Wonderful topic, and forgive me for tossing in my two cents: Isn't the basis for the plight of the ER primarily linked to the catastrophic and wholesale abandonment of primary care in this country? While some of the lengths undertaken to fix the symptoms of overcrowding, some nearly heroic, I think the fundamental issue is associated with access, coverage, and availability and utilization of primary care. As you mention in the case of the HCA hospitals in Florida, redirecting patients to clinics can save costs. But this kind of shift also comes much too late. Providing a global (national) accessibility to primary care could keep the 85 percent of the patients out of the ER who do not have genuine need of emergency services. It would also allow the most costly care in the system to be used appropriately and would shore up the primary care docs, who are soon to be found only in museums.
-Barry Trask, Senior Report Analyst
Physician Practice Solutions
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I have a few additional thoughts about the current state of emergency department (ED) performance you might want to consider:
1. Most EDs treat a lot of patients who really don't belong there at all. The patients I'm talking about are the patients who could have been "direct admissions" to the hospital but, for a number of reasons, their admitting physician directed the patient to the ED. If it takes longer to get ancillary tests performed for inpatients, if it's difficult to get a bed, etcetera, many community physicians will simply tell their patients to go to the ED. The patients then receive a work-up from the ED physician and are admitted to the hospital. Of course, in this day of prospective payment, the ED portion of care provided to the patient is a total financial loss to the institution. Hospitals with "express admitting" processes can reduce ED patient volume by several thousand patients per year.
2. EDs are notoriously poor and aligning staff with patient demand. Few EDs really understand the patient arrival process at their hospital. While everyone might agree that "Monday and Tuesday are our busiest days," staffing patterns are almost always level Monday through Friday. As a result, wait time and patients who leave without being seen are particularly high on Monday evenings.
3. No one had done the statistical homework to identify the time of day and day of week admission patterns from the ED to the hospital. With an understanding of these admission patterns, beds in the hospital can be reserved for yet-to-be-defined ED patients just as beds are reserved for patients treated in other areas (i.e. beds reserved for orthopedic surgery patients to correspond with the orthopedic surgical schedule). Every ED patient who requires admission to the hospital is treated as a complete surprise.
4. Within five minutes of placement in an ED exam room, with 98 percent certainty or better, ED physicians can tell you if a patient is going home or headed for hospital admission. However, it is usually several hours later, after the entire ED treatment process is completed, before the hospital is notified whether it needs a bed for this patient. Front loading the bed request can minimize the post-ED wait time for hospital bed placement.
5. There is a lot of "re-work" related to ancillary testing. It is not unusual to find EDs with lab rework on the order of 4 to 7 percent (i.e. hemolized blood, contaminated or mislabeled samples, and so on). Relatively easy improvements to reduce sample rework can save several hundred thousand dollars per year in a typical ED, not to mention the improvement in patient processing time and care quality.
6. Administrative processes such as registration and discharge are done in sequence with the medical treatment process. These administrative processes should be done in parallel (i.e. bedside registration) to speed patient flow.
7. There is a great deal of variation in practices of ED physicians for the same type of patients. In my experience, I usually find the following: For a particular disease-specific patient type…there are few "standard practices" and physicians are not consistently following the best practices shown in the medical literature.
One final note: A dedicated pediatric treatment area in an ED can be very problematic and expensive to operate. It really all depends on patient volume.
-Timothy J. Ward, Partner
TEFEN USA, Ltd.
Email: tward@tefen.com