Most experts predict higher volumes with reform EDs must prepare now
Many strategies available to minimize logjams
The bad news: Most ED experts believe that health care reform will only exacerbate the steady growth of volume in the nation's EDs. The good news: ED managers have several weapons in their arsenals to help keep patients flowing through and out of their departments.
There are two forces at work that indicate crowding will become an even greater problem in the future, says Charles L. Reese IV, MD, FACEP, chair of the Department of Emergency Medicine for the Christiana Care Health System in Newark, DE.
"There is a gradual reduction in availability of primary care services of all kinds, with fewer medical students choosing primary care and very few internal medicine people going into primary care, while those who are in it are retiring and getting older and have a much more difficult time making a living than in the past," Reese says. "Combine that with an aging population and increasing complexity in their medical problems, and both those forces favor more patients going to the ED."
The final dynamic, he notes, is empirical evidence coming out of Massachusetts, which passed health care reform of its own. "We've seen a very substantial increase in the number of patients going to their EDs," Reese says. "This indicates to me substantial pent-up demand being unleashed by people having the ability for their health care to be paid for."
David C. Seaberg, MD, FACEP, dean and professor of Emergency Medicine at the University of Tennessee College of Medicine in Chattanooga and an ED physician with the Erlanger Health System, also in Chattanooga, agrees with Reese. "Reform was about insurance, not access," Seaberg says. "We don't have enough primary care doctors." He says the true impact of reform will start to be seen once the health exchanges are set up.
"If you look at what's happened in Massachusetts, it's a microcosm of what may happen in the country," Seaberg says. "With 97% of the people having some form of insurance, you see ED visits going up 7%-9%, while the average for the rest of the country is 1% to 1.5%."
Reimbursement rates under reform also could impact ED crowding, says Lynn Massingale, MD, FACEP, chairman and CEO of TeamHealth, a Knoxville, TN-based clinical outsourcing firm that provides ED services to more than 400 hospitals nationwide. "For the currently uninsured, it will probably be nothing above Medicare and perhaps more like Medicaid," notes Massingale, who points out that there are so few doctors in communities now who will take Medicaid and not a lot who take new Medicare patients, "So those who have 'insurance' will not have access because there's not enough capacity in primary care practices." Impact also could be felt from subspecialties, he adds. "We know from seeing patients in the ED that many women are not getting pap smears, breast exams, or mammography because there's no place for them," he says.
What's more, the nurse practitioners in drug store clinics are not really adding net new capacity because "they're just in a new location," he says.
The acuity issue
Another challenge under reform is how, and how aggressively, to address the issue of acuity, observers say.
"Low acuity patients are not our problem; sicker patients are," says Reese. "In our own institution we see 25,000 a year, but we designed a very good low-acuity care model using two or three rooms to process those people." The real issue, he says, is patients with Emergency Severity Index scores of 1, 2, and 3, which he predicts will increase.
The recently released "National Hospital Ambulatory Medical Care Survey: 2007 Emergency Department Summary," from the Centers for Disease Control and Prevention (CDC), supports Reese's contention by showing that only 7.9% of all visits were non-urgent down from 12.1% in 2006, says Angela F. Gardner, MD, FACEP, president of the American College of Emergency Physicians (ACEP) and assistant professor, Division of Emergency Medicine, Department of Surgery, at the University of Texas Southwestern Medical Center in Dallas.
"One of the concerns ACEP has is that the administration may have based all its assumptions on a faulty premise: that they can decrease the amount of ED visits by improving primary care," Gardner says. "What we're predicting will happen is that EDs will grow busier and busier, and the CDC data supports that based on its preliminary report for 2008."
However, Seaberg says that Erlanger was sufficiently concerned with non-urgent pediatric patients that it established a federally qualified health center (FQHC) on campus to relieve the burden on the ED at T.C. Thompson Children's Hospital at Erlanger. (For more on the FQHC, see the story below.)
Other strategies can free space
There are several strategies ED managers can employ to combat the anticipated volume increases that reform will bring, Gardner says.
"The biggest thing we have to promote in the college is to ask the ED manager to get admitted patients out of the ED, which allows us the flexibility to see more patients," she says.
One strategy is to take those patients to a floor even before a bed is ready, Gardner says. "Floor nurses don't like that. They want the patients all tucked in their bed. But the patient probably gets better care on the hospital floor than in the hall of the ED," she says.
Of course, such a policy requires the agreement and backup of administration. How can the ED manager "sell" it? "You get more patients through your ED," says Gardner. "Obviously, you do not want to do that if you don't have a waiting line to get into your ED, but that's a rare occurrence." She points out that if there are 10 patients taking up half the ED's beds, two each can go to five floors (one on each wing). Not only will that movement relieve the ED, she says, but "if you put a patient on the floor in a bed, they will find a way to take care of that patient. They will find a bed."
Gardner recommends having a strategy in place for when your ED becomes too crowded. "Just that act brings attention to the issue and helps people resolve the problem," she says. "I've seen a number of hospitals develop these full-bed protocols."
Such protocols involve administration, nursing leaders, and the ED medical director, Gardner says. "The protocol is triggered at a certain point, and they come down to the ED and determine who needs to be admitted and where they can be put," she says. "You consider which patients can be discharged or can wait in another area. Just shining the light on it will cause solutions to come up."
ED managers need to make their hospital administrators aware of how they can help reduce boarding and crowding in the ED, adds Seaberg. "ACEP put out a paper a couple of years ago on solutions to ED boarding, and three of the main ones don't even involve the ED," he says. Those solutions include moving patients into floor hallways, smoothing the elective surgery schedule, and discharging admitted patients before noon, he says. (The ACEP publication on boarding solutions can be downloaded for free at www.acep.org/WorkArea/downloadasset.aspx?id=37960.)
How do you get administration on board? "Show them the Massachusetts data," Seaberg suggests. "Ask them to think about what a potential 7%-9% increase in volume would do." If they care about their customer services and patient safety scores and metrics, they will have to look at how to deal with these issues, he says. (Massingale says paying attention to best practices that improve efficiency will also help ED managers prepare for reform. See the story below.)
Sources
For more information on preparing for healthcare reform, contact:
- Angela F. Gardner, MD, FACEP, President, American College of Emergency Physicians, Irving, TX. Phone: (800) 798-1822.
- Lynn Massingale, MD, FACEP, Chairman and CEO, TeamHealth, Knoxville, TN. Phone: (865) 293-5775.
- Charles L. Reese IV, MD, FACEP, Chair, Department of Emergency Medicine, Christiana Care Health System, Newark, DE. Phone: (302) 733-1840. E-mail: [email protected].
- David C. Seaberg, MD, FACEP, Dean and Professor of Emergency Medicine, University of Tennessee College of Medicine, Chattanooga. Phone: (800) 947-7823, Ext. 6956.
Best practices boost efficiency If ED managers implement best practices to address efficiency it will better prepare them for the impact of health care reform, says Lynn Massingale, MD, FACEP, chairman and CEO of TeamHealth, a Knoxville, TN-based clinical outsourcing firm that provides ED services to more than 400 hospitals nationwide. One issue to address is unnecessary processing, Massingale says. A best practice encouraged by TeamHealth is a Lean technique called value-stream mapping. "What it does is allow you to simply see in black and white those pieces of the patient experience that really add value and those that don't," Massingale explains. "We all know that waiting does not add value, but this helps you realize what pieces add nothing except frustration." One example involves "keeping a vertical patient vertical," he says. In the "old days," Massingale notes, a female with a urinary tract infection symptoms would be brought to a bed where the doctor and nurse would take vital signs and order a urinalysis. The patient would stay in bed until the test results came back and she was ultimately discharged. "She does not want to be in bed. She wants to be in her own clothes sitting up," he says. "You can allow her to get dressed and go back to the waiting area or sub-waiting area and free up that bed." Another efficiency issue is unnecessary motion. To address it, the ED team conducts a tabletop exercise during which they walk through where every piece of equipment is and where supplies are, Massingale says. "If you draw pencil marks or put pin marks in different colors and see what actual steps are required, it becomes really staggering how many unnecessary motions are there," he says. "You should be able to walk in a room and have the supplies you commonly need like strep screens or suture trays, without having to go someplace else." The downside of this approach is that you can have a lot of inventory, so you have to find the right balance between too much and not enough, Massingale concedes. However, he adds, "if you look at the presenting complaints and discharge diagnoses you can forecast, for example, how many patients with lacerations are likely to come in today with a pretty high degree of accuracy." Unnecessary searching is a related issue. "Each time a physician has to search for a tool time is wasted," Massingale says. "Even 25 seconds spent searching for a tongue depressor can add up if an ED sees 50,000 patients in a year." To address the issue, he says, ED leaders should standardize the way tools and materials are stocked so physicians and others who staff the ED can immediately find the tools they need. To do that step, he says, ED teams can use another Lean tool, the "5 S Project," which stands for Sort, Simplify, Sweep, Standardize, and Sustain. Sorting means making sure no components or supplies are in disarray and that all are put back in the proper place, Massingale says. So, for example, all bandages are in one area, all linens in another, and so on. To simplify, he says, you should ask questions such as, "How many different types of sutures do we really need?" The ED physicians can agree on a "formulary" of supplies, Massingale suggests. "Sweep" means exactly what it sounds like: Keep the rooms clean. When it comes to standardization, "you should make as many generalized rooms as possible identical, just like all Waffle Houses look the same," says Massingale. "This way, for example, the doctor knows right where the trays will be." To "sustain" these changes, It should be someone's duty on a formal basis to check supplies and make sure they are where they are supposed to be," he says. ED staff members might tend to be less conscientious about items such as tongue blades, Massingale says. "But even that can slow us down," he says. Such an approach will help eliminate unnecessary searching, Massingale says. The final issue, unnecessary waiting, can be addressed in part with effective visual cues. "If there isn't a system whereby as soon as the lab results are back, a chart gets flagged, they can sit in the computer or on a physical chart for a very long time before the doctor knows the results are back," says Massingale. He notes that the system can be electronic or physical. "It's as simple as having a person charged with this in the ED," he says. "When they see lab results come across, they physically move the chart from one rack to another, so one rack indicates 'ready to discharge.' Or it can be as simple as putting up a flag." |
FQHC relieves some ED pressure Concern about a possible increase in non-acute patients under health care reform was one of the reasons that Erlanger Health System and University of Tennessee College of Medicine (UTCOMC), both in Chattanooga, co-developed a federally qualified health center (FQHC) in clinic space adjacent to the hospital's pediatric ED, says David C. Seaberg, MD, FACEP, dean and professor of emergency medicine at UTCOMC and an ED physician with the Erlanger Health System. The urgent care center, opened in December 2008, effected the diversion of a total of 6,530 (16.2%) of ED visits in its first 12 months of operation. Eventually, 44% of the FQHC patients bypassed the pediatric ED and began to directly visit the clinic for their primary care. "The center is open from 6 p.m. to midnight and is staffed with a pediatrician," says Seaberg. "The patients who come to the ED get medically screened, and if they are low acuity patients, they are given the opportunity to go down to the center. And 95% of them do." The center was funded by a grant from the Centers for Medicare and Medicaid Services (CMS). "It was a godsend during flu season, when volumes really went up," says Seaberg. In fact, he reports, "volume in our main peds ED has remained flat or is even down a bit." |
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