Today, EDs are crowded at levels they've never been before, and there's few if any signs the problem can be made better. Sure, smart hospitals can improve patient flow by investing in IT that tracks them efficiently. And there's always ways to make better use of time when patients are waiting--for example, I've heard of some that take blood samples and do an EKG while patients was boarding in the hallway.
But I'd argue that the answer isn't necessarily getting them in and through the system as quickly as possible--out the door or into beds--isn't necessarily the best way to think about dealing with this flood of patients.
After all, just because a patient isn't dying (and doesn't need to be admitted at that moment) doesn't mean that they're a) not just a bit too acute to be lightly sent home to bed, b) might benefit from palliative meds to tide them over until specialists can see them, or c) in need of more information to better self-manage their condition than the more or less useless handouts EDs typically provide. And that argues strongly for establishing at least some kind of primary/urgent stepdown presence in the ED for patients who still need help once it's been determined that they're not in immediate danger.
For one thing, a primary care-minded staff member such as a nurse practitioner can do much to help coordinate care between the ED and on-call staff at primary care practices. He or she can also ask a few probing questions of the primary care physician to see if there's tests or issues the patient might not have mentioned, something that ED physicians seldom has time to do.
What's more, an NP can help develop a slightly more robust care plan for moving forward than "here's a referral," which all many non-critical patients get. Such help not only improves outcomes overall, it also builds relationships with patients who may have a need to return to your ED someday.
On top of everything else, if hospitals place an urgent care person within the ED, that could serve as a funnel to future relationships with the patient and his or her family which could include ambulatory surgery referrals, relationships with affiliated primary care practices, physical therapy and more. In other words, while health systems may not get an admission out of that visit, but they could develop a longer-term relationship that proves fruitful for both sides.
So, folks, what do you think? Am I on base here? Is there something I'm missing? Write to me and tell me what you think. -Anne