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