Imran Nisar, MD

Design and Setting

In this prospective cohort study, we included all patients admitted to the hospitalist‐run SSU of Cook County Hospital, a 500‐bed public teaching hospital in Chicago, Illinois, from January through April of 2006. Our 14‐bed SSU opened in 2002 to reduce overcrowding on the traditional inpatient wards by admitting adult patients who require inpatient care but might be eligible for discharge within 3 days. The unit is geographically part of the ED but is staffed by resident physicians and a rotating group of hospitalist attending physicians from the Department of Medicine. At least 1 attending and resident physician are available throughout the day, including weekend days and holidays; evenings are covered by a resident who presents overnight admissions to an attending physician the following morning.

ED physicians admit general medical patients to the SSU 24 hours per day, 7 days per week. Though admissions do not require prior approval from SSU physicians, the Departments of Medicine and Emergency Medicine have collaboratively promoted 5 suggested admission‐location guidelines to admitting ED physicians (Figure 1). For candidate SSU patients, these 5 guidelines are not intended to be restrictive but to provide a framework for the complex decision‐making process that our ED physicians encounter, particularly during periods of extreme overcrowding.7 First, patients should have an anticipated stay shorter than 72 hours. Second, patients should not have an eventual need for admission to traditional inpatient services such as the general medicine wards or intensive care units; this guideline is intended to improve patient safety by reducing unnecessary handoffs between physicians.8 Third, patients with provisional cardiovascular diagnoses should be preferentially admitted to the SSU over the general medical wards; this guideline is intended to improve hospital‐wide efficiency because our SSU is equipped with continuous telemetry monitors, an exercise treadmill testing (ETT) laboratory, and other reserved cardiac tests (see Admission Characteristics and Services Received section, below). Fourth, patients' risk should be no higher than intermediate level. Admitting ED physicians are encouraged to use posted risk estimators for patients with provisional diagnoses of possible acute coronary syndrome (ACS), decompensated heart failure, asthma exacerbation, and out‐of‐control diabetes. Finally, patients should not need advanced ancillary services; these include bedside procedures (eg, central venous catheter insertions), time‐intensive nursing (eg, regular dressing changes), and complex social‐services (eg, long‐term care facility placements).

Figure 1

Subjects

The study subjects were all patients admitted to the SSU during the 4‐month study period. Patients were excluded from the entire study if they refused verbal consent to participate. All patients who consented were included in the description of patient admission characteristics. Thirteen patients who prematurely left the SSU against medical advice, however, were neither included in the descriptions of services received nor in the analyses of predictors of successful SSU stays. We excluded these patients because they needed services that they did not receiveincluding these patients in our analysis would tend to overestimate the efficiency of our SSU by shortening the length‐of‐stay (LOS) without adding diagnostic tests or treatments.

Data Collection

After receiving approval from the institutional review board, attending physician investigators conducted an interview, physical examination, and review of medical records for each enrolled patient within 12 hours of admission to the SSU. When ED attending physicians' provisional primary diagnoses included possible ACS or decompensated heart failure, which we knew from earlier pilot data were our 2 most common provisional diagnoses, investigators gathered patient data to be applied in validated models of risk after the study period (Figure 2).9, 10 Some of the clinical predictors required for these models are based on patients' findings on presentation to the ED. For example, Goldman's risk model for major cardiac events uses patients' initial systolic blood pressures on presentation to the ED.9 In such cases, investigators gathered needed data from electronic and paper charts generated in the ED. Upon discharge from the SSU, investigators reviewed patients' medical records a second time. All data were entered by investigators and instantly committed into an online database.

Figure 2

Admission Characteristics and Services Received

Patients were grouped according to the provisional diagnoses of ED attending physicians upon admission to the SSU (Figure 2). We chose to group patients by the provisional diagnoses of EDnot SSUattending physicians to better understand how ED physicians, the physicians who make the admission‐location decisions in our hospital, were using the SSU. Patients were first grouped as having possible ACS or heart failure, because patients with these provisional diagnoses were preferentially admitted to the SSU (Figure 1). When neither diagnosis was listed, patients were grouped according to ED attending physicians' first‐listed diagnoses. At the end of the study period, relevant risk models were applied to patients with possible ACS or heart failure and stratified as very low, low, intermediate, or high risk.9, 10 Patients with both possible ACS and heart failure were grouped according to the diagnosis with the highest corresponding risk assessment; if both risk assessments were the same, then the first‐listed diagnosis was used. Though developed to predict different clinical outcomes during different time periods, risk strata from the corresponding risk models were pooled across both diagnoses to develop a risk summary.

Upon discharge, investigators recorded which advanced diagnostic tests, specialty consultations, and acute care treatments patients received while in the SSU. Diagnostic tests were considered advanced if they were not routinely performed within 2 hours of being ordered. Advanced diagnostic tests were grouped into 2 types by their accessibility to ordering SSU physicians. Open access tests included echocardiograms and ETTs, which were reserved for SSU patients 6 days per week. Though the availability of open access tests was not unlimited, ordering physicians' needs for them rarely exceeded the immediate supply. On the other hand, limited access tests included both cardiac stress imaging studies, which were reserved for SSU patients on a very limited basis 4 or 5 days per week, and other tests that were not reserved for SSU patients, such as endoscopy, magnetic resonance imaging, or ultrasonography. Ordering physicians' needs for limited access tests often exceeded their immediate supply; in such cases, SSU patients were placed without priority into queues that included patients from the entire hospital.

Investigators recorded when patients received advanced diagnostic tests that were ordered by specialists. These tests, however, were not included in analyses of how services received by SSU patients affected SSU success, because SSU attending physicians were only indirectly involved in whether or not patients received these tests. Treatments were considered acute care treatments if they were commonly administered only in acute care settings, such as heparin for unstable angina or intravenous furosemide for pulmonary edema.

SSU Success

The SSU was designed to care for patients during brief stays and without eventual admission to traditional inpatient services. Therefore, we used patients' LOS and whether or not patients were admitted to traditional inpatient services as measures of SSU success. LOS was calculated from the time patients arrived in the SSU until the time they left. Therefore, neither time spent in the ED before admission to the SSU nor time spent on traditional inpatient services (if needed) contributed to our definition of LOS. Individual SSU patients were considered successfully cared for in the SSU if their LOS was less than 72 hours and they were discharged directly home from the SSU. We explored associations between these outcomes and provisional diagnoses, risk assessments, and services received.

Data Analysis

LOS data were right‐skewed; therefore, we used the Mann‐Whitney test for comparisons between 2 groups and the Kruskal‐Wallis test for comparisons among 3 or more groups. To test for trends of median LOS among ordered groupings, we used the method of Cuzick.11 We used Pearson's chi‐square test to compare proportions of patients grouped into categories and the chi‐square test for trends with equal scoring to test for trends among ordered groupings.

We performed multiple logistic regression to explore which variables were associated with SSU success. The following 5 demographic variables from Table 1 were insignificant in all single‐variable and multiple‐variable regression models that we tested and were, therefore, removed from further analyses to create more parsimonious models: gender, language, ethnicity, race, and whether or not patients had a primary care provider. Our multiple logistic regression models were fitted by maximum likelihood methods. In all of these models, odds ratios (ORs) were adjusted for patient characteristics that included age (in years), insulin‐requiring diabetes mellitus (yes or no), SSU attending physician, day of the week of SSU admission (weekday or weekend), and hospitalization during the preceding year. Confidence intervals (CIs) for predicted probabilities were computed using the delta method. All analyses were conducted with Stata Statistical Software, Release 9 (StataCorp, College Station, TX).

Subjects

During the 4‐month study period, 755 patients were admitted to the SSU. Among these patients, 4 were excluded from our study because they refused verbal consent. In the remaining study sample of 751 patients, all were included in the descriptions of patients' admission characteristics (Table 1), but 13 patients who left prematurely were excluded in both the descriptions of services received (Table 2) and the analyses of SSU success (Tables 3 and 4).

Admission Characteristics and Services Received

A narrow range of provisional diagnoses were listed by ED attending physicians and 641 patients (85% of 751) were grouped as having possible ACS or heart failure (Figure 2). Patients with these diagnoses were later risk‐stratified and, when pooled across risk strata, only 14 patients (2% of 641) exceeded the suggested admission‐location criterion for the SSU of lower than high risk. Despite the array and frequency of diagnostic and treatment services that patients received, SSU physicians worked mostly independently, requesting specialty consultations for only 19% of patients (141/738; Table 2).

SSU Success

The median LOS for all patients was 42 hours (interquartile range [IRQ] 22‐63) and 156 patients (21% of 738) had unsuccessful SSU stays (Table 3). The most common reason for an unsuccessful stay was a stay longer than 72 hours (71% of 156). Among the 66 patients who required admission to traditional inpatient services, nearly one‐half (48%) were admitted expressly to receive treatments not available in the SSU after having a specialty consult.

Patients' provisional diagnoses were associated with unsuccessful stays in bivariate analyses (Table 3). In addition, when patients were grouped into 3 risk stratums (very‐low, low, and intermediate‐and‐high), unsuccessful stays increased with increasing risk. For example, in patients with possible ACS, the proportion of unsuccessful stays increased from 17% of 306 very‐low risk patients to 27% of 55 intermediate‐and‐high risk patients (P value for trend = 0.012. Similarly, in patients with heart failure, the proportion of unsuccessful stays increased from 25% of 181 very‐low risk patients to 100% of 3 intermediate‐and‐high risk patients (P value for trend = 0.004).

However, in multiple variable models that simultaneously included patients' characteristics upon admission with services received during their SSU stay, only the provisional diagnosis of heart failure was associated with unsuccessful stays (OR, 1.9; 95% CI, 1.12‐3.18); risk assessments for possible ACS (P = 0.29) and heart failure (P = 0.32) were unimportant predictors of unsuccessful stays (Table 4). On the other hand, whether or not patients received diagnostic tests, acute care treatments, or specialty consultations were important predictors. In particular, patients who received specialty consultations were much more likely to require admission to traditional inpatient services than those patients who did not (OR, 13.1; 95% CI, 6.9‐24.9) and had a 52% chance of having an unsuccessful stay (95% CI, 42‐61%; Figure 3). In addition, the accessibility of a diagnostic test was inversely proportional to the chance of having a long stay; patients who received an open access test had a 12% chance of a long stay (95% CI, 8‐16%) whereas those who received a limited access test had a 29% chance of a long stay (95% CI, 20‐39%). Receiving acute care treatments was also a significant, though less important, predictor of an unsuccessful stay (Table 4).

Figure 3

Design and Setting

In this prospective cohort study, we included all patients admitted to the hospitalist‐run SSU of Cook County Hospital, a 500‐bed public teaching hospital in Chicago, Illinois, from January through April of 2006. Our 14‐bed SSU opened in 2002 to reduce overcrowding on the traditional inpatient wards by admitting adult patients who require inpatient care but might be eligible for discharge within 3 days. The unit is geographically part of the ED but is staffed by resident physicians and a rotating group of hospitalist attending physicians from the Department of Medicine. At least 1 attending and resident physician are available throughout the day, including weekend days and holidays; evenings are covered by a resident who presents overnight admissions to an attending physician the following morning.

ED physicians admit general medical patients to the SSU 24 hours per day, 7 days per week. Though admissions do not require prior approval from SSU physicians, the Departments of Medicine and Emergency Medicine have collaboratively promoted 5 suggested admission‐location guidelines to admitting ED physicians (Figure 1). For candidate SSU patients, these 5 guidelines are not intended to be restrictive but to provide a framework for the complex decision‐making process that our ED physicians encounter, particularly during periods of extreme overcrowding.7 First, patients should have an anticipated stay shorter than 72 hours. Second, patients should not have an eventual need for admission to traditional inpatient services such as the general medicine wards or intensive care units; this guideline is intended to improve patient safety by reducing unnecessary handoffs between physicians.8 Third, patients with provisional cardiovascular diagnoses should be preferentially admitted to the SSU over the general medical wards; this guideline is intended to improve hospital‐wide efficiency because our SSU is equipped with continuous telemetry monitors, an exercise treadmill testing (ETT) laboratory, and other reserved cardiac tests (see Admission Characteristics and Services Received section, below). Fourth, patients' risk should be no higher than intermediate level. Admitting ED physicians are encouraged to use posted risk estimators for patients with provisional diagnoses of possible acute coronary syndrome (ACS), decompensated heart failure, asthma exacerbation, and out‐of‐control diabetes. Finally, patients should not need advanced ancillary services; these include bedside procedures (eg, central venous catheter insertions), time‐intensive nursing (eg, regular dressing changes), and complex social‐services (eg, long‐term care facility placements).

Figure 1

Subjects

The study subjects were all patients admitted to the SSU during the 4‐month study period. Patients were excluded from the entire study if they refused verbal consent to participate. All patients who consented were included in the description of patient admission characteristics. Thirteen patients who prematurely left the SSU against medical advice, however, were neither included in the descriptions of services received nor in the analyses of predictors of successful SSU stays. We excluded these patients because they needed services that they did not receiveincluding these patients in our analysis would tend to overestimate the efficiency of our SSU by shortening the length‐of‐stay (LOS) without adding diagnostic tests or treatments.

Data Collection

After receiving approval from the institutional review board, attending physician investigators conducted an interview, physical examination, and review of medical records for each enrolled patient within 12 hours of admission to the SSU. When ED attending physicians' provisional primary diagnoses included possible ACS or decompensated heart failure, which we knew from earlier pilot data were our 2 most common provisional diagnoses, investigators gathered patient data to be applied in validated models of risk after the study period (Figure 2).9, 10 Some of the clinical predictors required for these models are based on patients' findings on presentation to the ED. For example, Goldman's risk model for major cardiac events uses patients' initial systolic blood pressures on presentation to the ED.9 In such cases, investigators gathered needed data from electronic and paper charts generated in the ED. Upon discharge from the SSU, investigators reviewed patients' medical records a second time. All data were entered by investigators and instantly committed into an online database.

Figure 2

Admission Characteristics and Services Received

Patients were grouped according to the provisional diagnoses of ED attending physicians upon admission to the SSU (Figure 2). We chose to group patients by the provisional diagnoses of EDnot SSUattending physicians to better understand how ED physicians, the physicians who make the admission‐location decisions in our hospital, were using the SSU. Patients were first grouped as having possible ACS or heart failure, because patients with these provisional diagnoses were preferentially admitted to the SSU (Figure 1). When neither diagnosis was listed, patients were grouped according to ED attending physicians' first‐listed diagnoses. At the end of the study period, relevant risk models were applied to patients with possible ACS or heart failure and stratified as very low, low, intermediate, or high risk.9, 10 Patients with both possible ACS and heart failure were grouped according to the diagnosis with the highest corresponding risk assessment; if both risk assessments were the same, then the first‐listed diagnosis was used. Though developed to predict different clinical outcomes during different time periods, risk strata from the corresponding risk models were pooled across both diagnoses to develop a risk summary.

Upon discharge, investigators recorded which advanced diagnostic tests, specialty consultations, and acute care treatments patients received while in the SSU. Diagnostic tests were considered advanced if they were not routinely performed within 2 hours of being ordered. Advanced diagnostic tests were grouped into 2 types by their accessibility to ordering SSU physicians. Open access tests included echocardiograms and ETTs, which were reserved for SSU patients 6 days per week. Though the availability of open access tests was not unlimited, ordering physicians' needs for them rarely exceeded the immediate supply. On the other hand, limited access tests included both cardiac stress imaging studies, which were reserved for SSU patients on a very limited basis 4 or 5 days per week, and other tests that were not reserved for SSU patients, such as endoscopy, magnetic resonance imaging, or ultrasonography. Ordering physicians' needs for limited access tests often exceeded their immediate supply; in such cases, SSU patients were placed without priority into queues that included patients from the entire hospital.

Investigators recorded when patients received advanced diagnostic tests that were ordered by specialists. These tests, however, were not included in analyses of how services received by SSU patients affected SSU success, because SSU attending physicians were only indirectly involved in whether or not patients received these tests. Treatments were considered acute care treatments if they were commonly administered only in acute care settings, such as heparin for unstable angina or intravenous furosemide for pulmonary edema.

SSU Success

The SSU was designed to care for patients during brief stays and without eventual admission to traditional inpatient services. Therefore, we used patients' LOS and whether or not patients were admitted to traditional inpatient services as measures of SSU success. LOS was calculated from the time patients arrived in the SSU until the time they left. Therefore, neither time spent in the ED before admission to the SSU nor time spent on traditional inpatient services (if needed) contributed to our definition of LOS. Individual SSU patients were considered successfully cared for in the SSU if their LOS was less than 72 hours and they were discharged directly home from the SSU. We explored associations between these outcomes and provisional diagnoses, risk assessments, and services received.

Data Analysis

LOS data were right‐skewed; therefore, we used the Mann‐Whitney test for comparisons between 2 groups and the Kruskal‐Wallis test for comparisons among 3 or more groups. To test for trends of median LOS among ordered groupings, we used the method of Cuzick.11 We used Pearson's chi‐square test to compare proportions of patients grouped into categories and the chi‐square test for trends with equal scoring to test for trends among ordered groupings.

We performed multiple logistic regression to explore which variables were associated with SSU success. The following 5 demographic variables from Table 1 were insignificant in all single‐variable and multiple‐variable regression models that we tested and were, therefore, removed from further analyses to create more parsimonious models: gender, language, ethnicity, race, and whether or not patients had a primary care provider. Our multiple logistic regression models were fitted by maximum likelihood methods. In all of these models, odds ratios (ORs) were adjusted for patient characteristics that included age (in years), insulin‐requiring diabetes mellitus (yes or no), SSU attending physician, day of the week of SSU admission (weekday or weekend), and hospitalization during the preceding year. Confidence intervals (CIs) for predicted probabilities were computed using the delta method. All analyses were conducted with Stata Statistical Software, Release 9 (StataCorp, College Station, TX).

Subjects

During the 4‐month study period, 755 patients were admitted to the SSU. Among these patients, 4 were excluded from our study because they refused verbal consent. In the remaining study sample of 751 patients, all were included in the descriptions of patients' admission characteristics (Table 1), but 13 patients who left prematurely were excluded in both the descriptions of services received (Table 2) and the analyses of SSU success (Tables 3 and 4).

Admission Characteristics and Services Received

A narrow range of provisional diagnoses were listed by ED attending physicians and 641 patients (85% of 751) were grouped as having possible ACS or heart failure (Figure 2). Patients with these diagnoses were later risk‐stratified and, when pooled across risk strata, only 14 patients (2% of 641) exceeded the suggested admission‐location criterion for the SSU of lower than high risk. Despite the array and frequency of diagnostic and treatment services that patients received, SSU physicians worked mostly independently, requesting specialty consultations for only 19% of patients (141/738; Table 2).

SSU Success

The median LOS for all patients was 42 hours (interquartile range [IRQ] 22‐63) and 156 patients (21% of 738) had unsuccessful SSU stays (Table 3). The most common reason for an unsuccessful stay was a stay longer than 72 hours (71% of 156). Among the 66 patients who required admission to traditional inpatient services, nearly one‐half (48%) were admitted expressly to receive treatments not available in the SSU after having a specialty consult.

Patients' provisional diagnoses were associated with unsuccessful stays in bivariate analyses (Table 3). In addition, when patients were grouped into 3 risk stratums (very‐low, low, and intermediate‐and‐high), unsuccessful stays increased with increasing risk. For example, in patients with possible ACS, the proportion of unsuccessful stays increased from 17% of 306 very‐low risk patients to 27% of 55 intermediate‐and‐high risk patients (P value for trend = 0.012. Similarly, in patients with heart failure, the proportion of unsuccessful stays increased from 25% of 181 very‐low risk patients to 100% of 3 intermediate‐and‐high risk patients (P value for trend = 0.004).

However, in multiple variable models that simultaneously included patients' characteristics upon admission with services received during their SSU stay, only the provisional diagnosis of heart failure was associated with unsuccessful stays (OR, 1.9; 95% CI, 1.12‐3.18); risk assessments for possible ACS (P = 0.29) and heart failure (P = 0.32) were unimportant predictors of unsuccessful stays (Table 4). On the other hand, whether or not patients received diagnostic tests, acute care treatments, or specialty consultations were important predictors. In particular, patients who received specialty consultations were much more likely to require admission to traditional inpatient services than those patients who did not (OR, 13.1; 95% CI, 6.9‐24.9) and had a 52% chance of having an unsuccessful stay (95% CI, 42‐61%; Figure 3). In addition, the accessibility of a diagnostic test was inversely proportional to the chance of having a long stay; patients who received an open access test had a 12% chance of a long stay (95% CI, 8‐16%) whereas those who received a limited access test had a 29% chance of a long stay (95% CI, 20‐39%). Receiving acute care treatments was also a significant, though less important, predictor of an unsuccessful stay (Table 4).

Figure 3

Design and Setting

In this prospective cohort study, we included all patients admitted to the hospitalist‐run SSU of Cook County Hospital, a 500‐bed public teaching hospital in Chicago, Illinois, from January through April of 2006. Our 14‐bed SSU opened in 2002 to reduce overcrowding on the traditional inpatient wards by admitting adult patients who require inpatient care but might be eligible for discharge within 3 days. The unit is geographically part of the ED but is staffed by resident physicians and a rotating group of hospitalist attending physicians from the Department of Medicine. At least 1 attending and resident physician are available throughout the day, including weekend days and holidays; evenings are covered by a resident who presents overnight admissions to an attending physician the following morning.

ED physicians admit general medical patients to the SSU 24 hours per day, 7 days per week. Though admissions do not require prior approval from SSU physicians, the Departments of Medicine and Emergency Medicine have collaboratively promoted 5 suggested admission‐location guidelines to admitting ED physicians (Figure 1). For candidate SSU patients, these 5 guidelines are not intended to be restrictive but to provide a framework for the complex decision‐making process that our ED physicians encounter, particularly during periods of extreme overcrowding.7 First, patients should have an anticipated stay shorter than 72 hours. Second, patients should not have an eventual need for admission to traditional inpatient services such as the general medicine wards or intensive care units; this guideline is intended to improve patient safety by reducing unnecessary handoffs between physicians.8 Third, patients with provisional cardiovascular diagnoses should be preferentially admitted to the SSU over the general medical wards; this guideline is intended to improve hospital‐wide efficiency because our SSU is equipped with continuous telemetry monitors, an exercise treadmill testing (ETT) laboratory, and other reserved cardiac tests (see Admission Characteristics and Services Received section, below). Fourth, patients' risk should be no higher than intermediate level. Admitting ED physicians are encouraged to use posted risk estimators for patients with provisional diagnoses of possible acute coronary syndrome (ACS), decompensated heart failure, asthma exacerbation, and out‐of‐control diabetes. Finally, patients should not need advanced ancillary services; these include bedside procedures (eg, central venous catheter insertions), time‐intensive nursing (eg, regular dressing changes), and complex social‐services (eg, long‐term care facility placements).

Figure 1

Subjects

The study subjects were all patients admitted to the SSU during the 4‐month study period. Patients were excluded from the entire study if they refused verbal consent to participate. All patients who consented were included in the description of patient admission characteristics. Thirteen patients who prematurely left the SSU against medical advice, however, were neither included in the descriptions of services received nor in the analyses of predictors of successful SSU stays. We excluded these patients because they needed services that they did not receiveincluding these patients in our analysis would tend to overestimate the efficiency of our SSU by shortening the length‐of‐stay (LOS) without adding diagnostic tests or treatments.

Data Collection

After receiving approval from the institutional review board, attending physician investigators conducted an interview, physical examination, and review of medical records for each enrolled patient within 12 hours of admission to the SSU. When ED attending physicians' provisional primary diagnoses included possible ACS or decompensated heart failure, which we knew from earlier pilot data were our 2 most common provisional diagnoses, investigators gathered patient data to be applied in validated models of risk after the study period (Figure 2).9, 10 Some of the clinical predictors required for these models are based on patients' findings on presentation to the ED. For example, Goldman's risk model for major cardiac events uses patients' initial systolic blood pressures on presentation to the ED.9 In such cases, investigators gathered needed data from electronic and paper charts generated in the ED. Upon discharge from the SSU, investigators reviewed patients' medical records a second time. All data were entered by investigators and instantly committed into an online database.

Figure 2

Admission Characteristics and Services Received

Patients were grouped according to the provisional diagnoses of ED attending physicians upon admission to the SSU (Figure 2). We chose to group patients by the provisional diagnoses of EDnot SSUattending physicians to better understand how ED physicians, the physicians who make the admission‐location decisions in our hospital, were using the SSU. Patients were first grouped as having possible ACS or heart failure, because patients with these provisional diagnoses were preferentially admitted to the SSU (Figure 1). When neither diagnosis was listed, patients were grouped according to ED attending physicians' first‐listed diagnoses. At the end of the study period, relevant risk models were applied to patients with possible ACS or heart failure and stratified as very low, low, intermediate, or high risk.9, 10 Patients with both possible ACS and heart failure were grouped according to the diagnosis with the highest corresponding risk assessment; if both risk assessments were the same, then the first‐listed diagnosis was used. Though developed to predict different clinical outcomes during different time periods, risk strata from the corresponding risk models were pooled across both diagnoses to develop a risk summary.

Upon discharge, investigators recorded which advanced diagnostic tests, specialty consultations, and acute care treatments patients received while in the SSU. Diagnostic tests were considered advanced if they were not routinely performed within 2 hours of being ordered. Advanced diagnostic tests were grouped into 2 types by their accessibility to ordering SSU physicians. Open access tests included echocardiograms and ETTs, which were reserved for SSU patients 6 days per week. Though the availability of open access tests was not unlimited, ordering physicians' needs for them rarely exceeded the immediate supply. On the other hand, limited access tests included both cardiac stress imaging studies, which were reserved for SSU patients on a very limited basis 4 or 5 days per week, and other tests that were not reserved for SSU patients, such as endoscopy, magnetic resonance imaging, or ultrasonography. Ordering physicians' needs for limited access tests often exceeded their immediate supply; in such cases, SSU patients were placed without priority into queues that included patients from the entire hospital.

Investigators recorded when patients received advanced diagnostic tests that were ordered by specialists. These tests, however, were not included in analyses of how services received by SSU patients affected SSU success, because SSU attending physicians were only indirectly involved in whether or not patients received these tests. Treatments were considered acute care treatments if they were commonly administered only in acute care settings, such as heparin for unstable angina or intravenous furosemide for pulmonary edema.

SSU Success

The SSU was designed to care for patients during brief stays and without eventual admission to traditional inpatient services. Therefore, we used patients' LOS and whether or not patients were admitted to traditional inpatient services as measures of SSU success. LOS was calculated from the time patients arrived in the SSU until the time they left. Therefore, neither time spent in the ED before admission to the SSU nor time spent on traditional inpatient services (if needed) contributed to our definition of LOS. Individual SSU patients were considered successfully cared for in the SSU if their LOS was less than 72 hours and they were discharged directly home from the SSU. We explored associations between these outcomes and provisional diagnoses, risk assessments, and services received.

Data Analysis

LOS data were right‐skewed; therefore, we used the Mann‐Whitney test for comparisons between 2 groups and the Kruskal‐Wallis test for comparisons among 3 or more groups. To test for trends of median LOS among ordered groupings, we used the method of Cuzick.11 We used Pearson's chi‐square test to compare proportions of patients grouped into categories and the chi‐square test for trends with equal scoring to test for trends among ordered groupings.

We performed multiple logistic regression to explore which variables were associated with SSU success. The following 5 demographic variables from Table 1 were insignificant in all single‐variable and multiple‐variable regression models that we tested and were, therefore, removed from further analyses to create more parsimonious models: gender, language, ethnicity, race, and whether or not patients had a primary care provider. Our multiple logistic regression models were fitted by maximum likelihood methods. In all of these models, odds ratios (ORs) were adjusted for patient characteristics that included age (in years), insulin‐requiring diabetes mellitus (yes or no), SSU attending physician, day of the week of SSU admission (weekday or weekend), and hospitalization during the preceding year. Confidence intervals (CIs) for predicted probabilities were computed using the delta method. All analyses were conducted with Stata Statistical Software, Release 9 (StataCorp, College Station, TX).

Subjects

During the 4‐month study period, 755 patients were admitted to the SSU. Among these patients, 4 were excluded from our study because they refused verbal consent. In the remaining study sample of 751 patients, all were included in the descriptions of patients' admission characteristics (Table 1), but 13 patients who left prematurely were excluded in both the descriptions of services received (Table 2) and the analyses of SSU success (Tables 3 and 4).

Admission Characteristics and Services Received

A narrow range of provisional diagnoses were listed by ED attending physicians and 641 patients (85% of 751) were grouped as having possible ACS or heart failure (Figure 2). Patients with these diagnoses were later risk‐stratified and, when pooled across risk strata, only 14 patients (2% of 641) exceeded the suggested admission‐location criterion for the SSU of lower than high risk. Despite the array and frequency of diagnostic and treatment services that patients received, SSU physicians worked mostly independently, requesting specialty consultations for only 19% of patients (141/738; Table 2).

SSU Success

The median LOS for all patients was 42 hours (interquartile range [IRQ] 22‐63) and 156 patients (21% of 738) had unsuccessful SSU stays (Table 3). The most common reason for an unsuccessful stay was a stay longer than 72 hours (71% of 156). Among the 66 patients who required admission to traditional inpatient services, nearly one‐half (48%) were admitted expressly to receive treatments not available in the SSU after having a specialty consult.

Patients' provisional diagnoses were associated with unsuccessful stays in bivariate analyses (Table 3). In addition, when patients were grouped into 3 risk stratums (very‐low, low, and intermediate‐and‐high), unsuccessful stays increased with increasing risk. For example, in patients with possible ACS, the proportion of unsuccessful stays increased from 17% of 306 very‐low risk patients to 27% of 55 intermediate‐and‐high risk patients (P value for trend = 0.012. Similarly, in patients with heart failure, the proportion of unsuccessful stays increased from 25% of 181 very‐low risk patients to 100% of 3 intermediate‐and‐high risk patients (P value for trend = 0.004).

However, in multiple variable models that simultaneously included patients' characteristics upon admission with services received during their SSU stay, only the provisional diagnosis of heart failure was associated with unsuccessful stays (OR, 1.9; 95% CI, 1.12‐3.18); risk assessments for possible ACS (P = 0.29) and heart failure (P = 0.32) were unimportant predictors of unsuccessful stays (Table 4). On the other hand, whether or not patients received diagnostic tests, acute care treatments, or specialty consultations were important predictors. In particular, patients who received specialty consultations were much more likely to require admission to traditional inpatient services than those patients who did not (OR, 13.1; 95% CI, 6.9‐24.9) and had a 52% chance of having an unsuccessful stay (95% CI, 42‐61%; Figure 3). In addition, the accessibility of a diagnostic test was inversely proportional to the chance of having a long stay; patients who received an open access test had a 12% chance of a long stay (95% CI, 8‐16%) whereas those who received a limited access test had a 29% chance of a long stay (95% CI, 20‐39%). Receiving acute care treatments was also a significant, though less important, predictor of an unsuccessful stay (Table 4).

Figure 3