This article appears in the May 2012 issue of HealthLeaders magazine.
Aside from a patient, perhaps no element of a hospital system is as in need of emergency care as the emergency department itself.
Health systems know this and are working to overcome ED bottlenecks by initiating improved throughput systems. They are imposing fast-track, split-care programs to improve patient flow and decrease wait times by caring for patients with lower acuity in one area, freeing up beds for those with more severe illnesses.
It may seem like a dizzying array of models, but hospitals don't have much time in the we-can't-wait-much-longer ED world to improve patient flow and provide safer access to care.
Hospitals are improving coordination among nurses and physicians to ensure that the sickest of patients are seen quickly, working with primary care providers to develop different care for too-frequent ED users, and installing electronic medical record systems to hasten and coordinate care through outpatient centers as well as in the hospital.
Hospitals have been systematically revamping and implementing changes in the wake of a 2007 Institute of Medicine report that called the ED a growing national crisis, citing not only delays of care, but also diversion of ambulances to other hospitals and inadequate capacity to handle a large influx of patients requiring boarding. The IOM described in the report "a widening gap between the quality of emergency care Americans expect and the quality they actually they actually receive."
Moving toward ED improvements is a bumpy journey, but one of slow, steady progress if properly managed, with health systems finding direct throughput gains not by singular, but collective changes, hospital leaders say. The 455-licensed-bed Holy Cross Hospital in Silver Spring, Md., like many hospitals, uses a variety of approaches to ED throughput "to make sure the sickest of the sick gets to see a doctor immediately," says James Del Vecchio, MD, FACEP, CMIO and medical director of the department of emergency medicine at Holy Cross.
To improve patient flow, the work begins as soon as a patient enters the hospital and is seen by a clinician, instead of sitting around and waiting to be registered. And quickly, the hospital separates patients having serious conditions from those who do not. By evaluating patients having "minor sore throats" for instance, "the hospital can siphon off 20% of 240 patients going to the ED on any given day," he says.
"Theoretically," Del Vecchio says, "those patients could have been seen at an urgent care clinic or have gone to a primary care physician, but may not have had one," he says. By redirecting patients who don't need ED services to an in-hospital urgent care center called Express Care, the hospital has a quicker response for patients with conditions, such as severe stomach ailments or potential appendicitis cases, who should be seen in the ED.
Of those patients sent to Express Care, the hospital counts 87% of those patients as "written for discharge at Express Care in 90 minutes," says Del Vecchio. "We are aiming for 90%, but still, it's pretty good," he says.
Hospitals like Holy Cross use other techniques to improve patient flow. For example, Holy Cross empowers nurses to begin taking tests on potentially more serious conditions, such as severe stomach pains or potential appendicitis cases. It stations a physician in an area near the ED for at least 11 hours a day to, in effect, conduct ED business without interfering with the ED, Del Vecchio says. "It's doing waiting room management so patients can be seen but not interrupt the flow." In the meantime, a multidisciplinary team coordinates other areas of the hospital, whether it's lab staff or housekeeping, to free up bed space and, Del Vecchio adds, to effectively reduce wait times.
Hospitals are trying new programs to deal with increasing numbers of patients visiting the ED and the resulting impact on wait times. From the moment patients enter an ED until they are discharged from the ED, the average time spent in waiting rooms nationally was 4 hours and 7 minutes in 2009, an increase of 4 minutes compared to 2008 and 31 minutes more than the national average in 2002, according to Press Ganey 2010 ED Pulse Report.
Hospitals don't see the situation easing any time soon. At least 32 million people who are currently uninsured will have coverage under PPACA—and hospital leaders can hope those patients get nonemergent care from a primary care physician and not the ED. But the country faces years of primary care shortages. The United States has about 350,000 primary-care physicians, but about 45,000 more will be needed by 2020, according to the Association of American Medical Colleges.
"My concern is if there are going to be enough primary care providers in place for them to go for appropriate healthcare," Del Vecchio says. "There will be an ongoing and worsening of the problem of the ED if there is a lack of primary care physicians."
Success key No. 1: Taking pressure off the ED
For many hospitals, the time from the afternoon to the evenings is one of overcrowding and nervousness inside the ED, and it has been no different at the 713-bed Memorial Regional Hospital in Hollywood, Fla., and its 72-bed ED, says Maggie Hansen, RN, BSN, chief nursing officer.
"We have our saturation point [beginning] in the afternoon," says Hansen. "Usually, it is Monday through Thursday, from 3 p.m. to 1 a.m."
The hospital has launched special programs to deal with overcrowding and potentially dangerous situations. One of its most effective ways of reducing the number of patients using the ED has been working with local community centers that provide patient care beyond the hospital, says Hansen.
Like many healthcare systems, Memorial has a high percentage of patients—about 20%—who do not have a primary physician or medical home, Hansen says. While Memorial's ED volume increased rapidly from 2005 to 2010, Hansen says, it has "stabilized" in the past year, increasing from 91,000 in 2009 to 92,000 in 2011.
Hansen attributes the relatively small increase to the hospital's community health services ED discharge program, "which seeks to provide primary care in South Broward for residents who qualify," she says.
"We have also worked diligently with many providers in the community to partner with them regarding patients who are considered high ED utilizers to develop specific plans of care to meet their needs on an outpatient basis," Hansen adds.
The hospital has an ED discharge clinic that provides follow-up care for recently discharged patients. It also has an ED diversion clinic to establish "quick care" for patients who were unable to schedule an appointment with their primary care physicians.
"There are a lot of people who don't have a payer for healthcare. It's our mission to care for people regardless of their ability to pay," Hansen says. "But we don't want them to overutilize the ED services because they don't have a primary care physician. If they come to our ED for an illness—say, heart failure—we can refer them to a community health service so they can be followed up, so they have a medical home."
Having working relationships in the community must be connected with the hospital's own "patient flow team" that evaluates its staffing each day for the ED unit, which includes 62 acute care beds and focuses on patients who leave the ED without treatment, against the advice of hospital staff, Hansen says.
Hansen says that only 1.8% of ED patients leave without being seen, which is better than the national average of 2.5%.
The patient flow team, which includes physicians and nurses, "looks at all components that impact patient flow to identify challenges and barriers, and work on ways to remove them," Hansen says.
The hospital has a "split flow" design in which ED areas are separated into acute care, quick care, and "super-track," depending care the patient may need, Hansen says. The average treat-and-release time for all ED patients is 210 minutes, but for those seen under quick care the time is 110 minutes.
Quick care is a separate area within the ED staffed with a physician and nurses who see patients who "will not need a lot of resources and can be out soon," Hansen says. The super-track room, located outside the ED, where a physician extender sees patients having the "most minor of complaints," Hansen adds. "A patient can be out in 38 minutes," she says. "You can't even go to a doctor's office and be out that quickly."
To keep patients from returning to the ED, the hospital also has a disease management program "especially for those people who don't really have a primary care physician or payer source to have their healthcare managed by a physician or nursing staff. The idea is to help them care for themselves by showing them how to make appointments, take medications," Hansen says. "We help them with following appointments and answer questions they need."
The program is connected to the community health service "to avoid unnecessary ED visits, focusing on preventing readmission of congestive heart failure in particular," Hansen says.
Success key No. 2: EMR in the ED
Hospitals are using electronic health systems to improve coordination and care in the ED, but first they have to recognize one caveat: These systems may not be more efficient, at least initially, than paper records.
The 265-licensed-bed MidMichigan Medical Center in Midland, Mich., turned to an EMR system primarily due to federal mandate, but the transition has become a slow process that involves working with physicians to improve their handling of the records. Hospital officials found that it was important not to just wait for everyone to adapt to the EMR, but to introduce other changes in the ED, as well.
"When the EMR was rolled out at our institution in March 2011, it led to a marked increase in our wait times and throughput times," says Danny Greig, MD, emergency physician at MidMichigan Medical Center. "We were the first people to switch to EMR before the rest of the hospital came on board. It was a huge struggle, just the learning curve, and initially that cut our productivity at least 40%. Initially, a lot of docs were fighting it and wanted to do paper."
As the hospital physicians struggled to deal with the EMR, there were other ramifications, such as a decrease in patient satisfaction, "as waiting times are the major complaint from patients who visit the ED," he adds.
The hospital leaders didn't wait for everyone to come around on EMR.
Because of those early difficulties with the EMR, the hospital could not simply rely on electronic innovation to improve its throughput. Instead, hospital administration and Midland ER Corp. relied on other strategies, such as adding overlap physician shift coverage for afternoons and evenings on a rotational basis, he adds. Essentially, the hospital increased physician coverage from having four to five 10-hour shifts each day.
In addition, the hospital instituted an expedited care model, leaving rooms open for patients with more minor complaints and a nurse staffed to focus on them to move them quickly through the department. From adding the extra shift and expedited care, overall ED wait times were reduced from 236 minutes to 215 minutes, Greig says.
"I think we're putting all the pieces together," he says. "The hospital is getting patients out of the ED, up to the floors when they need to be admitted, and not boarding them in the ED for six or eight hours or occupying beds that can be used. In the meantime, they are beefing up x-ray, EKG, and lab services to use with the ED. Patients aren't waiting a half hour or 45 minutes to get an ankle x-ray or blood drawn."
More of the doctors are seeing improvements in working with EMR.
"Becoming facile with the EMR is almost completely a function of time," Greig says. "We saw a great improvement at about 2 months, and by 6 months physicians have generally become as good as they are going to get with the technology—again never getting quite as efficient as before it was instituted.
"I embraced it, and it's no question that EMR is the way to go," Greig adds, citing the potential of "improved patient outcomes, the reduced drug errors, the completeness of discharge instructions, in the long run."
Success key No. 3: Frequent fliers
For EDs nationwide, one of the biggest problems is "frequent fliers," those patients who repeatedly use the ED as an alternative to primary care. Many of those patients need psychiatric services or should be seen for alcohol or drug abuse conditions.
Too often, those patients are dismissed by their primary care physicians for failure to follow instructions—and are "fired" by the practitioners, says R. Corey Waller, MD, a specialist in addiction and emergency medicine and director of the Spectrum Health Medical Group Center for Integrative Medicine. Most of the patients have been diagnosed as having mental health or substance abuse issues or poorly controlled medical issues, such as diabetes, or pain issues that "were never fully vetted or diagnosed," he says.
Spectrum Health, based in Grand Rapids, Mich., had initiated the program in late 2011 after identifying nearly 1,000 patients who used the ED at 847-licensed-bed Spectrum Butterworth and 284-licensed-bed Blodgett hospitals more than 10 times in a year. By focusing on these patients, Spectrum has channeled them to cheaper care programs and away from the ED, with hundreds of thousands of dollars saved, Waller says.
Under the program, physicians ask the patients if they would agree to coordinated care treatment; most of the nearly 200 patients contacted early this year said they would. The center's treatment team uses addiction specialists, RN case managers, and medical social workers to evaluate the medical issues, such as pain or diabetes, but also addiction or alcohol abuse that may be driving patients to the ED.
"Of the patients in our system, more than 60% have been preidentified as having been engaged in our local mental health system and substance abuse service," Waller says. Those patients accounted for more than 20,000 total visits and up to $50 million a year in costs to the hospital system. The program was started after he began seeing the same type of patients and it became frustrating, Waller adds.
At least 40% of the patients are neurobiologically addicted to some substance. Through a regimen that combines medication and behavioral therapy, at least 90% have stayed clean since starting treatment, he adds.
When patients "show up here, we have a four-hour initial visit in which they see a case manager, a social worker, and myself," Waller says. "We look over the last five years or more of their records to determine what's been done, what hasn't been done, what's been missed, what's been diagnosed."
Over time, Waller encourages the patients to work with primary care physicians, beginning with phone consultations. Often, those physicians can "identify previously undiagnosed illness," he adds.
"The hardest part is getting these people placed into appropriate therapies," he says. "The goal is to come up with a screening tool so we can identify them and get them the social or psychological or medical services they need before they turn into a high-frequency user of the ED," Waller says.
In that way, he says, the cycle of patients going to the ED is curtailed.
Success key No. 4: Collaborating competitors
A major frustration for hospitals has been trying to access information from previous treatments at other hospitals that could be helpful to avoid redundant or unnecessary tests.
But that is changing in Maryland where competing hospitals are sharing information as well as among doctors' offices. Doctors can access operative notes, discharge summaries, consultations, lab reports, and x-rays from a surgery that took place a short time earlier at a different hospital, with the impact of improving care for ED patients, says Del Vecchio.
The Chesapeake Regional Information System for Our Patients is formally designated as Maryland's statewide health information exchange and has also been named Maryland's Regional Extension Center for Health. The nonprofit membership corporation works to help healthcare providers use EHRs in a meaningful way and to enable providers to share clinical data with other providers and hospital systems across the state.
"From a throughput perspective, the biggest impact of this is when you have medical records to review," says Del Vecchio. "Traditionally you would have to get a signed release, fax it to the other facility, and hope that someone is available to pull the records and send them to you. You try to find the necessary information. The whole process could take hours. Now you automatically find a patient's visit from another hospital using a medical record" available 24 hours a day.
Del Vecchio says that the exchange program is particularly useful in thwarting unnecessary tests. He cited the example of an exchange of data that was particularly helpful related to a patient with abdominal pains who had been in a motor vehicle accident two days earlier and treated at another ED in Maryland, so there were x-rays and CT scans. "I found all her lab results and other clinical information quickly, and that they had done a thorough workup," Del Vecchio says. "That process could have taken hours—if I was lucky enough to get the reports faxed over. By not having unnecessary tests or procedures, you've already improved throughput and patient care."
This article appears in the May 2012 issue of HealthLeaders magazine.
Reprint HLR0512-7
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
