Emergency Department Efficiency

Healthcare leaders are recognizing the need for efficiency in supporting nonemergent care in the emergency room.

This article first appeared in the May 2016 issue of HealthLeaders magazine.

Emergency departments are optimized to provide emergency care, of course. The timing of medical emergencies cannot be predicted, so EDs must be ready to provide care always. The open-door policy brings patients who need emergency care, patients who worry that they might need emergency care, and patients who don't need emergency care at all. This third category is resilient—a fact of ED life. So, even though ED operations are designed for emergency care, they also must optimize the activities that support patients who do not need emergency care. While the effective handling of patients with emergent conditions remains a principal focus, to deliver that care, EDs need techniques to be effective with nonemergent patients, as well.

Optimize the whole flow
Transferring patients to inpatient floors is identified as a top bottleneck for in-ED flow by 70%, the item mentioned most frequently. Although EDs have a variety of tactics for accommodating patients pending their move to an inpatient bed, the presence of such bottlenecks is inevitable, and their resolution often requires active participation by other hospital departments.

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Of course, there are cases where additional ED capacity or additional inpatient beds are required, but more often, capacity is not the issue, says Trisha Cassidy, chief strategy officer for AMITA Health, whose facilities include four hospitals, a center for behavioral health, and seven immediate care centers in the northwest suburbs of Chicago.

"My hunch is that in most of the country there's not a shortage of inpatient beds. There may be a flow issue of when discharges happen, or when ED admissions happen, but I think that's probably a utilization issue as opposed to a capacity issue."

At the top of the list of techniques for managing ED throughput are fast track or split flow for low-acuity patients (67%), streamlined registration for arriving patients (57%), and direct or immediate bedding (51%).

Daniel Nadworny, RN, MSN, clinical director of operations for ED and urgent care at Beth Israel Deaconess Medical Center in Boston, with 672 licensed beds and approximately 1,250 full-time and part-time physicians, sees these high levels of response as indications of widespread attention to the whole ED patient flow, instead of intense focus on freeing ED beds via transfer to inpatient floors or discharge from the ED.

He says, "For so long, it was just 'Get them out, get them out.' Now, we're looking at how we have opportunities to improve from start to finish. The focus for a long time had been on disposition. But now we're being thoughtful of the whole process."

Addressing avoidable ED visits
More than half of respondents (59%) include coordinating with primary care providers among their tactics for minimizing avoidable visits to their EDs, the item mentioned most frequently. While a common tactic is for care coordinators or other ED staff to help find a provider for those without a primary care physician, Nadworny notes that a primary care provider/patient relationship may not be enough. Lack of availability of the primary care physician is behind some avoidable visits.

"Quite often I see that a patient has called the primary care physician, but appointments are not available, so the patient is referred to the emergency room. If your first decision point is that the patient doesn't need the emergency room, but then the reason for sending the patient to the emergency room is there isn't an available primary care appointment, then that's a missed opportunity."

More than half (53%) rank primary care physicians first in effectiveness in helping patients make more appropriate use of EDs. But the effect primary care providers may have on helping patients make appropriate use of the ED may be diminished, as mentioned earlier, by the lack of primary care availability and by recommendations to visit the ED that are sometimes offered when a timely appointment is not possible.

For 42% of survey respondents, urgent care centers are among the tactics used to minimize avoidable ED visits. At AMITA Health, urgent care centers coordinate closely with primary care. "In our system," Cassidy says, "the urgent care clinics are connected to a primary care office. They do everything they can to make sure that the patients who come to urgent care have a primary care physician."

Nadworny notes that the urgent care center can place a patient on a path of coordinated care. "Our urgent care providers are making decisions not only for the condition of the moment but also decisions about how to plug that patient into the healthcare system. That gives us a new benefit. Urgent care is not only a point of care but also a point of entry to the organization. So that person now is getting not just the urgent care coverage, but they're getting introduced into the network and getting more definitive care set up for them."

Patient knowledge, patient preference
Four-fifths (81%) of healthcare leaders from organizations with urgent care clinics or that are planning urgent care clinics say that the need to provide a setting for patients with nonemergent conditions is among their top motivations for pursuing an urgent care clinic. More than half (52%) say they want to improve access through extended hours.

The broader trend behind taking advantage of additional care settings and paying more attention to care coordination is that providers are helping patients to become more aware of their choices. So both patient and provider play a role in the patient receiving care in the appropriate setting.

Compared to last year's survey, there are decreases in the percentages of healthcare leaders who expect increases in uninsured/self-pay (50% to 41%, down nine points) and nonemergent ED patients (45% to 32%, down 13 points).

Cassidy observes two dynamics at work: "A couple of things are happening now that a significant number of patients who were uninsured are now on the exchange. Number one, some are learning how to use their health insurance and are calling a primary care physician instead of going to the ER. When you're not insured, it's not always easy to get a physician appointment." Second, insured patients see a difference in out-of-pocket costs, as well. "Patients are beginning to recognize the difference in the bill if they go to the ER or if they go to a doctor's office."

More than one-third of respondents (38%) coordinate with community social services to minimize avoidable ED visits. The ED staff at Penrose-St. Francis, which operates Penrose Hospital and St. Francis Medical Center with 522 licensed beds combined as well as four urgent care centers in the Colorado Springs area, holds quarterly meetings with a task force of community-based resources.

Says Cynthia Latney, PhDc, MSN, RN, NE-BC, chief nursing officer and vice president of patient care services, "There is a community task force consisting of agencies for mental health, substance abuse, and other community resources. We come together on a quarterly basis so our hospitals and community leaders can talk about how to share resources, how to communicate, and how to enhance transfer of patients."

When it comes to efficiency and patient flow, emergency departments will never lose their focus on the importance of transferring patients from the ED through admitting and onto an inpatient floor. But the attention that healthcare leaders are paying to care alternatives, case management, and care coordination indicates that ED decision-makers are examining the supply side of patient flow as well.