Emergency Department CDU Operational Policy



Background

The Emergency Department Clinical Decision Unit (CDU) is an integral part of the Emergency Department (ED).

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Its sole use is for ED patients who require a short period of observation or treatment, typically for a maximum of 24 hours.

Staffing, responsibility and admission procedure

  1. The unit will be staffed by Emergency Department personnel.
  2. Medical responsibility lies with the duty emergency medicine consultant.
  3. A consultant or registrar in Emergency Medicine will undertake a review of all patients in the CDU every morning and afternoon. Further reviews will occur on an ad hoc basis.
  4. Patients will be admitted to the CDU at the behest of the duty emergency medicine consultant or registrar in consultation with senior nursing colleagues.
  5. The duty Consultant/Registrar should confirm trolley availability on the CDU and appropriateness of admission. They should ensure that an appropriate history has been recorded and a comprehensive clinical examination has been undertaken. The reason for admission and a management plan should be clearly documented. A medication, fluid and medical gas prescribing chart should be completed. A copy of the original ED notes should be placed with the CDU documentation.
  6. Patients must have essential wound care prior to transfer to the CDU*.
  7. Patients who have specific medical conditions will be referred early to the appropriate in-patient team.

Inappropriate admissions.

The following cases are not suitable for the CDU

  1. Psychotic or extremely violent patients
  2. Patients judged to be at extreme risk of suicide
  3. Complex medical problems (e.g. Diabetic Keto-Acidosis)
  4. Unstable physiological parameters (e.g. sustained tachycardia)
  5. Obstetric and gynaecological cases
  6. Patients who are unlikely to be fit for discharge within 24 hours
  7. Patients who are under the active ** care of other in-patient consultants (unless prior consultation with specific attending team Registrar)
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Criteria for admission.

The following sorts of cases may be suitable for management in the CDU:

  1. Deliberate self-harm/overdose
  2. Minor traumatic brain injury
  3. “Rule out” subarachnoid haemorrhage
  4. Minor trauma requiring analgesia e.g. soft tissue injuries
  5. Acute soft tissue infection e.g. cellulitis
  6. Alcohol intoxication
  7. Acute allergic disorders (e.g. treated anaphylaxis or angio-oedema)
  8. Victims of high-energy trauma without clear diagnoses

Referral to other specialties

  1. If it transpires that CDU patients require more than 24 hours hospital care, they will be referred to the duty in-house consultant at that stage. For example, a patient admitted to the CDU on a Sunday, but found on the Monday to warrant continuing hospitalization, will be referred to the relevant Monday on-take consultant and transferred to an in-hospital bed after assessment by the admitting team.
  2. The relevant in-patient teams will be informed prior to discharge of patients who were admitted with a specific “medical” problem e.g. prior to discharge, the endocrine team will be made aware of known diabetic patients admitted with hypoglycaemi

Bed Planning

  1. Constant efforts will be made to minimize the length of time patients spend on trolleys.
  2. The “trolley wait time” will be recorded on all patients (both those in the main Emergency Department and those in CDU).
  3. CDU patients who require continuing in-patient care (i.e. beyond 24 hours) should be transferred back to the main ED or directly to an in-hospital area with agreement by the in-patient team.

CDU Performance Assessment

  1. CDU activity will be subject to continuous scrutiny. Data will be collected every month regarding the following:
  2. Daily trolley occupancy rate.
  3. Mean length of CDU stay.
  4. Diagnosis on admission and discharge.
  5. Deaths on the CDU (or in former CDU patients).
  6. Patients who have remained on the CDU for more that 24 hours.
  7. Critical incident reports.

When the CDU is full, otherwise “CDU suitable” patients (e.g. DSH patients) will be referred directly to the appropriate duty in-patient team.


(*) Wound debridement or closure by ED staff. Patients requiring operative intervention will be admitted to an in-patient bed. Such patients will not return from theatre to the CDU.

(**) Admitted to in-patient bed within last six months or seen in out-patients (with same problem) within last two years


Content by Dr Íomhar O’ Sullivan, Dr Gerry McCarthy, 06 January 2004.Last review Dr. ÍOS 3/09/14 .