Anyone else have Extended ER???

We call this Clinical Decision Unit. It's for overnight, ambulatory patients who might need a stress test in AM or non urgent appy for example, tele is available.

Hmmmm, it sounds like you are talking about pts being admitted as observation, which, for billing purposes, is treated like an ED visit for the first 23 hours. There are some exceptions that go longer than that, but I couldn't begin to tell you what they are.

As for what qualifies them for extended ER, or observation, I don't know that either. Criteria depends on a lot of things, and one larger hospital that I work for has utilization review nurses who work right in the ER to make sure patients who are admitted as inpatients or observation actually meet criteria, and the CRM nurses change it if they don't. Docs can disagree (though they rarely do) and still admit a patient as observation or inpatient even if they don't meet critera, but they will then have that case put up for review and potentially be penalized by the hospital if they are wrong.

So, in short, it can be complicated and not something the average nurse knows how to determine.

We call this Clinical Decision Unit. It's for overnight, ambulatory patients who might need a stress test in AM or non urgent appy for example, tele is available.

I think this is a good general statement. But just to clarify this for the OP, different CDUs can have their own criteria concerning which patients they will accept to that unit, but for purposes of classifying a patient for observation to the CDU, they don't have to be ambulatory, and they could be admitted for many different reasons besides those stated above.

Edited to add: Observation, extended ER, whatever they are called, those patients don't HAVE to go to the CDU. If the CDU is full, obs patients can be placed in a room on the floor without compromising their observation status or the hospital's ability to bill as obs.

I should also add that the CLASSIFICATION of a patient as observation or extended ER is for billing purposes and is different than extended ER, or CDU as a location where these types of patients typically stay while in the hospital, so the criteria you are looking for may be based on location rather than billing. If so, then that's a different ballgame. I also work at a smaller hospital that doesn't have a separate CDU, so all obs patients are admitted to the floor.

I once had an obs patient at this hospital stay right in the ER because the 23 hour clock includes all time spent in the ER from the time patients are first admitted to the ER, and by the time he was dispositioned, it didn't make sense to move him to a bed upstairs for the remaining few hours that he would be there.

Thank you for all the information!!! Leads me to another question. How long does everyone keep their pts in the ER? For example, a pt comes in dehyrdrated and IVF are started. This pt is not put in obs, but kept in the ER recieving fluids. Anyone have a policy stating how long a pt like this can be kept? Is anything over 4 hrs acceptable in other ER departments? Do other ER departments have a time limit on whether to admit a pt (either full admit or obs)?

Thank you for all the information!!! Leads me to another question. How long does everyone keep their pts in the ER? For example, a pt comes in dehyrdrated and IVF are started. This pt is not put in obs, but kept in the ER recieving fluids. Anyone have a policy stating how long a pt like this can be kept? Is anything over 4 hrs acceptable in other ER departments? Do other ER departments have a time limit on whether to admit a pt (either full admit or obs)?

I think there are several things wrapped up in your question.

In and out of the ER in under 4 hours ... is either a low-acuity/urgent care type patient on a good, not very busy, fast-moving day OR a sick-as-crap patient who quickly heads to the OR, cath lab or ICU (on a magical day when there are ICU beds immediately available).

Your "dehydration" example is pretty generic -- lots of folks who are not elderly or do not have other acute conditions or multiple comorbidities can and do come in to the ER after a day or two of vomiting/diarrhea with "dehydration" and we tank them up with some fluids and then discharge them if they show sufficient improvement. It's not necessary to admit them, but their total ER time may well be longer than 4 hours.

Clinical Decision Units can be very successful at pulling out patients who don't quite meet the threshhold for a typical obs admission out of the main ER flow.

I've not worked anywhere where there was a "time limit" by policy on a decision to admit -- because it's so dependent on so many factors beyond the control of ER physicians and nurses.

Is your ED trying to implement what you're calling "extended ER" and finding difficulty/resistance? If so, what are the sticking points?

GM2RN,

My problem is we are a rural hospital with no CDU. We either admit (full admit or observation, treat and release, or transfer). Somehow, over the years "extended ER" has developed in our ER. Basically, doctors place this pt in that status to receive numerous treatments. It varies from IVF, to q 1 hr FSBS, to just watching the pt. We do not have a policy covering "extended ER". Several Pts are being kept from anywhere from 2-24 hrs as "extended ER". Our "extended ER" is unofficial and needs guidelines. Just attempting to get an idea on how others handle or even deal with situations like this. I am finding most do not!!! I have found that at Stony Brook University Hospital, they have a policy in place to make a decision to admit, DC, or transfer after 8 hrs.

Sorry forgot one more thing. The average stay for an "extended ER" pt is 16 hrs.

GM2RN,

My problem is we are a rural hospital with no CDU. We either admit (full admit or observation, treat and release, or transfer). Somehow, over the years "extended ER" has developed in our ER. Basically, doctors place this pt in that status to receive numerous treatments. It varies from IVF, to q 1 hr FSBS, to just watching the pt. We do not have a policy covering "extended ER". Several Pts are being kept from anywhere from 2-24 hrs as "extended ER". Our "extended ER" is unofficial and needs guidelines. Just attempting to get an idea on how others handle or even deal with situations like this. I am finding most do not!!! I have found that at Stony Brook University Hospital, they have a policy in place to make a decision to admit, DC, or transfer after 8 hrs.

Gotcha! So you need to talk to people who do have a CDU, cuz you got one even if that's not what you call it.

I can tell you more about mine when I have a bit more time. Gotta get ready for work now...