Large, metropolitan emergency departments that serve more than 50,000 patients each year represent just 17.7% of all emergency departments in the nation, but they accounted for 44% of all ED visits in 2007, a new Centers for Disease Control and Prevention survey shows.
The survey, conducted by the CDC's Division of Health Care Statistics, notes that over the last several decades the role of the ED has expanded from treating seriously ill and injured patients to providing urgent and unscheduled care for Medicaid and uninsured patients unable to access primary care.
The inability to transfer ED patients to an inpatient bed once they're admitted is a big factor in crowding. "As the ED begins to 'board' patients, the space, the staff, and the resources available to treat new patients are further reduced," the survey states. "A consequence of overcrowded EDs is ambulance diversion, in which EDs close their doors to incoming ambulances. The resulting treatment delay can be catastrophic for the patient."
The survey says that approximately 500,000 ambulances are diverted annually in the United States–an average of one diversion per minute.
The CDC survey, which is part of the National Hospital Ambulatory Medical Care Survey, also found that one-half of all hospitals with EDs had a "bed czar," 58% had elective surgeries scheduled five days a week, and 66% had bed census data available instantaneously.
Electronic medical records–either all electronic or part paper and part electronic–were reportedly used in 61.6% of EDs. Basic EMR systems containing patient demographics, problem lists, clinical notes, orders for prescription, and viewing laboratory and imaging results were reported in 15% of EDs.
However, the CDC report could not accurately determine ED use of fully functional EMRs–which includes prescription orders sent electronically, warnings of drug interactions, orders for tests, out-of-range test levels highlighted, medical history and follow-up, and reminders for guideline-based interventions.
The survey also found that:
EDs with more than 20,000 annual visits comprised more than 70% of EDs in metropolitan statistical areas. When compared to EDs in rural areas, EDs in MSAs were twice as likely to have a bed coordinator or bed czar in their hospital–60.7% compared with 30%; and board patients for more than two hours in the ED while waiting for an inpatient bed–77% to 32.8%.
More than one-third of EDs had an observation or clinical decision unit. Admitted ED patients were boarded for more than two hours in the ED while waiting for an inpatient bed in 62.5% of EDs. Among EDs that boarded patients, nearly 15% used inpatient hallways or another space outside the ED when it was critically overloaded.
In the previous two years, 24% of EDs increased the number of standard treatment spaces. Although more than 19% of EDs expanded their physical space in the last two years, 31% of those that did not expand their physical space plan to do so within the next two years.
The frequency of ED patient care techniques was as follows: bedside registration–66%; computer-assisted triage–40%; zone nursing–35.3%; electronic dashboard–35.2%; separate fast track unit for non-urgent care–33.8%; pool nurses–33.2%; full capacity protocol–21%; and radio frequency ID tracking–10%.
When compared with small EDs, large EDs were more likely to have a bed coordinator in their hospitals–71.2% compared with 33.8%; have an observation or clinical decision unit–53.5% to 32.5%; board patients for more than two hours in the ED while waiting for an inpatient bed–86.5% to 39%; and use bedside registration–89% to 54.2%; computer-assisted triage–62.2% to 24.3%; and zone nursing–62% to 19%.
Is your organization better prepared for a pandemic having experienced the swine flu? The H1N1 flu hasn't hit as hard as initially was expected, but it's not over yet. The CDC estimates there are close to 6,800 cases in the U.S. as of last week. Even worse is the possibility of it circling back in a mutated form six months from now, say hospital leaders. I spoke recently to Bruce Cadwallender, director of safety and emergency management for the University of Michigan Hospitals and Health Centers, about current planning and lessons learned from the H1N1 flu, which have ramifications for those focused on the balance sheet side of the business.
With the threat of the swine flu very real, leaders at Ann Arbor-based UMHHC—which is part of the larger University of Michigan Health System and includes 913 licensed beds, three hospitals and an ambulatory care services network—were forced to solidify strategic plans for mass care demand pretty quickly last month.
Cadwallender says UMHHC, like a lot of other organizations, began planning for a pandemic in earnest back in 2005 when the avian flu was becoming a worldwide threat. Because the system is both an academic medical center and a large ambulatory network, Cadwallender says planning was broad in scope and focused on ways to expand inpatient capacity while dealing with a potential surge in its ambulatory care network. While the threat of the swine flu has diminished somewhat, planning is still full throttle at UMHHC and leaders there are already looking at lessons learned so that they are prepared for an even bigger threat.
Check out these three planning areas UMHHC addressed in its most recent round of pandemic planning.
Labor
Labor is one of the bigger unknowns in terms of planning and costs for a pandemic. How do you adequately staff up and, more importantly, how do you keep staff on duty who may need to be at home, due to child care or any other number of reasons, including illness? "There is a chess game," that happens, says Cadwallender, noting that the reality is organizations are going to probably have more patients and fewer staff. "In this most recent H1N1 event, public health is calling for the closing of schools and day care centers so that throws another curve at your staffing because you may have single parents or two-income parents where one person may have to stay home."
Moreover, being part of a university, policies may call for staff to stay home because there is a public order banning large gatherings, says Cadwallender. "So now you are faced with the question of 'okay, they are staying home, but are they getting paid and if they are getting compensated then what about my folks who have this duty to come in to work? Do we have to augment their pay?' We never got any good answers nailed down to those questions," he acknowledges.
Cadwallender says other labor costs came up during the intense planning for the swine flu, including time leaders and staff spent away from regular duties. "Our lead physician in infectious diseases had to rearrange clinic schedules and reschedule patients and he will be seeing some changes in his revenue over this whole thing," he says.
Cadwallender adds that while leaders have determined that they can reduce the pace, work needs to continue so that the system is ready with executable plans. "It is a hard thing in today's financial environment to say 'yeah I am going to take people offline on patient care and do routine duties for contingency planning for something that may or may not happen, but it is essential for business continuity to invest in this type of thing."
Inpatient demand
Creating additional inpatient capacity or repurposing beds is another cost for which organizations must plan in the case of a pandemic. Cadwallender says at one point H1N1 looked as if it would cause a surge on the system's ambulatory care network as opposed to a lot of hospitalization. This shifted the focus to managing the ambulatory care system he says. "Our most extreme plans call for concentrating resources. If we have falling staffing and huge patient demand, we are looking at potentially closing some of the smaller locations and concentrating our staff in some of our bigger ones."
In dealing with the latest threat of the swine flu, the University of Michigan Hospitals and Health Centers also had to determine how to expand its respiratory isolation rooms. Cadwallender says in the case of over-capacity, plans also call for "cohorting" patients who need to be isolated. In addition to determining where to place those patients, UMHHC had to ensure that it could adequately staff up and provide them with specialty care providers. "Once again it becomes a chess game," says Cadwallender. "We spent the last couple of weeks meeting quite frequently to talk about very specific ideas about what we would do if it came to that and fortunately in the meantime things have eased up."
Supplies
How many supplies do you keep on hand and when do you buy them are other questions that come up in planning. UMHHC has been stockpiling certain supplies, something that flies in the face of today's hospital policies of just-in-time delivery. One issue for those with an eye on the budget is that a stockpile is well, just that. It is huge and there is a good chance that it will not be used before it has to be replaced. Organizations like UMHHC also may have to store supplies at another location because of limited on-site storage.
"We thought we had plenty of masks but now we have decided we need more and that concept of stockpiling things bumps up against our finance and procurement folks," says Cadwallender, adding that the system would like to increase its 20,000 masks to 30,000. "There is a real potential that this thing could come back in fall. If the virus mutates it may not be responsive to antivirals like it was this time." In addition to respiratory masks, UMHHC has stockpiled pharmaceuticals and bottled water.
Purchasing in advance ensures supplies will be available when you need them and avoids having to face rationing. Cadwallender says that as the system tried to purchase additional masks for the swine flu it was told by its supplier that a federal emergency had been declared and that the government would dictate where supplies went. "That was quite a revelation," he says.
While each crisis will have its own set of planning requirements, the swine flu has perhaps forced many organizations to provide some finality to their pandemic or mass care plans. At the very least the experience has offered them a more on-target assessment of strengths and weaknesses. In the case of UMHHC, questions around labor and inpatient planning still need to be worked out.
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The impact of a shrinking pool of primary care providers, combined with an increased demand for primary care services, has created a crisis of sorts in healthcare delivery. Keeping this in mind, now may be the time to consider newer approaches in care delivery in order—especially with healthcare reforms on the horizon—to improve quality and outcomes, according to a new report, Remaking Primary Care: From Crisis to Opportunity by the New England Healthcare Institute.
On the demand side, primary care is faced with a growing percentage of Americans who are living longer, often with one or more chronic diseases. "Most people assume that's just the wave of the Baby Boomers and that's not the case," said Wendy Everett, NEHI's president.
Currently, 87% of Americans aged 65-79 live with at least one chronic condition. Much of the care provided to this population has shifted from hospitals to ambulatory care settings, and this is expected to increase—stressing the primary care system.
It has been estimated that roughly 5% of that population accounts for 50% of Medicare costs. If universal coverage is approved, it will mean redefining the healthcare system and focusing on coordinating care for that group of patients, Everett said. "Primary care is the place to do it."
On the supply side, NEHI cited the lower pay of primary care physicians and dissatisfaction over high workloads, long hours, and a sense of being undervalued as pushing existing providers out of the profession while stopping new physicians from pursuing primary care. The proportion of primary care physicians has decreased from 50% of all physicians in 1950 to just over 30% in 2007.
"The biggest shift is going to be to get physicians to think about delivering primary care in a team model," Everett said.
This type of transformation would mean training physicians to work with teams of registered nurses, medical assistants, and other professionals to help deliver more seamless, effective care, according to the report.
Other innovations to consider are:
Patient-centered medical home to centralize care at a single clinical setting.
New sites of care that offer primary care services at retail clinics and worksites.
Health information technology, such as electronic medical records and computerized prescription ordering to free up physician time during visits and help in coordinating care.
Improved pay-for-performance to pay for outcomes will move the system away from paying for episodic care.
Shared medical appointments to help improve access to physicians.
Better efforts to teach children and their parents about controlling asthma can greatly reduce pediatric emergency room visits, according to an analysis published today of 38 asthma intervention studies involving 7,843 children around the world.
Asthma is the leading cause of childhood admission to a hospital and is the most common chronic pediatric illness, affecting one in five children in the U.S., says the Asthma and Allergy Foundation of America. American children with asthma spend nearly 8 million days per year restricted to bed.
But educational interventions from health providers, such as physicians, nurses, and trained health educators, can teach parents and their children the importance of complying with preventive treatment plans, according to the Cochrane Collaboration, which produced this new report.
Education techniques reduced subsequent emergency room visits by 25% and resulted in fewer unscheduled trips to the doctor.
Strategies include teaching families how to better monitor breathing, utilize controlling versus rescue medications, use the right drugs early during an asthma attack and seek local medical assistance only if a patient’s condition was not improving, the studies demonstrate.
"Although educational programmes for children with asthma have been in use for decades, many hospitals do not have a routine approach for the education of children and their families about appropriate asthma management," the authors wrote. "One reason for this could be the lack of a systematic evaluation of the evidence base in this area, since the results of single studies have not consistently demonstrated reduced asthma morbidity or hospital re-attendances following education."
The Cochrane Collaboration is an international non-profit group that promotes the systematic search for evidence-based health solutions. The group's report is the second major evaluation of studies showing that education can prevent emergency visits. But previous studies were done in adults. This is the first collective evaluation of whether education can also work in a pediatric population.
The researchers could not single out any education techniques that were superior to others. Nor could they say whether interventions that lasted longer or were more intense than other efforts were more effective. But they concluded that one important tool was to educate parents about potential triggers in the home, such as smoking.
Although the number of subsequent emergency room visits made by the child was the primary endpoint analyzed, secondary outcomes measured included hospital admissions, unscheduled doctor visits, lung function tests, quality of life and functional health status, and the number of days a child stayed home ill.
Beginning in 2011, Medicare will begin paying for dialysis services for individuals with end-stage renal disease using an expanded bundled payment that is designed to encourage home dialysis.
However, several factors could make those home services somewhat more expensive—and less desirable to providers—according to a new General Accounting Office report.
Some dialysis experts and providers have estimated that anywhere from less than 10% to up to 50% of dialysis patients could be good candidates to perform dialysis at home. Currently, only about 8% of individuals undergoing dialysis do it at home. In 2006, Medicare was the primary payer for approximately 84% of dialysis patients nationwide.
Currently, the details of the bundled payment are still under development, according to officials from the Centers for Medicare and Medicaid Services. At the time of the GAO review, CMS indicated it might give providers the same payment regardless of whether the dialysis was performed at home or in a facility.
CMS officials acknowledged to GAO that while some costs might be higher for home dialysis patients—such as supplies—other costs would be far less. These costs would be offset by efficiencies created in lower-cost categories, such as drugs, staff, and overhead projections, according to CMS.
However, costs related to training patients how to perform dialysis at home could make treatment costs higher, according to the providers interviewed by GAO staff. For instance, it may take three to six weeks, with up to five training sessions per week, to train a patient to perform home dialysis. For those performing peritoneal dialysis, the training period might be about one to two weeks.
Also, patients undergoing treatments at home may perform them more than three times a week (which is the average for dialysis procedures performed in facilities). Charges for single dialysis treatments performed in a facility are higher (about $240 on average), compared to treatments at home (between $90 to $130). However, weekly costs could end up the same or more depending on how often treatments were performed at home.
GAO recommended that CMS should establish and implement a formal plan to monitor the bundled payment system's effect on home dialysis utilization rates and determine whether home dialysis utilization rates may be higher than initially estimated.
Antitrust lawyers say doctors, hospitals, insurance companies and drug makers will be running huge legal risks if they get together and agree on a strategy to hold down prices and reduce the growth of health spending. Robert F. Leibenluft, a former official at the Federal Trade Commission, said, "Any agreement among competitors with regard to prices or price increases—even if they set a maximum—would raise legal concerns." Already, some leaders of the healthcare industry who appeared at the White House on May 11 say the president may have overstated their cost-control commitment.
Conservative groups are battling Democrats' proposed health-system overhaul with advertising campaigns contending that the changes could result in long waits for surgery and difficulty obtaining prescription drugs. Americans for Prosperity Foundation, a conservative advocacy organization, plans to launch a $1.7 million television-advertising campaign that negatively likens the U.S. healthcare system envisioned by lawmakers to Canada's publicly administered system.
Federal prosecutors in Miami have charged an employee at Tenet Healthcare Corp.'s Palmetto General Hospital in Hialeah and an accomplice with theft of patient records and felony HIPAA violations.
Jacquetta L. Brown, 29, a medical records employee at the 360-bed acute-care hospital, and accomplice Tear Renee Barbary, 25, face multiple felony counts of conspiracy to commit access device fraud, and criminal HIPAA violations. Brown also faces aggravated identity theft.
According to the indictment, Brown took records containing personal information of PGH patients, and she and Barbary used the stolen personal information in a credit card fraud scheme. The stolen patient profile records included patients' names, birthdates, Social Security numbers, addresses, drivers' license numbers, and next of kin contacts, the indictment states.
According to United States Attorney for the Southern District of Florida, Brown used the stolen identifying information to obtain patients' credit card account numbers, and gave patient profile records and credit card account numbers to Barbary, who used the information to make unauthorized credit card purchases. Officials say that when police arrested the duo, Brown was found with 41 patient records and Barbary was found with six patient records.
When contacted by HealthLeaders Media, Palmetto General Hospital released the following statement: "We take protecting patient information extremely seriously at Palmetto General Hospital. While we have policies and procedures in place to prevent this unfortunate situation, the employee in question deliberately circumvented these safeguards. We have taken steps to provide those who may have been affected with the information and tools they need to protect their identity. The person involved has been identified and the proper authorities have been notified. The employee involved is no longer employed by Palmetto General Hospital."
Georgia-based WellStar Health System plans to spend $800 million over the next decade in expansion and improvements, including a new $14 million outpatient campus and a $100 million hospital. The health system's plans buck a trend among hospitals to scale back on spending and building projects, and WellStar officials acknowledged some challenges ahead. The new hospital requires state approval, the outpatient campus is the subject of a lawsuit over the property's rezoning, and the economy could force the delay or scaling back of some elements.
People who have lost their employer-provided health insurance because of a layoff, early retirement, or other reasons are turning to forming a small business, or using an existing one, to buy a group policy. The strategy is used by groups as small as one person, and is particularly useful for people with chronic health problems that insurers refuse to cover or that result in steep premiums. Group health plans, under federal law, are required to cover such conditions, as long as the individual doesn't go uncovered for more than 63 days.
