Council Connection: ED Performance and Viability

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This article appears in the September 2013 issue of HealthLeaders magazine.

According to our May Intelligence Report, while 84% of healthcare leaders expect their ED patient volume to increase within the next three years, at least six in 10 expect their ED's operating margins and reimbursement rates to decline during that period.

What is your organization doing to improve ED performance and ensure the ED's operational viability?

Tim Maurice
CFO
UC Davis Health System
Sacramento, Calif.

On the ED and community need: Our emergency department is very important to the community. We are the only level 1 trauma center for inland Northern California, representing an area from the Oregon border to Bakersfield, Calif.

On getting Lean and changing processes: We have been engaging quite extensively in Lean Six Sigma process improvement in the emergency services area to improve the patient experience and throughput throughout the facility. We have put a physician in the triage area so they can perform the screening exam and test the patients while they are waiting to be seen. We implemented a nurse navigator process to have the nurses work with the physician teams to navigate patients through the emergency services area.

On building new protocols: We have been involved in a number of research projects regarding appropriate use of emergency services for patients with head traumas, patients that may have bacterial infection or a meningitis risk. We are really on the cutting edge in identifying protocols that can be used effectively to determine the right level of care for patients to reduce the risk of excess radiation exposure.

On the changing role of the ED: With the Affordable Care Act, I don't expect to see a big increase in the emergency usage. I do expect that over time we are going to use varying levels of care in the emergency department. We feel emergency services are a viable resource not just for the real severe emergencies but also for other levels of care that can be provided within the triage capability of the team.

Kyle Martin, MD
Medical Director for the Emergency Department
St. Mary's Hospital
Madison, Wis.

We anticipate that our volumes will continue to climb as compensation decreases. We are going to do a deeper dive on managing our costs. One of the pieces we have looked at recently is how we compare to some of our hospital peers. For example, indirect care time for staff is actually quite a bit higher than it is most of our peer hospitals.

Our department has been markedly successful in working our door-to-doc time. When I started as medical director in 2007 our average door-to-doc time was around 45?50 minutes. We have gotten that down to be around 13 or 14 minutes. That really is the core to having a safe ED where patients are getting in front of a provider in a relatively short period of time to make sure they don't need a stabilizing intervention, but also improving how quickly they can move through the ED.

We are looking at how we are staffed and other ways where we could continue to maintain that level of efficiency and that level of care while perhaps relying less on the nursing hours and seeing if there are more tasks that technicians or paramedics could help with.  As we shift toward value and away from volume it is important that you are doing things in as efficient a manner as possible.

David M. Zechman, FACHE
President and CEO
Ozarks Medical Center
West Plains, Mo.

We started with improving the physician and nursing documentation chart along with audit reviews, not only by our documentation integrity team, but also by our medical director, Dr. Kathryn Egly. As part of that, hours of one-on-one education have been provided to the ED physician staff and nurses on appropriate documentation to show the true level of care that a patient is receiving.

The second thing we have done is decrease a metric we call the left before exam rate. Five or six years ago our LBE before our new ED opened was anywhere from 5%?7%. In 2012 it was 3.2% and year to date it is 1.2%. We are capturing more patients who were leaving the ED without being seen and we've done that through putting a nurse practitioner in a fast track right at triage.

Finally we have terrific physician leadership in our emergency department. I am a big believer in physician champions with clinical service lines. Under Dr. Egly's leadership has we are creating new mechanisms for efficiency as well as measuring quality and holding the physicians accountable for quality and patient satisfaction.

Alex M. Rosenau, DO, FACEP, CPE
Senior Vice Chair of Emergency Medicine
Lehigh Valley Health Network
Allentown, Pa.
President-elect, American College of Emergency Physicians

Coordination of care is very important. We are looking at observation unit benefits. If a person is admitted for emergency medicine observation, our patients are in and out in an average of 18 hours. But we have some very well defined protocols for observation units; for instance, when internal medicine creates an observation status for an admitted elder patient that has multiple medical problems, we aren't going to be able to get them in and out in 24 hours because there is so much to deal with.

Many hospitals have established a rapid assessment unit where we placed physicians in triage and we emptied out the waiting room. So instead of having a triage nurse, the patient comes right into an area where a doctor, a nurse and the registrar come into the room together, listen to your history, and get your treatment going. We see much more of a role for nurse practitioners and advance practice clinicians.

We need a better infrastructure to interact with and we need to continue making those ties integrated with the outpatient world. At Lehigh Valley Hospital?Cedar Crest, we established a pediatric hospital within the hospital and we opened a pediatric emergency department with 12 beds. It has a lot of support from the community. We have the people who are committed to the care of children and that has also opened up space in the main ED which can then be filled with that coming tsunami of adult patients.


This article appears in the September issue of HealthLeaders magazine.