About Short Stay Units

What are Short Stay Units?

Short Stay Units are described in the literature in many different ways.

Examples include:

Older Persons Evaluation Review & Assessment (OPERA)
Emergency Medical Units (EMU)
Short Stay Observation (SSO) Units
Clinical Decision Units (CDU)
Medical Assessment and Planning Units (MAPU)
Admission Units
Chest Pain Units (CPU)
Surgical Acute Review & Assessment (SARA)
23 hour wards.

These are examples of the range of units that are used to facilitate a short stay admission both nationally and internationally.

For the purpose of clarity the generic term Short Stay Unit (SSU) will be used in this document.

SSUs have three main functions:

Observation.
Specialist assessment and diagnosis.
Short-term high-level management.

The governance of these units varies and is dependent on the core business function of each unit. Whilst there is a difference in name and ownership, key elements and management principles are consistent across all types of Short Stay Units.

Why use them?

Short Stay Units (SSU) have been developed to provide a short period of assessment, course of therapy or observations for a group of patients who no longer require active ED care. In the past these patients would have just remained in the ED.

These units are designed to provide short-term (<24 hours) assessment and/or therapy for select conditions in order to streamline the episode of care. SSU front load resources to provide an intensive period of evaluation, treatment and supervision. The emphasis
is on enhancing patient flow through ED by allowing for early transfer out and improving ED bed access (Cooke: Higgins & Kidd 2003: Hassan 2003: American College of Emergency Physicians 1994).

What do they look like?

While there are differing forms of Short Stay Units (SSU), each with a different core purpose, they all are similar in their staffing and organisational requirements.

The effective functioning of SSUs is dependent upon proactive management; appropriate, dedicated nursing and medical staffing; clearly defined clinical govenance; and a multidisciplinary approach to patient care. It is also dependent on a clear set of policies in terms of admission and care, and a culture of frequent assessment and short-term therapy (Royal Melbourne Hospital p45. 2004: Hassan 2003: Cooke et al 2003).

In general, medical responsibility for patients managed in SSUs lies with the most appropriate clinical specialty. SSUs should have clearly defined policies and procedures for management of clinical conditions within specific time limits. Hassan (2003) notes ‘evidence suggests that the ideal ward should be time limited (<24 hours) and be staffed by senior personnel. Strong management and policing of operational policies is vital. In particular, procedures for transfer out after 24 hours must be adhered to.

The criteria for admission to an SSU will vary between institutions but should be consistent with the following principles.

There should be a focused goal for the period of observation.
SSUs should target patients with a range of low to moderate risk symptom complexes that with optimal diagnostic support could be discharged within a 6–24 hour period.
SSUs can have a significant impact in minimising clinical risk for certain occult life-threatening conditions using clear diagnostic care pathways eg Low to moderate risk chest pain. (Hassan 2003: American College of Emergency Physicians 1994).

The size of each SSU is different and defined depending on local practices and clinical management strategies/pathways. Typically the bed base for SSUs in their various forms ranges from 8–24 beds.

What types of conditions are managed in SSUs?

There are ranges of conditions that are managed within SSUs including those that:

are undiagnosed and are undergoing lengthy evaluation
are likely to respond to a brief course of therapy, which then can be modified so that treatment can be continued at home
are of uncertain severity or seriousness, which are expected to rapidly evolve and fully declare themselves
need prolonged observation that should resolve within 12 to 24 hours.

SSUs have also been shown to be of use for the elderly population. Westmead Hospital has recently implemented a successful model called OPERA for the management of aged patients through the ED.

Advantages

As well as being advantageous to patients and their carers, a SSU model of care is complementary to ED aims and objectives and allows the ED to function more efficiently by:

increasing ED turnover
reducing ED length of stay
facilitating ambulance off load.

The establishment of SSU increased the overall hospital bed capacity and results in saving hospital bed days.
Reduced length of stay of general medical patients, and improved patient flow through the hospital.
The combined impact of reduced length of stay and early allied health intervention in the MAPU and OPERA models can result in reduced levels of deconditioning in elderly patients whilst they are in hospital.
Allow for focused allied health assessment and intervention.

Keys to success:

An organisational structure that is based on strong leadership, dedicated staffing and effective patient flow.
Responsibility and authority for the SSU should be carefully delineated. A Medical Director should be designated with ultimate responsibility and authority.
Clearly defined admission criteria, well-planned policies and procedures. It is important that the policies and procedures of the unit reflect input from all disciplines of staff.
A clear vision shared among all staff.
Structural organisation must encompass a clear strategy, operational policies, and specified critical pathways of care for individual groups of patients (Hassan 2003: Royal Melbourne Hospital 2004).
Regular key performance indicator and utilisation review. Regular reviews of the types of patient presentations ensure that the conditions managed within the unit are appropriate to patient.