While many functions of the emergency department must be reactive in nature, with proper preparation, an effective response can ensure optimal outcomes.
This article appears in the May 2014 issue of HealthLeaders magazine.
While many functions of the emergency department must be reactive in nature, with proper preparation, an effective response can ensure optimal outcomes.
Much of what happens in the emergency department is related to how many and what kind of patients come through the doors. And while patient volume and acuity may be predictable, to an extent, for the most part, those are factors that the ED team cannot fully control. But with proper preparation, an effective ED response can ensure optimal outcomes, improved patient satisfaction, and efficient throughput with reduced wait times.
"I divide factors that contribute to wait times into two categories: those which the ED can control and those which it can't," says Darren Shafer, DO, the service line medical director of emergency medicine, urgent care, and the Albuquerque (N.M.) Ambulance Service for the eight-hospital, Albuquerque-based Presbyterian Healthcare Services.
Intelligence Report: The ED Fix—Triage, Coordination, and Navigation
One-quarter (25%) of the respondents to the HealthLeaders Media 2014 ED Strategies Survey report annual visits in excess of 70,000 patients. That includes 43% of health systems but only 17% of hospitals. Facility size certainly is a factor: More than half of large hospitals (51%) see more than 70,000 patients per year in their EDs. Overall, more than half (55%) say their ED is always or often overcrowded, and size, again, is a factor: 71% of respondents with net patient revenue of $1 billion or more say their ED is always or often overcrowded.
Longer wait times are one consequence of overcrowding. While one-fifth of all respondents (19%) report an average time patients spend in the ED before being seen by a healthcare professional of less than 15 minutes, in EDs characterized as always or often overcrowded, the average time patients spend in the ED before being seen by a healthcare professional is 46 minutes. In EDs characterized as occasionally, rarely, or never overcrowded, average waits are 23 minutes.
Because there is an element of unpredictability about patient volumes, there also is an element of unpredictability about wait times. But unlike patient volume, there are many ways to address wait times. Here's why ED leaders pay a lot of attention to wait times: "Even if a patient is not back in a bed, for instance, if they're in our waiting area and not being seen by a doctor, they're still our responsibility," says Judy Horton, RN, director of emergency services for the 726-bed Texas Health Harris Methodist Hospital Fort Worth.
Peter P. Semczuk, DDS, MPH, vice president of clinical services at Bronx, N.Y.–based Montefiore Medical Center, which operates six hospitals on five campuses, including the 745-bed Montefiore Medical Center, says, "One of the things that keeps me up at night, that's absolutely top of mind, that I worry about all the time, is patients that are left in the waiting room. It really frightens me because bad things happen to patients in waiting rooms. We want you inside, around the clinical team that's caring for you."
Joseph S. Prosser, MD, MBA, CPE, FACPE, vice president and chief medical officer of Texas Health Harris Methodist Hospital Fort Worth and three other hospitals in the Texas Health Resources system, conveys a similar sentiment: "Our mission is to have no patient wait in the waiting room."
At Montefiore and elsewhere, stationing experienced clinical staffers right in the waiting room is a way of ensuring that those who need care the most will get timely attention. "We think the triage process should begin in the waiting room," says Montefiore's Semczuk. "I think that is the single most important thing that we can do as ED leaders to increase efficiency." Doing triage in the waiting room has another benefit besides launching patient flow and treatment. "The biggest benefit," he observes, "is you've got someone watching patients all the time while they're waiting."
Focus on patient flow
One way or another, care at virtually all EDs starts with triage. Nearly three-quarters of respondents (72%) say their triage activity supports ED throughput efficiency. Streamlined registration (63%) and channeling low-acuity patients to a fast-track area (65%) are other leading techniques to increase throughput efficiency.
On the top of the list of efficiency techniques to institute next: 38% expect to speed up transfers for patients to be admitted. ED-to-inpatient transfer is the bottleneck identified most frequently, by 61% of survey respondents, including 69% of those who characterize their ED as always or often overcrowded. "If I look back at the challenging cases we've had in the last year or so, almost every single one of them have to do with an admitted patient that was waiting a prolonged period of time for an inpatient bed," says Semczuk, lead advisor for this Intelligence Report.
Prosser from Texas Health Harris Methodist Hospital Fort Worth says its team pursues transfer or discharge from the very beginning: "We are doing discharge planning from the moment a patient comes in the emergency room." To make room for more ED patients when inpatient occupancy is high, Texas Health admits certain patients who then occupy screened-off hallway beds. Says Prosser, an advisor for this report, "That way we can get a patient out of the emergency department and take them up to the floor until a bed opens up. The patients actually want to do that—they want to get out of the emergency room and upstairs in the hospital where they're being managed by nurses and staff that are familiar with their pathophysiology."
Staffing for throughput
Semczuk sees the trend toward using more midlevels, nurses, PAs, and allied health professionals for patient care in EDs, and says, "I think it's a mistake." About a decade ago, he says that
Montefiore recognized that "Many of the people that were seeing sick patients in our ED were people who had full-time jobs as hospitalists or internists or nurse practitioners. [We felt that] those who were not trained in emergency medicine were not investing the time and effort to learn emergency medicine. What we needed to do was to staff our emergency departments with residency-trained emergency medicine physicians. Now patients know that if they come here, they're going to be seen by a board-certified emergency medicine physician who has dedicated his or her life to this field. They're not going to be seen by someone who happens to work a shift that day in the emergency department."
Nonetheless, 46% expect to invest in midlevel caregivers for their EDs within the next three years, nearly twice as many who expect to invest in physician staff (25%). Shafer, from Presbyterian Healthcare Services, offers this perspective: "Midlevels may not be able to see patients with quite the same acuity as a physician would, but by having them here, we can greatly extend the ability of the physician to cover more patients. Because it's going to be a cost savings, in healthcare we're going to see it more and more. The way the economics are, that's the future."
Semczuk reminds us, though, that those who have specific training can be very productive. "I encourage leaders to think about hiring more doctors at the expense of the midlevels. Doctors are incredibly productive when they're working in an emergency room setting if they're board-certified—they could easily see three or four patients an hour."
Redirecting patients
Another way to foster efficient throughput is to minimize the number of nonemergent patients who visit EDs. At the top of the list of tactics to minimizing avoidable ED visits is limiting prescriptions for opioids, a method used by 66%. In addition, nearly half (45%) track patients who visit EDs seeking opioid prescriptions. More than half (54%) help minimize avoidable ED visits through better coordination with primary care practices and clinics.
One quarter (24%) redirect nonemergent patients, and 29% say that they expect to begin redirecting nonemergent patients within the next three years. Care coordinators and patient navigators are one way to accomplish this.
Shafer explains, "Not only do our navigators work within our system, but they also are in touch with all the other clinics in the city—low cost, no cost, or physicians starting up a private practice. They find out who's got any capacity to see patients and which patients they are taking." Shafer admits that referring nonemergent patients without insurance or who otherwise have no ability to pay for care presents a problem. "We have to be cautious," he says. "We might have to absorb that cost within our own healthcare system."
Shafer notes that navigator follow-through ensures that physicians accept the concept of redirecting nonemergent patients. "As physicians in the emergency department, a doctor will worry that this is our one chance to make the diagnosis on a patient, so we might order a full set of labs and other tests. However, if we know the patient is going to be seen and evaluated by another set of medical eyes within the next 12 to 24 hours, and continuity of care is going to be established with that patient, we don't need to do as intense a workup in the ED because we know that that's going to be taken care of."
Care continuum relationships
Healthcare leaders endorse communication as a way of fostering relationships along the continuum of care. Two-thirds (68%) are improving or expect to improve communications with primary care practices. And 61% are improving communication about their patients through improved integration of care partners' EHRs.
One-third of EDs (33%) have a strong working relationship with community-based clinics, a slight increase over last year's 28%.
Texas Health is in the Dallas-Fort Worth area, and the increased demand for healthcare that is accompanying population growth is straining primary care capacity at the same time it is increasing ED volume. Says Prosser, "Conceptually, if people are educated that they have other avenues of care, then they're going to choose those avenues rather than come to an emergency room and sit around for several hours. But part of the challenge in our community is that the primary care physicians are already busy, and by the sheer population growth, demand is outstripping supply, so patients have trouble getting into primary care offices."
Investments in care
Prosser notes that smooth transfers are a benefit of closer working relationships with care continuum partners. "We have worked with some of our postacute facilities to improve communications so that they will accept patients in transfer more readily, and with [EHR] information exchange, patient transfer is smoother and more efficient."
Shafer says information enhances care partnerships, fostering teamwork. "With EHRs, primary care providers can see exactly what happened in the emergency department. They see what tests were done, so they don't have to repeat any tests. If a diagnosis wasn't made and the patient was merely stabilized, they can see exactly what the next steps are in terms of the workup. This way, the ER becomes a full team member in care, whereas previously it was more episodic, and the ER didn't know what was going on in primary care."
Information technology helps EDs track performance and track patient status. Overall, 40% of survey respondents expect to make ED-related IT investments over the next three years. Says Semczuk, "We collect some 40 different indicators on our ED performance. I cannot imagine managing 370,000 visits a year without having a lot of data at my disposal because, without measuring it, we can't manage it." Making decisions and providing care in such a fast-changing environment can be aided by tracking real-time status of the in-ED patient population. Says Prosser, "In our emergency room, computer screens show who's been registered but hasn't been seen. Physicians either see those people or they mark on the computer that they're the next one in."
Telemedicine is finding a place in EDs, too, with 36% expecting to invest. At Presbyterian, telemedicine helps support behavioral health assessments and diagnoses, which is significant, given that 49% of survey respondents indicate that psychiatric patients occupying beds represent a major source of ED bottlenecks. Shafer describes how telemedicine helps: "Behavioral health patients can take up a tremendous amount of time in the emergency department. You can be holding a bed for hours and hours when you haven't made a disposition, and you have to get a consult done. Finding someone to be able to do that consult can be really challenging."
Some busy EDs can remove a bottleneck if they have an in-ED pharmacy, but overall, only 11% intend to invest in an in-ED pharmacy, indicating that for many, the level of service from their existing pharmacy setup is suitable. In-ED labs (9%) and imaging (8%) have similarly low readings. Fourteen percent of those whose EDs are always or usually overcrowded intend to invest in an in-ED pharmacy, compared to 8% of those whose EDs are occasionally, rarely, or never overcrowded.
Reprint HLR0514-3
This article appears in the May 2014 issue of HealthLeaders magazine.
Michael Zeis is a research analyst for HealthLeaders Media.