This article appears in the May 2012 issue of HealthLeaders magazine.
Among the greatest challenges in the emergency department is improving patient flow, and this comes with a sense of urgency amid deep concerns about patient safety due to overcrowding. In addition, the latest HealthLeaders Media Intelligence Report reveals that healthcare leaders expect worsening ED revenue margins and an increasing volume of uninsured patients.
Hospitals are trying to reduce ED congestion and wait times by creating systems to care for patients with lower acuity in one area, and by freeing up beds for those with more serious illnesses. They are improving coordination among nurses and physicians to ensure the sickest patients are seen quickly.
But while many healthcare leaders have identified patient flow as their main challenge, many continue to deal with overcrowded EDs and concerns about patient safety. When asked about their greatest strategic challenge involving the ED, 43% said patient flow. Another 46% described their EDs as overcrowded, and of that group, 93% expressed concern about patient safety as a result of the overcrowding. That represents about 43% of all respondents expressing concern.
“You have multiple things going on—the wave of Baby Boomers about to hit retirement age, being Medicare eligible,” says Randy Davis, senior vice president and CIO of 72-bed NorthCrest Medical Center in Springfield, Tenn. “Across the U.S., there is a huge access issue with the shortage of primary care physicians, and with anticipated higher volume in the ED. Access to a primary care physician may be limited, leaving people to go to the ED as their only choice.”
And for Phil Newbold, president and CEO of the 350-staffed-bed Memorial Hospital Health System in South Bend, Ind., and 260-staffed-bed Elkhart (Ind.) General Hospital, it was no surprise that more than four in 10 respondents were concerned about patient safety in the ED. Among the 46% who said they have overcrowded EDs, nearly all respondents said they are concerned about safety issues.
“I think safety is a big concern as more older people with medical problems will be sicker and showing up in the ED, and all this means everyone is going to take longer to go through the system,” says Newbold.
As health systems try to improve their EDs, healthcare leaders are watching the financial framework with caution. About 80% said they expect their ED reimbursement margins will worsen as a result of healthcare reform, and 78% said their reimbursement also will get worse. Those factors coupled with an expected increase in the uninsured patient population are a formula for uncertainty for administrators running an ED, according to Gary Tiller, CEO of Ninnescah Valley Heath Systems, which operates the 25-staffed- bed Kingman Community Hospital, 35 miles west of Wichita, Kan.
“We are going to get overrun,” Tiller says, predicting an influx of patients who want to use the ED in the wake of healthcare reform. “I don’t know if we are going to be able to handle it, truth be known. It’s going to be a mess. The thing is we, like everyone else, don’t have enough primary care doctors, so we’re looking at beefing up on our mid-level physician assistants and other providers to assist. We have our waiting times now in the ED at 54 minutes, but we may be seeing them at two or three hours again, so we’re recruiting more doctors for the ED.”
Waiting is still a given for the ED, though health systems are working to reduce the times, with some posting their schedules on websites as marketing tools to show they may be faster than another facility. According to the survey, 41% of healthcare leaders said the average ED wait time for patients to be seen by a clinical provider is from 0–30 minutes, while 35% said it’s from 31–60 minutes, and another 23% put it at more than an hour.
Most healthcare leaders, 56%, reported an increase in ED inpatient admissions over the past two years, with just 13% noting a decrease. Among hospitals that indicated an increase, 55% reported growth of 1%–10%.
“The reason we are going to see fewer inpatient admissions and higher ED volumes is because the people aren’t sick; patients are utilizing the ED as their primary care physician office instead of using the ED as it should be” Davis says.
Stress on the nation’s EDs could grow, as 27% of respondents said they expect a significant increase in the number of uninsured in their ED in the coming year, and 58% expect a slight increase.
An overwhelming share of hospital leaders—95%—said they have current or ongoing efforts to improve throughput in the ED.
Among the most effective techniques they cited to increase ED efficiency are fast-track areas for severe illnesses or injuries, 65%; a triage medical evaluation process, 56%; and coordination with inpatient floor nurses, 55%.
Only one third of healthcare leaders said they have programs in the ED that focus on diverting patients with specific conditions. Among those that have programs, 42% focus on psychiatric health issues, 33% target prescription drug abuse, and 22% home in on alcohol-related issues.
Such programs may become more important for ED efficiency as hospital officials handle increasing patient volume, Davis says.
“As unemployment rises, as economies tighten, flexible spending goes down; as divorce rates go up, people are under more stress, and there’s more psychiatric visits. But small community hospitals don’t have dedicated psychiatric services and psychiatric beds,” he says.
More hospitals are operating or attempting to get involved in running urgent care centers. Some 51% operate urgent care centers or have a formal or informal relationship with one. An overwhelming 78%, however, said a freestanding ED is not in their plans.
Outpatient programs will be continually crucial as health systems try to relieve the pressure on the ED, and innovation is needed, says Newbold. “The ED is so complex, and you have different levels of care needed,” he says. “We have big gaps that we have to close as an industry.” Newbold says his system and others need to be innovative and “start setting up EDs in areas that will take the load off the current EDs, with 24-hour urgent care centers and convenience express care centers.
And while most healthcare leaders said they have programs or initiatives specifically aimed at addressing patient experience in the ED, nearly one in five does not.
“It is time to think fundamentally about better experiences for the patients,” Newbold says. “Over time, people will be shopping for lower waiting times and compare satisfaction scores, like a retail experience.”
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