www.emtldr.com

The Emergency Short Stay Unit (ESSU) is a low-acuity, high-turnover, inpatient ward/unit (like any other) for patients likely to be discharged within 2-24 hours. You wouldn’t admit a cardiology patient under the surgeons. Similarly, you would not admit a non-dischargeable patient to ESSU. ESSU patients require a clear working issue, plan and endpoint. As a rule of thumb, short stay patients could be autopiloted by a PGY1 intern without much difficulty. There is a trend to place complex undifferentiated patients, many who require admissions, into short stay overnight. This is partially due to the power-distance between the night PGY1/2 doctors who staff short stay and the doctors on the ED floor, who are usually PGY 3 and above. This article aims to avoid inappropriate ESSU admissions overnight. It includes a template that JMS can use when receiving a handover.

□ Patient is likely to be discharged/transferred.

Admitted patients and patients requiring inpatient admissions cannot be admitted to ESSU unless there are exceptional circumstances, as this would indicate that the hospital system is under severe strain (access block) – the operations consultant / director need to be aware of this at a very minimum, and escalation to the executives for a code yellow (internal emergency) is not unreasonable.

If there is a planned transfer to a private hospital, the following conditions must be met:
□ A handover has already occurred to a receiving physician/specialist.
□ Bed confirmed available within 12 hours with transport booked
□ Name of specialist and bed manager clearly documented.
^ If any of the criteria above are not met, it can be assumed that the private bed is not emergently available – hence a local admission under the relevant subspecialty should be arranged. DO NOT place these patients in ESSU as beds very often fail to materialize. Imagine placing a private cardiac patient in a public rehab/surgical ward awaiting transfer to a private cardiac bed. It doesnt make sense. Hence you would not place a subspeciality patient in ESSU awaiting transfer when the hospital has the subspecialty available.

□ Patient is stable, does not require escalated nursing care, and is unlikely to die unexpectedly.

As a rule of thumb, patients with abnormal vitals require inpatient admissions (eg. hypoxic patients requiring supplemental oxygen). Sometimes, it may be appropriate to send a patient with abnormal vitals to ESSU, but this needs a clear plan from a senior clinical decision maker (Senior Reg overnight). For example, patients with rapid AF awaiting effect of a rate control medication prior to discharge.

Behavioural patients or patients likely to escalate (eg. Mental health / AOD / Drug Abuse) are not suitable for ESSU (3)

Patients that could potentially deteriorate quickly are not suitable for ESSU. There is a recurring theme in Mortality/Morbidity (M&M) meetings of elderly patients dying unexpectedly awaiting scans in Short Stay (eg from a ruptured AAA) – keep these patients in a visible acute cubicle at least until the CT has been sighted by a SCDM (may not need to wait for formal report)

□ Patients awaiting tests must have an endpoint.

Patients awaiting a scan/test require one of the following documented:
1) Patient is cleared for discharge if scan/test is unremarkable.
OR
2) If the scan/test is positive, what actions need to be taken for outpatient management.

Best illustrated by examples:
“Mild RUQ pain awaiting US Gallbladder tomorrow morning, fasted, to exclude cholecystitis. Refer to surgical outpatient clinic for biliary colic and elective lap chole if test positive for cholelithiasis.”
“Awaiting CT Scan to look for complications of diverticulitis. If CT shows uncomplicated diverticulitis, please discharge home on antibiotics per therapeutic guidelines, with GP to review in 2-3 days and to return if becomes more unwell”
“Likely renal colic, for conservative management. Review CT KUB report. If calculi <5mm, optimize analgesia and aim for pain to settle prior to discharge. Admit urology if pain persisting, or if calculi >5mm and unlikely to pass. If surgical cause of pain found, please refer to surgeons.
“Moderate risk chest pain with HEART score of 5. Cleared for discharge if second troponin at 2230 not rising. For outpatient CT Coronary angiogram per cardiology” …be reasonable, if after hours, it is reasonable that the ESSU team calls the cardiology team in the morning to discuss appropriate followup.

If the patient’s key differential cannot be managed as an outpatient, ESSU is highly inappropriate (eg. Clinical appendicitis, Severe abdominal pain, high risk chest pain w/ HEART > 6, clinical cholecystitis, crescendo angina or ongoing chest pain despite antianginals). Refer to relevant inpatient teams instead. I cannot stress this enough – ESSU is for patients likely to be discharged.

□ Allied Health / Rapid Assessment and Discharge Team (RAD) referrals have a clear indication.

Allied Health / RAD Team Referrals:
“The patient just needs Allied Health / RAD” is an acceptable ESSU admission indication. eg CAM boot for an ankle fracture with fracture clinic in 1 week.
Ensure there is an indication for RAD documented, such as: pt could benefit from gait aid / need to ensure safe at home with stairs / could benefit from escalated home care package. It must be documented clearly that ED medical issues have been sorted out with a clear plan. There is a trend to place patients with significant other medical issues that require admissions ending up in ESSU as they “just need a RAD review”. RAD will not solve a patient’s delirium or sepsis!

Drug and Alcohol Abuse (AOD) Patients
Ensure AWS initiated.
Ensure no indication to admit for ETOH abuse. (documented no signs of delirium tremens, wernicke’s encephalopathy, or korsakoffs dementia)

Ensure referring doctor has documented:
– Name of Allied Health clinician notified.
– Medical issues that have been sorted in the main ED acute area along with the outpatient plan.
^This is not done out of spite. It ensures that referrals and reviews are not delayed as the initial treating ED doctor knows the patient well and can sort out the outpatient plan and allied health referrals quickly (instead of relying on a re-review by the ESSU team).

□ Initial Medical Workup Performed by The Referring Doctor

Ensure that the referring doctor documents the initial medical workup (working diagnosis, plan, and disposition). This is blindingly obvious, but if not done could seriously delay care to the patient and result in missed diagnoses / unstable patients being sent to short stay, especially overnight.

Examples include:
Trauma patients: A Primary and Secondary survey has been conducted, with relevant investigations ordered (eg XR for sore limbs)
Low/moderate cardiac chest pain patients: what do do if second troponin is normal (ie. the cardiology outpatient plan).
Abdo Pain Patients: Clear criteria for discharge based on working diagnosis (eg size of renal calculi, complicated/uncomplicated diverticulitis)

Template for JMS Receiving Handovers Overnight

This template is designed to alleviate anxiety over receiving handovers as it places the responsibility of the decision to admit to ESSU on the initial treating doctor and SCDM. It aims to provide a clear plan that can be auto-piloted by a junior doctor in ESSU. It also avoids wasting time from unnecessary reviews and doubling up on work - most patients dont even need to be seen until tests are reported/back.

Decision to admit to ESSU made by Dr _____, who has discussed the patient with Senior Clinical Decision Maker Dr _____.
Information provided to me as follows:
ESSU Working Diagnosis:
–
Safety Issues:
–
Plan:
–
Disposition:
–
The ESSU Team will review the patient when ______
The initial treating doctor above will ensure:
– initial assessment notes are completed and signed.
–

Examples of Appropriate Short Stay Admissions

ESSU Resident D HOWSER
Decision to admit to ESSU made by Dr Joe, who has discussed the patient with Senior Clinical Decision Maker Dr RegistrarMcSenior.
Information provided to me as follows:
ESSU Working Diagnosis:
– Moderate risk angina, with a HEART score of 5
Safety Issues:
– Note morphine allergy. Fentanyl well tolerated.
Plan:
– 4hr troponin at 2230 please. Nurses have been notified.
– PRN GTN if pain returns. if requires opiates, for senior review and consideration for cardiology admission.
Disposition:
– The ESSU Team will review the patient when the second troponin result is available. Patient is for discharge with a PRN GTN spray, daily aspirin 100mg, and an outpatient CTCA booking with cardiology chest pain clinic review within 2 weeks.

The initial treating doctor above will ensure
– initial assessment notes are completed and signed.
– a clear plan (+/- cardiology discussion) documented for outpatient followup if the second troponin is not elevated.
– the patient is pain/tightness/angina free prior to transfer to ESSU.

ESSU Intern N RIVIERA
Decision to admit to ESSU made by Dr Blogs, who has discussed the patient with Senior Clinical Decision Maker Dr GrumpyMcNightReg.
Information provided to me as follows:
ESSU Working Diagnosis:
– Acute alcohol intoxication, with risk of withdrawal when sobers up.
– Homelessness
Safety Issues:
– Note likely voluntary when sobers up, request senior input regarding capacity if pt attempts to DAMA while severely intoxicated.
Plan:
– Diazepam per Alcohol Withdrawal Scale
– Drug/Alcohol Support/Peer worker input in the morning.
– Social Work input regarding crisis accomodation.
Disposition:
– The ESSU Team will review the patient in the morning when sober, and liase with AOD/SW if not seen by 10am.

The initial treating doctor above will ensure
– initial assessment notes are completed and signed.
– AWS has been initiated. No signs of delirium tremens. AOD/SW referrals done.