Use UCC to address overcrowding in ED
To address overcrowding, Harbor-UCLA Medical Center in Torrance, CA, built an urgent care center (UCC) that triages 18,000 patients a year from the ED. Patients with conditions not requiring immediate medical attention are triaged to a UCC. In the ED, traditional triage is followed by a secondary medical screening exam, to identify patients who can be seen at a later appointment or the following day at the UCC, Robert Hockberger, MD, FACEP, chair of the department of emergency medicine explains.
The UCC is open from 9 a.m. to 5 p.m. Monday through Saturday. "A lot of our patients come in after hours. So when patients come to the ED, we triage them into one of five levels of care: level one is critical, two is emergent, three is urgent, four is non urgent, and five is chronic," Hockberger explains.
In addition to triaging out patients who don’t require immediate care in the ED, the system ensures that uninsured patients who have no other options for care don’t fall through the cracks, reports Hockberger. "Many of these patients are working during the day at low paying jobs or have to take care of young children or older people at home, and their schedule may not be able to correspond with hours that the clinics are open," he says.
"[The UCC] is one way we have been able to unload our lower acuity patients, who come to us primarily because they have no other options," says Hockberger.
Patients identified for the UCC
Patients who receive a rating of 4 or 5 based on the nursing assessment are offered the option of waiting to be seen in the ED or of being scheduled for a specific appointment in the UCC. "If a patient comes in early in the morning, we usually assign them for an appointment that day, but we do send some people home to come back the following day," says Hockberger.
Initially, [the referral system was tested] on a trial basis. "If we found that a substantial amount of patients wouldn’t take the referrals, we probably would have had to hire the extra staff [to keep the UCC open longer]. But enough people do take the referrals, so this system has worked for us so far," Hockberger notes. "We thought it was the more appropriate way to go, than to hire additional staff to keep the UCC open until midnight."
A system was implemented to avoid violating EMTALA requirements, Hockberger notes. "We put together a committee of physicians and nurses and developed guidelines to perform a medical screening exam at triage, which is done in greater depth than our usual triage. This was adopted by our medical committee as policy," he explains.
If patients choose to take the appointment, the triage nurse performs the medical screening exam. "If that confirms they are a low-risk patient, we schedule the appointment. But if it comes up with something more than the superficial triage exam did, we elevate the patient to a higher level and see them as soon as we can get to them," Hockberger says.
An ongoing QI process ensures follow-up with patients that come back the following day. "If they don’t come back, the nurse calls them to find out why didn’t keep the original appointment, and encourages them to make a second appointment," Hockberger says. JCAHO surveyors recently found the system acceptable, he adds.
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