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Fewer Emergency Dept. Visits vs. Right Care at Right Time

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   May 07, 2015

An increase in emergency room visits doesn't mean a healthcare system is failing. Rather, policy makers are focused on the wrong thing, says the American College of Emergency Physicians.

A report from the American College of Emergency Physicians disputes the need to focus on reducing emergency department visits. A short online survey that captured the opinions of 2,009 emergency physicians (a 9% response rate of its membership) showed that ED physicians had seen increases in ED traffic over last year.

The sample size of the survey is small, but it reflects the reality of rising ED rates across the country.

Atlanta-based Grady Memorial Hospital, part of Grady Health System and one of the largest public health hospitals in the country, had a record number of 126,000 ED visits in 2013. The hospital is one of the largest public health hospitals in the country.

"Overall volume has gone up," says Hany Atallah, MD, chief of emergency medicine at Grady, noting that Grady's nearby walk-in clinic, which is within walking distance to the hospital's ED, has helped offload patients who don't have a true emergency. "We explain they'll get faster care," he says.

The urgent care clinic opened last year to coincide with the expected increase in patient volumes due to more people having access to health insurance through health insurance exchanges. The fact that the urgent care clinic hasn't made a significant dent in Grady's ED traffic is also indicated in ACEP's survey.

>>>2015 ACEP Poll Affordable Care Act Research Results
More than 40% of respondents reported that ED patient visits remained the same despite the availability of retail clinics and urgent care centers.

"We're a big believer in patients getting the right care at the right time," says Atallah.

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Part of the reason that retail clinics and urgent care clinics may not be diverting ED traffic from large urban hospitals may be due to the fact that patients who use an ED for less acute needs are used to that particular care site.

Grady is trying to educate its patients, but for the 316,000 Georgians—and the 8 million who enrolled in health plans nationwide in 2014—navigating the healthcare system with insurance coverage is new. It's too high of an expectation to expect them to adopt new usage patterns, too.

Different Site, Same Story
Another Atlanta-area hospital that has seen its ED volume grow is WellStar Paulding Hospital, a 53-bed hospital (it will expand to a 112-bed hospital in 2016) that is part of the WellStar Health System, a nonprofit health system with five hospitals, seven urgent care centers, and a medical group practice.
Located in Hiram, GA, about 32 miles from Atlanta, Wellstar Paulding opened a new ED in 2014 that can accommodate 80,000 visits a year.

"We're tracking 70,000 now," says hospital president Mark Haney. "We expected we'd see 45,000 [patients] when we moved in [the first year]." Haney says the hospital has seen an increase in Medicare patients using its new ED.

"We saw a 40% increase in new patients, and we can surmise that we are so close to Atlanta that some of the patients decide to come here," he says. "It could also have to do with high deductible health plans."

To accommodate the unexpected spike, Haney says the hospital added nurses and readjusted the ED physician shifts. Grady is also planning a new emergency department. An additional 15,000 square feet of space will be ready by late next year.

Having two hospitals that are close to each other with similar ED facilities suggests that although ACEP's sample size for its survey is small, the results shouldn't be dismissed.

Implications for Patients
ED physicians work diligently to quickly attend to patients; however, a patient's experience in an emergent situation can color the rest of their stay if they're admitted to the hospital. Grady and WellStar Paulding are paying attention to the patient experience in their EDs. Grady is focusing on reducing its door-to-provider time, which is down to 98 minutes from 133 in 2013.

>>>View Slideshow

At Wellstar Paulding, they're aiming to see 75% of patients in under 180 minutes. As of February, they were making strides, seeing 10% of patients in under 90 minutes. The hospital received three stars from CMS for patient satisfaction. Grady received two stars. The best rating a hospital can get is five stars.

While patient satisfaction and experience in the ED isn't formally being measured by CMS yet, it is an important component of the total hospital experience, and an important site that patients will continue to demand care from, and can't be ignored, says Angela Gardner, MD, FACEP, past president of ACEP, and an associate professor of emergency medicine at UT Southwestern Medical Center in Dallas. She believes the survey results ultimately show that diverting ED patient is ineffective.

The Right Care at the Right Time
"Spending on emergency care only accounts for 2% of the federal health care budget," she says. "Eliminating unnecessary visits as defined by policy makers, would only save pennies. Because people may not be able to determine whether something is an emergency or not without medical evaluation, potentially very sick people may be denied access to care."

The concern over treating patients appropriately is very real, says Haney. WellStar Health System has a total of seven urgent care clinics, and there are plans to add more, but the level of its ED patients' acuity is growing, which those types of clinics can't handle.

"Our patients need to get to the right place," he says.

Jacqueline Fellows is a contributing writer at HealthLeaders Media.

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