Lower ED Margins Demand a Better Strategy

In this new Intelligence Report, we examine how resolving organizational problems in the emergency department will remain a challenge as demand for ED services increases, overcrowding elevates patient safety concerns, and quality metrics draw greater attention.

This article appears in the May issue of HealthLeaders magazine.

The emergency department continues to be challenged by its own internal problems even as it seeks to work with other hospital departments to overcome bottlenecks that can affect the efficiency and quality of patient care.

The results of the 2013 HealthLeaders Media Emergency Department Survey show that resolving these issues will remain an uphill battle as demand for ED services increases, quality metrics draw public attention, and ED overcrowding raises patient safety concerns. Reimbursement challenges and declining operating margins will further complicate matters.

See Also: ED Solutions: Preparing for Increased Volume and Decreased Margins

Even as the healthcare industry transitions its delivery systems to emphasize patient-centered medical homes, care coordination, and the continuum of care, almost nine in 10 healthcare leaders (86%) expect their ED volumes to increase within the next three years.

It seems counterintuitive that demand for ED services is projected to grow just as millions of newly insured will enter the healthcare marketplace, but that has been the experience in Massachusetts where, in 2006, the state adopted a healthcare reform system that requires all residents to carry a minimum level of healthcare insurance.

Since then, ED volume across the state has "increased by about 1.5% annually," according to Assaad Sayah, MD, chief of emergency medicine at the three-hospital Cambridge (Mass.) Health Alliance. He notes that his own ED recorded 77,000 patients in 2005 (before Massachusetts healthcare reform), 98,000 in 2012, and is on track for 100,000 patient visits in 2013.

Sayah says physician shortages, especially in primary care, fuel much of the ED demand. "With healthcare reform, although the solution is to provide coverage for patients, the true solution is that there needs to be more patient access to primary care."

Overcrowding
As demand for ED services increases, more healthcare leaders describe their EDs as overcrowded. While 46% of respondents described their ED as being overcrowded in our 2012 ED survey, 61% do so in this year's survey. Overcrowding exacerbates some common ED challenges. About one-third of respondents (32%) said patient flow is the greatest challenge facing their ED, wait time was mentioned by 15%, and patient boarding by 13%.

Survey respondents cite a number of effective ED operations techniques to improve ED throughput: fast-track area for lower acuity (61%), triage medical evaluation process (58%), and streamlined registration process (53%).

Systemwide issues also cause headaches for the ED. "The ED only flows as well as the hospital flows," says Leon L. Haley, MD, deputy senior vice president for medical affairs and chief of emergency medicine at Grady Health System in Atlanta. "On some level, we've done ourselves a disservice by talking about ED overcrowding. We should be talking about hospital crowding and hospital flow."

Depending on the ED issue at hand, Haley says the throughput committee at Grady might consider environmental services staffing and room cleaning, radiology department staffing and testing hours, physician staffing, lab processes and structure, and possibly guest services and transportation. "It's all tied together," he says.

Bottleneck
About three-quarters of healthcare leaders (73%) identified ED-to-inpatient transfers as the biggest bottleneck for ED flow. "Keep in mind that every time you delay a discharge upstairs for an hour, it backs up in the course of the day and can be a two- or three-hour delay for the ED, says Marlon Priest, MD, executive vice president and chief medical officer for Marriottsville, Md.–based Bon Secours Health System, a 19-hospital system that serves seven states.

Protocols
Less than half of the survey respondents (44%) identified standardized handoff protocols as a method they use to increase ED throughput efficiency. That surprised Priest. "Much of the stuff that goes into the ED has pretty standard complaints. If you could figure out how to use predetermined evaluations, you could often have lab tests or x-rays done before the patient gets to the main ED area."

Priest suggests placing a physician or a nurse practitioner in a triage area to take brief patient histories and order diagnostic tests according to protocol. The protocols can "help reduce wait time between triage to ED room, to ED physician, to test area, and to test back."

Still, Sayah cautions that these techniques are only a part of the solution. "Those things work, but they don't work by themselves. They've been used for years and yet here we are today with overcrowding and long waits. What's missing? The ultimate solution needs to be a hospitalwide commitment to relieving the ED from being overcrowded, which includes rapid admission and rapid throughput."

Also important, says Sayah, is to get a C-suite commitment to help with immediate, one-off solutions. When all else fails, even in the middle of the night, the ED needs to be able to turn to the "three or four people within the hospital with the authority to escalate processes across the entire hospital system."

Staffing
Half of the healthcare leaders (50%) identified better nurse workload balancing as the most effective staffing technique to increase ED throughput efficiency. This response reinforces the systemic relationship the ED has with other hospital departments and functions.

Safety
Overcrowding is a huge concern when it comes to patient safety in the ED. Some 96% of healthcare leaders with an overcrowded ED are either "concerned" (45%) or "very concerned" (51%) with patient safety as a result of that overcrowding, which can cause delays in treatment, reduce the quality of care received, and increase the risks for some patients.

As they work toward ED improvements, healthcare leaders are keeping a watchful eye on finances. While a plurality of respondents (44%) report that their ED has a positive operating margin, one in five (18%) reports a negative ED operating margin, and 60% say they expect their ED operating margin to decrease within the next three years; only 9% expect increased ED operating margin.

In addition, 65% expect ED reimbursement rates to decrease within the same time frame, and 58% expect an increase in uninsured/self-pay patients.

As the industry continues its transition from volume to value, leaders will need to address clinical and operational concerns not only within the ED itself but also throughout the organization and the continuum of care.

Reprint HLR0513-3

This article appears in the May issue of HealthLeaders magazine.