First, she felt a little faint. Then the chest pain started: "It was steady and constant, not jabbing," Mary Atkins recalled. She called her doctor, who told her to go to the nearest emergency department. The 81-year-old San Jose resident decided to drive to the hosptial.

Nurse practitioner Garrett Chan and physician Matthew Strehlow work in Stanford Hospital's Clinical Decision Area, where patients are observed to determine whether they should be admitted to the hospital.

Physicians in the emergency department ordered diagnostic tests and, after several hours, offered to move Atkins to the 11-bed Clinical Decision Area just down the hall. "They said it would be quieter, with fewer lights and less confusion," she said.

Atkins was able to get some sleep as nurse practitioners and physicians' assistants evaluated her condition through the night. "In the hospital, it can take two days to get studies performed and lab results, but the CDA is able to compress that, saving time and money for both the patient and the hospital," said Matthew Strehlow, MD, medical director of the unit and a clinical assistant professor of emergency medicine.

By mid-morning, about 10 hours after she was transferred to the CDA, Atkins was feeling chipper and was trying to charm some information out of the nursing team. "They are adorable," she told a visitor. "But you can't bribe them-they won't talk."

"That's right," clinical nurse specialist and nurse practitioner Garrett Chan, PhD, said, with a theatrical wink. "Not until we have all the results in hand."

Emergency department patients like Atkins increasingly are being seen in CDAs, also known as observation units, which have been launched in hospitals nationwide over the past 10 years. A 2003 survey in the American Journal of Emergency Medicine reported that almost 20 percent of U.S. hospitals had observation units, and Stanford established its CDA in April 2006. Last month the unit moved into a remodeled space in the hospital, and it will be relocated within the emergency department in the new hospital that is scheduled to open in 2015.

CDAs are designed as 23-hour diagnostic and treatment units for low- to moderate-risk patients who are too sick to be sent home, but not sick enough to be admitted to the hospital. Like Atkins, they might have persistent chest pain that needs to be monitored. Or perhaps they're suffering from an asthma attack, back pain, gastroenteritis, alcohol intoxication, allergic reactions, hypertension or transient ischemic attacks.

"Unfortunately, the volume of patients coming to emergency departments is increasing every year, while the number of EDs is decreasing," Strehlow said. "If your door is open, you're going to be full, and the observation unit is a way to decompress the hospital by treating someone in less than 24 hours."

The seven members of  the CDA team "are used to taking care of a variety of patients who could have anything," Strehlow said. "They have become adept at caring for patients with traumatic, neurologic and cardiac emergencies, among others, and that wide array of experience makes them excellent providers for this location."

A patient typically spends between three and four hours in the emergency room before being transferred to the CDA, where the team is trained to administer more than 25 different protocols. "These patients have our undivided attention," said Chan. "We can turn them around with intensive therapy or treatment."

Instead of giving an asthmatic patient inhaled medicine every four hours, for example, the team might bump it up to inhalations every two hours. To treat a patient with a bacterial skin infection, they might administer a fast-working intravenous antibiotic and observe its effectiveness.

Most CDA patients are admitted in the evening, and the following morning an attending emergency physician reviews their workups to decide, with other members of the team, whether they should be admitted to the hospital or discharged. The No. 1 complaint in the CDA is chest pain, Chan said. But only 4 percent of patients are found to have heart disease that requires intervention, and the rest are sent home.

Atkins, for example, was discharged when diagnostic tests confirmed that she did not have any life-threatening problems with her heart, lungs, carotid arteries or great vessels. "We called her primary provider to let him know what our workup was," Chan added. "And we suggested that future investigation of her chest pain might include a Holter monitor, to look for electrical disturbances."

Atkins left at 3 p.m.-some 20 hours after she arrived-without having to be admitted to the hospital. Thanks to the CDA, she was able to get a thorough review of her case and return home with something a quicker visit to the emergency department might not have provided: peace of mind.

 

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