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State of Emergency

Elyas Bakhtiari, for HealthLeaders Magazine, October 8, 2009
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The nation's emergency departments are feeling the effects of the economic downturn, but innovations in patient throughput and other strategies offer hope for a beleaguered system.

For most hospitals, the majority of admissions—as high as 60% in some cases—come in through the emergency department. And in the current economic downturn, many hospitals' financial and operational struggles have entered the organization through the same path.

Fifty-seven percent of hospitals have seen an increase in ED visits during the recession, and 30% have seen an increase in admissions through the department, according to analysis from the American Hospital Association. And more ED volume has brought with it more uncompensated care and patients on Medicaid or Medicare.

High volumes and a poor payer mix are a problem for EDs in normal times. But as millions of Americans have lost jobs, they have often also lost health insurance, and like many uninsured they have begun to rely on the ED as a primary source of medical care.

"We're seeing more patients that have less insurance, no insurance, or higher copays, all of which drive them to the ED in a more acute state," says Robb White, director of emergency services at Tomball (TX) Regional Medical Center, a 357-bed facility northwest of Houston. "What I see a lot here is that previous two-income households now are one-income households or they've taken a job that pays less. They have less money in their budget and they don't go see the doctor because it's a $50 copay for an office visit, for instance."

Although Texas hasn't been impacted as severely by the recession as other states, the percentage of self-pay patients utilizing Tomball's ED has jumped 5% since last November, and the percentage of uncompensated care has jumped from 19% to 30% in the past three years, says White.

For a bleaker picture, hospital leaders can look to California, which ranks last in the nation in access to emergency care with only 7.1 EDs per 1 million people. Fifty-five departments have closed in the last 10 years while the number of severely acute patients, as well as patients without true emergencies, visiting EDs has climbed. The situation has become so severe for providers that a group of emergency physicians sued the state of California earlier this year over a lack of funding that they claim threatens to collapse the state's safety net.

Is the rest of the nation destined to follow the same path? That depends, in part, on national factors out of hospitals' control. But hospitals can take steps on a local level to ease crowding, improve quality, and make the ED more financially viable. It isn't an easy task, and it may require hospitals to look at the ED more like a valuable service line than a safety net or financial sinkhole.

Service Line Success Key No. 1: Redesign the ED
Many of the problems that stem from the ED can be traced back to a single challenge: throughput. Sure, providing emergency care has other unique difficulties and shares many quality and operational challenges with the rest of the hospital. But figuring out how to reduce backups that lead to long patient waits and a chaotic culture would go a long way toward downgrading emergency care from crisis mode.

Most areas of the country are treating a greater volume of patients in EDs that haven't been substantially expanded in decades. But what if a hospital could start from scratch? How much could a better design help in improving patient flow through the ED?

Sharp Healthcare, a nonprofit regional healthcare delivery system based in San Diego, had a chance to test that out when it opened a new 350,000-square-foot, 332-bed hospital earlier this year. One of the goals in building Sharp Memorial Hospital was to redesign the ED and trauma center for efficiency and throughput, says Dan Gross, executive vice president of operations for Sharp, which includes four acute care and three specialty hospitals, two medical groups, and a health plan.

Designers started by expanding the patient waiting area to ease overcrowding and tripling the triage department so patients could be admitted faster. A smaller, three-bay "minor treatment area" was added so patients with minor problems could be moved swiftly out of the general ED waiting area, says Gross, who was CEO of Sharp's Metropolitan Medical Campus, where the new hospital is located, during the design and construction phase.

An additional critical decision unit was built for the cohort of patients who may need a longer diagnostic and workup time. Instead of putting these patients in a holding bed in the general ER, they are moved to the critical decision unit while physicians work to decide if they should be admitted into the hospital.

"Oftentimes what happens is, to kind of clear the ER, there can be a tendency to want to just admit them upstairs to an inpatient unit to keep the throughput going, which is not the most cost-efficient way of care," says Gross.

A final component of the redesign was a diagnostic and imaging center—including a 64-slice CT scanner and two general radiology rooms—within the ED to reduce turnaround time for tests. Instead of being transported on a wheelchair or gurney to the hospital's radiology department to get in the hospital's general imaging queue, patients are scanned in the ED and assessed much more quickly.

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