LO27: System outcomes associated with an emergency department clinical decision unit
Bibliographic record
Abstract
Introduction: A clinical decision unit (CDU) is an area within the emergency department (ED) that allows for protocol-driven treatment & observation of patients who may not require hospital admission, but are not ready for discharge after initial assessment & treatment. A CDU was established at BC Children’s Hospital in 2014 as a means to optimize hospital resource utilization. Preliminary administrative data review revealed a return to ED (RTED) rate of 15% following a CDU stay, 2-3 times the RTED rate reported in the literature. Whether this is the expected cost of reducing hospital admissions remains unclear. Research exploring the underlying reasons for RTED following a CDU stay is limited. Objectives: Following a CDU stay, to describe 1) disposition outcome distribution; 2) underlying reasons for RTED; and 3) the proportion of potentially preventable RTED. Methods: Retrospective cohort study of all ED visits with a CDU stay from Jan 1, 2015 to Dec 31, 2015. Health records data was extracted & entered into standardized online forms by trained research assistants, then blindly reviewed by two investigators to determine a) the most probable cause of each RTED & b) the number of RTED that were clinically unnecessary. Results: Of the 1696 index CDU visits, 1503 (89%) were discharged home. However, 139 (9%) had ≥1 associated RTED. Among these, 48 (35%) were deemed clinically unnecessary (89% agreement, Kappa=0.79) & therefore potentially preventable. The most common reason (88%) for unnecessary RTED was mismatch between expected natural progression of disease (not requiring further medical assessment or treatment) & families’ understanding of disease symptom range & duration. In 90% of these cases, anticipatory guidance regarding natural progression of disease was not communicated to parents upon discharge. Among the remaining 1364 (91%) that did not return, 750 had an initial visit total ED length of stay of >8 hours, thus were considered averted hospitalizations attributable to the CDU. Conclusion: The CDU has had a positive impact on patient & system outcomes through the prevention of several inpatient admissions. However, we observed a relatively large proportion of RTED, 35% of which were clinically unnecessary & 27% of which had inadequate discharge instructions. This highlights opportunities to further optimize the effectiveness of the CDU through quality improvement initiatives focusing on the ED discharge process.
Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.
How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.004 | 0.035 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.001 |
| Bibliometrics | 0.002 | 0.003 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.003 | 0.001 |
| Open science | 0.001 | 0.003 |
| Research integrity | 0.000 | 0.002 |
| Insufficient payload (model declined to judge) | 0.017 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".