Guideline
Short Stay Unit, Admissions
Guideline Responsibilities and Authorisation
Department Responsible for Guideline
Emergency medicine Administration
Document Owner Name
John Bonning
Document Owner Title
Clinical Director
Sponsor Title
John Bonning
Sponsor Name
Clinical Director
Disclaimer: This document has been developed by Waikato District Health Board specifically for its own
use. Use of this document and any reliance on the information contained therein by any third party is at
their own risk and Waikato District Health Board assumes no responsibility whatsoever.
Guideline Review History
Version
Updated by
Date Updated
Description of Changes
2
Changed to new format and reviewed content
Doc ID:
1572
Version:
02
Issue Date:
1 OCT 2016
Review
1 OCT 2019
Document Owner:
Clinical Director
Department:
Em
ergency Department
IF THIS DOCUMENT IS PRINTED, IT IS VALID ONLY FOR THE DAY OF PRINTING
Page 1 of 6
Guideline
Short Stay Unit, Admissions
1. Purpose
• The guideline outlines the criteria for utilisation of the Emergency Department Short
Stay Unit (SSU). Whilst it is called an SSU the unit also will provide the functions of an
Observation Unit (OU. It will allow extended ED care in a more conducive environment
and offer a safe alternative to premature or high risk discharge of patients.
• A secondary benefit is to improve flow through acute treatment beds for new patients.
• The guideline has been drawn up with the assistance of the draft guidelines (April
2010) of the National ED Services Advisory Group and with the input of the National
Clinical Director of ED Services.
• If a patient is admitted to the SSU in accordance with these guidelines the ED acute
6-hour clock will stop.
• This document also describes which patients may be lodged as “observed” (and stop
the 6-hour clock) in the main department if there is a reason they cannot go to the
SSU.
2. Responsibility
• The Department of Emergency Medicine (DEM) has sole administrative jurisdiction
over the SSU.
3. Guideline
• The SSU is currently a 10 bed monitored unit forming part of the Emergency
Department.
• The unit is intended for the management of stable patients who have an expected
length of stay greater than 6 but less than 24 hours. There is an expectation that any
patient admitted to the ED SSU overnight will be able to be discharged the next
morning.
• The reason for admitting patients to SSU is to move those patients with conditions
described below who require extended assessment, investigation or observation from
the at times hectic acute environment to a more pleasant, comfortable and quieter
ward-like environment.
• The common theme in all has to be that they are under the care of DEM with no, or
unlikely need for input from in-patient teams and with the intention to discharge the
patient within the defined time period.
• Patients may be identified as appropriate for SSU and sent there early in their ED stay
(for example toxicology patients) and can go there even if they do not need >6 hours
in ED.
• The SSU includes 6 ‘lazy-boy’ chairs for patients who do not need beds
• At times (see below), selected inpatient team patients may be placed in ED SSU (if
there is no other appropriate place for them e.g. Medical SSU) at the sole discretion of
the duty EPIC and NIC if they satisfy the criteria for an observed patient, require a
short defined period of observation and have a defined plan of care, full
documentation including a discharge plan.
• The clock doesn’t drive the admission to the SSU, good care does
Doc ID:
1572
Version:
02
Issue Date:
1 OCT 2016
Review
1 OCT 2019
Document Owner:
Clinical Director
Department:
Em
ergency Department
IF THIS DOCUMENT IS PRINTED, IT IS VALID ONLY FOR THE DAY OF PRINTING
Page 2 of 6
Guideline
Short Stay Unit, Admissions
4. Examples of conditions suitable for admission to the SSU
• Anaphylaxis responding to initial treatment needing a brief period of observation
depending on the severity of the initial presentation
• Minor head injury and other minor trauma.
• Toxicology, including alcohol intoxicated patients. Prolonged periods of observation
may still be referred for admission by in-patient teams. Whilst it is theoretically
possible to keep OD patients in SSU (even for their 24-hours of NAC) we are not
generally set up for this, and to do so is at the sole discretion of the EPIC who must
ensure that there is resource in the department to do so and that effective
documentation and handover between shifts occurs
• Patients with febrile illnesses (e.g. pneumonia, pyelonephritis, tonsillitis) requiring
further treatment (fluids, antibiotics, steroids) prior to discharge.
• Elderly patients unsafe to discharge overnight or requiring complex discharge planning
and some input from other ancillary services such as OPRS, START, ACC.
• Paediatric conditions such as bronchiolitis, asthma and gastro-enteritis requiring
treatment in a paediatric SSU under DEM care but still likely to be discharged (Not in
the adult SSU).
• Stable patients requiring blood transfusion then discharge (only to be done on rare
occasions where they are true acute presentations and only if not better done
elsewhere e.g. Medical day-stay Unit in a sub-acute fashion, refer to the transfusion
guideline).
• Patients awaiting further investigation such as CT or USS, for example renal colic
and? DVT patients, for whom the other conditions, above, are met (under care of
DEM, no need or unlikely need for input from in-patient medical staff and likely to go
home after the investigation).
• Patients (with for example stable headache, chest, abdominal or back pain) under the
care of DEM requiring workup (for example CT, LP or serial troponins)
• Note: Patients will be observed “for a clinically appropriate amount of time” depending
on a variety of clinical issues, the severity of their initial condition, their red flags for
serious complications, their age and their social circumstances. The reflex term “4
hours observation” is valid. It may be appropriate for a period of one hour, or for longer
periods overnight, especially in the elderly. Any patient requiring more than 24 hours
observation should be referred early to an inpatient team.
General Issues
• The duty Emergency Physician (EP) will adjudicate as to whether the patient should
be admitted to hospital in unclear cases. Similarly the duty EP can decide that
selected inpatient specialty patients present in the ED who are highly likely to be
discharged within the next 6-8 hours may be appropriate to be managed in the SSU as
an observed patient.
• The purpose of admission to the SSU is to improve the patient’s care, by having them
in a unit focused on their needs – observation, ongoing management, and discharge –
rather than keep them in the ED where they have less comfort and where the focus of
the staff is appropriately on new, sick and undifferentiated patients. While admission to
the SSU ‘stops the clock’ for ED length of stay, the purpose of admission is to provide
good care in an appropriate environment.
Doc ID:
1572
Version:
02
Issue Date:
1 OCT 2016
Review
1 OCT 2019
Document Owner:
Clinical Director
Department:
Em
ergency Department
IF THIS DOCUMENT IS PRINTED, IT IS VALID ONLY FOR THE DAY OF PRINTING
Page 3 of 6
Guideline
Short Stay Unit, Admissions
5. Exclusions:
• Any unstable patient
• Any patient who has a high likelihood of becoming unstable
• Any patient with uncontrolled pain
• A patient where the management plan is unclear (the diagnosis may still be unclear)
• Any patient merely awaiting a ride home but not requiring a bed (should be discharged
and put in the waiting room)
• Any patient who from the outset needs admission by an in-patient team
6. SSU Admission and Discharge Process
• Any ED doctor or nurse can indicate they have a patient suitable for SSU. If
indications are clear they just arrange that with the SSU nurses. The NIC and the
EPIC can be involved
• The NIC and the EPIC on duty will look for patients deemed appropriate for the SSU.
They can go there at any stage in their ED stay (i.e. it can be early if they fit criteria)
• All patients being admitted to the SSU should be discussed with the duty EP whilst
they are on duty in ED.
• Prior to going home the EPIC will ensure all patients in SSU are appropriate (fit
appropriate criteria described above) as well as discussing any patients who appear to
be potentially suitable for SSU admission overnight with the night DEM registrars prior
to going home.
• All patients admitted to SSU overnight will be discussed with the EPIC at 0800hrs
handover.
• All patients who are admitted for any reason other than social circumstances should
be reviewed in the morning by an oncoming duty ED consultant (or delegated senior
registrar) prior to discharge.
• The plan to admit to SSU and expectation to discharge within 24 hours is discussed
with the patient.
• Clinical notes must be completed, including a diagnosis (or at least a differential
diagnosis), management plan with a goal to discharge within 24 hours and parameters
when the patient must be reviewed including at what time.
• Handover from medical staff must occur at change of shift so that the responsibility of
the care of the patient is clearly documented in the notes and on the computer. If the
patient is handed over between shifts it is mandatory that the initial assessing and
treating doctor starts the electronic discharge summary (that will be finished by the
doctor taking over care)
• All patients in SSU whose care is handed over between doctors/shifts (this is
especially important overnight) require a written handover note that will be completed
Doc ID:
1572
Version:
02
Issue Date:
1 OCT 2016
Review
1 OCT 2019
Document Owner:
Clinical Director
Department:
Em
ergency Department
IF THIS DOCUMENT IS PRINTED, IT IS VALID ONLY FOR THE DAY OF PRINTING
Page 4 of 6
Guideline
Short Stay Unit, Admissions
by the initial treating doctor and passed on to the next doctor (to reduce the risks of
multiple handovers).
• The DEM patient assessment sheet must be completed for all patients who are likely
to require ongoing or regular medication, including the allergies sections.
• Radiology as indicated should be arranged (e.g. CT, USS) prior to transfer to SSU.
• For overnight admissions requiring radiological investigations that can reasonably wait
till the morning a request form shall be faxed to USS or CT & the Night DEM Registrar
with responsibility for the patient will liaise with Radiology.
• An electronic discharge summary (EDS) must be drafted by the admitting Doctor and
saved. Prior to discharge the discharging doctor reviews and updates the EDS.
• Occasionally patients may be discharged by a nurse without a final medical review (in
particular medically cleared patients post psychiatric assessment) if this is clearly
documented in the notes and a discharge letter can be printed and given to the
patient.
• If the patient has an injury the ACC (ACC45) form must be completed.
• Patients may be discharged to the Transit Lounge weekdays if they have finished their
clinical care and are awaiting transport home.
• Patients admitted to the SSU (with conditions deemed appropriate above) under the
care of DEM will be lodged as ‘OBS’ and will “stop the clock” on the 6-hr target.
7. Quality control of SSU patients
• Patients must be reviewed in a timely fashion – the time for review or definitive
management or disposition decision will be documented in the plan (in the notes and
on the computer).
• Prolonged waits for investigations or results are not acceptable and must initiate
discussions with relevant services (e.g. Radiology) to facilitate improved service
delivery, including immediate phone calls to that service and incident forms.
• Discharge (home) rate from the SSU is expected to be >80%. It is expected that up to
20% of patients might “fail” their period of observation and need to be admitted.
• Use of the SSU and ‘OBS’ will be audited regularly by the Assistant Group Manager
for Ambulatory Care and External Liaison and the Clinical Director for appropriateness
of use.
8. “Observed” patients outside SSU
• Patients who meet the criteria for admission for the SSU but for whom there is a valid
reason that transfer to the SSU cannot occur or is inappropriate (see points below)
can be lodged as ‘OBS’ and will “stop the clock” on the 6 hour target even though
they remain in the acute care area.
o SSU is full
Doc ID:
1572
Version:
02
Issue Date:
1 OCT 2016
Review
1 OCT 2019
Document Owner:
Clinical Director
Department:
Em
ergency Department
IF THIS DOCUMENT IS PRINTED, IT IS VALID ONLY FOR THE DAY OF PRINTING
Page 5 of 6
Guideline
Short Stay Unit, Admissions
o Infection control issues especially MDRO
o Behavioural issues
o Clinical issues (e.g. still needing more intensive monitoring)
• Clinical spaces outside SSU where this can occur are adult cubicles 11 and 12, the
family rooms, and Kids ED spaces 6 to 10 (for children only).
Doc ID:
1572
Version:
02
Issue Date:
1 OCT 2016
Review
1 OCT 2019
Document Owner:
Clinical Director
Department:
Em
ergency Department
IF THIS DOCUMENT IS PRINTED, IT IS VALID ONLY FOR THE DAY OF PRINTING
Page 6 of 6
Document Outline
- 1. Purpose
- The guideline outlines the criteria for utilisation of the Emergency Department Short Stay Unit (SSU). Whilst it is called an SSU the unit also will provide the functions of an Observation Unit (OU. It will allow extended ED care in a more conducive...
- A secondary benefit is to improve flow through acute treatment beds for new patients.
- The guideline has been drawn up with the assistance of the draft guidelines (April 2010) of the National ED Services Advisory Group and with the input of the National Clinical Director of ED Services.
- If a patient is admitted to the SSU in accordance with these guidelines the ED acute 6-hour clock will stop.
- This document also describes which patients may be lodged as “observed” (and stop the 6-hour clock) in the main department if there is a reason they cannot go to the SSU.
- The Department of Emergency Medicine (DEM) has sole administrative jurisdiction over the SSU.
- The SSU is currently a 10 bed monitored unit forming part of the Emergency Department.
- The unit is intended for the management of stable patients who have an expected length of stay greater than 6 but less than 24 hours. There is an expectation that any patient admitted to the ED SSU overnight will be able to be discharged the next mo...
- The reason for admitting patients to SSU is to move those patients with conditions described below who require extended assessment, investigation or observation from the at times hectic acute environment to a more pleasant, comfortable and quieter w...
- The common theme in all has to be that they are under the care of DEM with no, or unlikely need for input from in-patient teams and with the intention to discharge the patient within the defined time period.
- Patients may be identified as appropriate for SSU and sent there early in their ED stay (for example toxicology patients) and can go there even if they do not need >6 hours in ED.
- At times (see below), selected inpatient team patients may be placed in ED SSU (if there is no other appropriate place for them e.g. Medical SSU) at the sole discretion of the duty EPIC and NIC if they satisfy the criteria for an observed patient, r...
- The clock doesn’t drive the admission to the SSU, good care does
- Anaphylaxis responding to initial treatment needing a brief period of observation depending on the severity of the initial presentation
- Minor head injury and other minor trauma.
- Toxicology, including alcohol intoxicated patients. Prolonged periods of observation may still be referred for admission by in-patient teams. Whilst it is theoretically possible to keep OD patients in SSU (even for their 24-hours of NAC) we are not...
- Patients with febrile illnesses (e.g. pneumonia, pyelonephritis, tonsillitis) requiring further treatment (fluids, antibiotics, steroids) prior to discharge.
- Elderly patients unsafe to discharge overnight or requiring complex discharge planning and some input from other ancillary services such as OPRS, START, ACC.
- Paediatric conditions such as bronchiolitis, asthma and gastro-enteritis requiring treatment in a paediatric SSU under DEM care but still likely to be discharged (Not in the adult SSU).
- Stable patients requiring blood transfusion then discharge (only to be done on rare occasions where they are true acute presentations and only if not better done elsewhere e.g. Medical day-stay Unit in a sub-acute fashion, refer to the transfusion g...
- Patients awaiting further investigation such as CT or USS, for example renal colic and? DVT patients, for whom the other conditions, above, are met (under care of DEM, no need or unlikely need for input from in-patient medical staff and likely to go...
- Patients (with for example stable headache, chest, abdominal or back pain) under the care of DEM requiring workup (for example CT, LP or serial troponins)
- Note: Patients will be observed “for a clinically appropriate amount of time” depending on a variety of clinical issues, the severity of their initial condition, their red flags for serious complications, their age and their social circumstances. ...
- General Issues
- The duty Emergency Physician (EP) will adjudicate as to whether the patient should be admitted to hospital in unclear cases. Similarly the duty EP can decide that selected inpatient specialty patients present in the ED who are highly likely to be di...
- The purpose of admission to the SSU is to improve the patient’s care, by having them in a unit focused on their needs – observation, ongoing management, and discharge – rather than keep them in the ED where they have less comfort and where the focus...
- Any unstable patient
- Any patient who has a high likelihood of becoming unstable
- Any patient with uncontrolled pain
- A patient where the management plan is unclear (the diagnosis may still be unclear)
- Any patient merely awaiting a ride home but not requiring a bed (should be discharged and put in the waiting room)
- Any patient who from the outset needs admission by an in-patient team
- Any ED doctor or nurse can indicate they have a patient suitable for SSU. If indications are clear they just arrange that with the SSU nurses. The NIC and the EPIC can be involved
- The NIC and the EPIC on duty will look for patients deemed appropriate for the SSU. They can go there at any stage in their ED stay (i.e. it can be early if they fit criteria)
- All patients being admitted to the SSU should be discussed with the duty EP whilst they are on duty in ED.
- Prior to going home the EPIC will ensure all patients in SSU are appropriate (fit appropriate criteria described above) as well as discussing any patients who appear to be potentially suitable for SSU admission overnight with the night DEM registrar...
- All patients admitted to SSU overnight will be discussed with the EPIC at 0800hrs handover.
- All patients who are admitted for any reason other than social circumstances should be reviewed in the morning by an oncoming duty ED consultant (or delegated senior registrar) prior to discharge.
- The plan to admit to SSU and expectation to discharge within 24 hours is discussed with the patient.
- Clinical notes must be completed, including a diagnosis (or at least a differential diagnosis), management plan with a goal to discharge within 24 hours and parameters when the patient must be reviewed including at what time.
- Handover from medical staff must occur at change of shift so that the responsibility of the care of the patient is clearly documented in the notes and on the computer. If the patient is handed over between shifts it is mandatory that the initial as...
- All patients in SSU whose care is handed over between doctors/shifts (this is especially important overnight) require a written handover note that will be completed by the initial treating doctor and passed on to the next doctor (to reduce the risks...
- The DEM patient assessment sheet must be completed for all patients who are likely to require ongoing or regular medication, including the allergies sections.
- Radiology as indicated should be arranged (e.g. CT, USS) prior to transfer to SSU.
- For overnight admissions requiring radiological investigations that can reasonably wait till the morning a request form shall be faxed to USS or CT & the Night DEM Registrar with responsibility for the patient will liaise with Radiology.
- An electronic discharge summary (EDS) must be drafted by the admitting Doctor and saved. Prior to discharge the discharging doctor reviews and updates the EDS.
- Occasionally patients may be discharged by a nurse without a final medical review (in particular medically cleared patients post psychiatric assessment) if this is clearly documented in the notes and a discharge letter can be printed and given to th...
- If the patient has an injury the ACC (ACC45) form must be completed.
- Patients may be discharged to the Transit Lounge weekdays if they have finished their clinical care and are awaiting transport home.
- Patients admitted to the SSU (with conditions deemed appropriate above) under the care of DEM will be lodged as ‘OBS’ and will “stop the clock” on the 6-hr target.
- Patients must be reviewed in a timely fashion – the time for review or definitive management or disposition decision will be documented in the plan (in the notes and on the computer).
- Prolonged waits for investigations or results are not acceptable and must initiate discussions with relevant services (e.g. Radiology) to facilitate improved service delivery, including immediate phone calls to that service and incident forms.
- Discharge (home) rate from the SSU is expected to be >80%. It is expected that up to 20% of patients might “fail” their period of observation and need to be admitted.
- Use of the SSU and ‘OBS’ will be audited regularly by the Assistant Group Manager for Ambulatory Care and External Liaison and the Clinical Director for appropriateness of use.
- Patients who meet the criteria for admission for the SSU but for whom there is a valid reason that transfer to the SSU cannot occur or is inappropriate (see points below) can be lodged as ‘OBS’ and will “stop the clock” on the 6 hour target even tho...
- o SSU is full
- o Infection control issues especially MDRO
- o Behavioural issues
- o Clinical issues (e.g. still needing more intensive monitoring)