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Nascent clinical-decision unit is reaping huge benefits in Nanaimo

Emergency RN Louise Cowlishaw looks through patient records at the new 5-bed Clinical Decision unit at Nanaimo Regional General Hospital.

Geoff Howe for the Globe and Mail/geoff howe The Globe and Mail

On a good day, trying to cope with the crush of emergency patients at a major city hospital makes the job of a Delhi traffic cop seem a snap in comparison.

Then, there are the bad days, when the stress is off the charts.

The emergency department at Nanaimo Regional General Hospital is no exception.

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In the past nine years, the number of patients thronging emergency has grown from about 30,000 a year to 54,000.

And yet, thanks to organizational changes, plus the incentive of extra government cash for meeting waiting time targets, the average length of stay in the hospital's emergency department has been cut in half.

Now, the department has taken another bold step to further reduce congestion.

Just down the corridor, an innovative, clinical decision unit (CDU) has been set up to ease crowding, both upstairs in acute care and in the adjacent emergency department.

After only seven months, the CDU is showing solid results. The average stay of emergency patients is going down again, and money is rolling in from the government for meeting more and more of its treatment targets.

"Nanaimo is one of the hospitals that have figured out exactly what we want, and they've figured out how to do it very well," said Les Vertesi, head of the Health Services Purchasing Organization that oversees B.C.'s patient-focused funding.

"They've done a good job and should get credit for it."

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What the CDU does is provide on-the-spot treatment to patients who require some hospital care, such as for asthma or elder frailty, but not enough for a lengthy admission.

In the past, as at almost every other hospital in the province, these patients would have languished in emergency, waiting for an in-patient bed to become available. During that time, their condition would often worsen.

Today, emergency patients who appear to qualify for a short, rather than a long, stay are whisked down the hall to the CDU.

There, they are treated, tested, and monitored, without having to be transferred to a bed elsewhere in the hospital. About 80 per cent are discharged within 24 to 48 hours.

After that time, those still in the CDU have first claim on an in-patient bed in another area.

"We want the right person in the right bed at the right time," said Suzanne Fox, manager of emergency services at the hospital.

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Reducing the number of patients transferred to acute care frees up more in-patient beds, leading to quicker admissions for those in emergency who need it.

"We can now see more patients in the same space for the same amount of money, and provide the same quality, or arguably, better quality," said Drew Digney, chief of the hospital's emergency department. "The CDU is a big factor in that."

The idea is simple enough, but making it work is a challenge.

According to Dr. Digney, the key to success is mastering patient flow through tough, disciplined decision-making, He noted that similar concepts tried by other hospitals have floundered, when patients were not moved out of their specialized treatment units fast enough.

"Too often, hospitals have tiny pods, with their own internal processes, that all sort of bump into each other," he said. "Nobody is taking a patient-focused, comprehensive, front-to-back-door approach."

It cost $350,000 to establish the CDU. Dr. Digney said he originally hoped the unit would generate about half a million dollars from the provincial pot of extra money for patient-focused funding.

"I was wrong," he said. "It's actually going to generate almost $700,000. It's paying off in spades."

The CDU also has a special protocol for elderly patients, who often end up in emergency merely because of a mishap that occurs from lack of home support.

Instead of being admitted to a hospital bed, they stay a night or two in the CDU, where staff arrange additional resources.

On Monday, two of the unit's five patients fell into this category, said Ms. Fox.

"Before, they would have stayed in emergency and gone into another in-patient bed, staying maybe three to five days, before things were set up," she said. "Now, we can send them right back home.

"We are a pretty innovative group here, but the clinical decision unit is definitely one of our big successes. It works."


Freeing up beds a priority


What it is

This special, five-bed patient room is located close to the hectic emergency department at Nanaimo Regional General Hospital.

The beds are set aside for patients who require enough treatment to justify a one- or two-night stay, but not so much they must occupy a bed "upstairs' in the hospital's acute-care wards, which are almost always full.

How it works

There are 19 carefully defined criteria for patients to be admitted to the new unit, all of them related to the likelihood of a a short hospital stay. In the old days, the patient would have had to be admitted to an in-patient bed.

Now, these patients are treated within the CDU, and 80 per cent are discharged within one or two days. This frees up beds in the rest of the hospital that would otherwise have been needed to accommodate them, and reduces congestion in the emergency department, where many patients requiring admission to the hospital faced excruciatingly long waiting periods for a bed.

At the same time, thanks to performance-based bonus money from the province's patient-focused funding program, the emergency department is reaping revenue from the CDU.

"It's all about flow," said Drew Digney, chief of the hospital's emergency department.

- Rod Mickleburgh

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