951 1,985 221 14,909 13,869 13,862 1,040
Obs % of total 27% 24% 25% 29% 23% 22%
• IP Admissions flat YTD
• > 1,000 OBs admissions YTD 2012 v 2013
• 7% increase in OBs admissions in just 1 year
THE OBSERVATION SURGE
2
Problem:
– 25-40% of patients in a bed at
MN are in Observation status
– Estimate approximately $5K in
payment difference
– OBs pts scattered across the
house
– Staff, providers, and hospital
treat OBs and IP similarly
– Little difference, little urgency
– 3 Main open and closes in
response to volume/need
CDU
3
A SOLUTION → CDU
– Aggregate OBs patients on
3 Main
– Keep open 24/7
– Focus staff on rapid
treatment and decisions
– Dedicated CM & staff
– Aligned messaging to
patients
– Bills audited prior to drop
CDU
4
Inclusion Diagnoses:
– Low Risk CP
– Abdominal pain
– Asthma
– Atrial Arrhythmias
– Allergic Rx
– Back Pain
– Dehydration
– Syncope
– TIA
– Low Risk CHF
CDU: The Patients
5
Inclusion Criteria:
– OBs status
– Tele/Remote Tele/RNF
– Ambulate independently
– Perform ADLs independently
Exclusion Criteria:
– Isolation (beyond contact)
– Titration of meds
– O2 > 6L/M or O2 Sat < 93%
– BH or addiction issues
– Nursing home or placement issues
CDU: The Patients
6
Effective Monday March 4:
– 13 beds (can double up)
– Tele/Remote Tele
availability
– Currently 1 bed/room
– Short stay ADM
assessment
– 2 RNs/1 PCT 7A-11P
– 2 RNs 11P
– Tracking board
– Order sets
CDU: The Organzaiton
7
Collaborative Approach
– Over 10 meetings with ED, Hospitalists, &
Cardiologists
– Nursing Supervisors, Nurse Leaders, CM
etc
The Drivers:
1. ED Physicians
• Identify patients by diagnoses,
inclusion, and exclusion criteria
• Work with CM to optimize
criteria/status
• Enters floor
2. Hospitalists
• Further identify patients
• May change room/unit
• Manage care on 90% of patients
3. Cardiologists
• Manage their own patients
CDU: The Physician Drivers
8
Mr L
• 53 YO Male
• Recent onset CP, heart racing
• Hx CAD
• ED at 08:54 AM
• CDU at 11:39 AM
• 3 Troponin Levels negative
• Stress negative at 14:00
• Patient asymptomatic
• Tummy ache
• DC at 16:20
• Appointment with PCP 1 week
Ms W
• 45 YO Female
• Recent onset Resp Distress
• Hx COPD and HIV
• ED at 06:01 → nebs, roids, fluids
• CDU at 10:11
• Potassium, antibx, roids
• Observed resp status
• Monitored O2 requirements
• Needed HH and 02 Tank
• DC at 18:25
• HH appointment following day
CDU: Success Stories
9
A CQI Process
– Learning curve
– Practice curve
– Role of CM, RN, & MD
– Already shifted to boxed lunches
– Improve DC times
– Optimize status
– Better manage hospital resources
– Place IPs in IP beds
CDU
10
THE VISION
• 26 patients in 13
rooms
• How many
beds/rooms?
• Home meds
• Meals
• Order Sets
• Inclusion/Exclusion
Criteria
CDU
11
CDU
12