One-stop shop for care

Hos­pi­tal ERs see­ing in­crease in pa­tients, cap­i­tal

Modern Healthcare - - COVER STORY - Beth Kutscher

When Dr. Rich Zane ar­rived last year at the Univer­sity of Colorado Hos­pi­tal to be­come chair of its newly formed emer­gency medicine depart­ment, he found an emer­gency room built to han­dle 25,000 pa­tients a year but was see­ing 60,000.

Pa­tients faced long wait times, sat­is­fac­tion plum­meted and many sim­ply left with­out treat­ment. The ER was con­stantly on diver­sion. Like most hos­pi­tals, Zane said, it was op­er­at­ing un­der “a process that’s pred­i­cated on 1960s medicine and we’re prac­tic­ing it in 2013.”

He set out to trans­form ER op­er­a­tions. Last month, the 467-bed hos­pi­tal un­veiled a re-en­vi­sioned emer­gency depart­ment. It has no wait. There’s no such thing as triage, and pa­tients see a doc­tor as one of their first points of con­tact.

The Aurora-based hos­pi­tal is the lat­est ex­am­ple of med­i­cal cen­ters con­fronting the cen­tral para­dox of to­day’s emer­gency-room care: more and more pa­tients—and their pri­mary-care doc­tors—are tak­ing ad­van­tage of the emer­gency depart­ment’s abil­ity to of­fer a 24/7, one-stop shop for all their ail­ments. And as they do, hos­pi­tals are see­ing new op­por­tu­ni­ties to tap into that de­mand.

The change is be­ing driven by a fun­da­men­tal shift in how peo­ple in­side the health­care sys­tem are be­gin­ning to see the emer­gency depart­ment. An in­creas­ing num­ber of of­fice­based pri­mary-care providers are con­cen­trat­ing solely on well­ness and chronic-dis­ease man­age­ment. When they see pa­tients with more ur­gent com­plaints, of­ten re­quir­ing more so­phis­ti­cated tests and pro­ce­dures, they send them to the hos­pi­tal.

This emerg­ing prac­tice pat­tern is chal­leng­ing the con­ven­tional wis­dom about emer­gency care—that high uti­liza­tion is nec­es­sar­ily a bad thing. “Emer­gency de­part­ments have be­come a por­tal for pa­tients to get care very quickly,” said Dr. Robert Nor­ris, chief of emer­gency medicine at 477-bed Stan­ford (Calif.) Hos­pi­tal & Clin­ics. “To be hon­est, I think that’s one of the real ad­van­tages of emer­gency medicine.”

Last year, Sil­i­con Val­ley’s lead­ing aca­demic med­i­cal cen­ter took a num­ber of steps that would ul­ti­mately im­prove wait times and al­low the hos­pi­tal to see and at­tract more pa­tients, even those with lower-acu­ity con­di­tions. With Stan­ford’s rep­u­ta­tion as a qua­ter­nary-care cen­ter, “the word was that you went other places for mi­nor lac­er­a­tions and an­kle sprains,” Nor­ris said. “And that al­ways both­ered me.”

Nor­ris ar­gued that the cost of de­liv­er­ing care in the ER is not more ex­pen­sive than it would be in a doc­tor’s of­fice. In fact, see­ing lower-acu­ity com­plaints is ac­tu­ally an ef­fi­cient use of fixed hos­pi­tal re­sources, par­tic­u­larly staff and clin­i­cians. “They’re there and they can see pa­tients,” Nor­ris said.

The changes are oc­cur­ring at a time when the emer­gency depart­ment has been a con­sis­tent bright spot for hos­pi­tals in terms of vol­ume, even as growth in in­pa­tient ad­mis­sions has stag­nated. Hos­pi­tals now see new op­por­tu­ni­ties to be more in­volved at the point where pa­tients are ac­tu­ally ac­cess­ing the sys­tem since the ER has be­come the pri­mary dri- ver of hos­pi­tal ad­mis­sions, which is where hos­pi­tals make the bulk of their rev­enue.

A study last week from RAND Health found that emer­gency de­part­ments are now re­spon­si­ble for about half of in­pa­tient ad­mis­sions, and ac­counted for all of the growth in ad­mis­sions be­tween 2003 and 2009. Di­rect re­fer­rals from physi­cians in the com­mu­nity, mean­while, are on the down­swing. The dra­matic re­ver­sal means that even though hos­pi­tals ad­mis­sions in­creased only 4% over the pe­riod—not even keep­ing pace with pop­u­la­tion growth—ER-re­lated ad­mis­sions jumped 17%.

The shift is driv­ing hos­pi­tals to be­gin mak­ing sig­nif­i­cant in­vest­ments in their ERs, a marked change from past prac­tice. Dr. An­drew Ag­wunobi, who leads the hos­pi­tal per­for­mance im­prove­ment prac­tice at Berke­ley Re­search Group, noted that hos­pi­tals tra­di­tion­ally did not in­vest much cap­i­tal in the ER in the be­lief that it pro­vided mostly un­com­pen­sated care. In ad­di­tion, the un­der---

ly­ing as­sump­tion was that de­liv­ery sys­tem re­form would ul­ti­mately re­duce the num­ber of ER vis­its and steer pa­tients to­ward low­er­level care set­tings.

“What they found was that the fi­nan­cial health of the hos­pi­tal was ac­tu­ally in jeop­ardy,” Ag­wunobi said. “Most of the rev­enue of the hos­pi­tal was ac­tu­ally com­ing from the emer­gency depart­ment.”

Af­ter ex­am­in­ing their rev­enue streams, hos­pi­tal ex­ec­u­tives found that peo­ple show­ing up for nonur­gent care ac­tu­ally did have in­sur­ance or other means to pay. What they didn’t have was other op­tions for treat­ment. “It is not only the unin­sured and un­der-in­sured that use the ER—it is ev­ery­one,” Ag­wunobi said. “The ER depart­ment pro­vides 24/7 open ac­cess in a health­care set­ting that very of­ten has closed ac­cess.”

Pri­mary-care physi­cians are in­creas­ingly us­ing the emer­gency room as a fall­back. RAND re­searchers found that the in­crease in ER-re­lated ad­mis­sions co­in­cided with a 10% de­crease in di­rect ad­mis­sions from doc­tors’ of­fices and other out­pa­tient set­tings.

“It’s in­creas­ingly com­mon for pri­mary-care physi­cians to see them­selves as ded­i­cated to their own of­fices,” said Dr. Wes Fields, an emer­gency medicine physi­cian and a board mem­ber of CEP Amer­ica, an acute-care man­age­ment and staffing firm. “If a pa­tient calls with chest pain or short­ness of breath, they’re not even go­ing to think about work­ing them up in their of­fice. The same is true for mi­nor trauma.”

The good news in the RAND re­port was that in­creased ER use didn’t nec­es­sar­ily drive up avoid­able ad­mis­sions. For in­stance, de­spite more pa­tients show­ing up to the ER with chronic con­di­tions such as asthma and heart fail­ure, ad­mis­sions for th­ese con­di­tions re­mained flat.

More­over, the RAND study high­lighted that even though emer­gency rooms ac­count for 11% of all out­pa­tient vis­its, they rep­re­sent only 2% to 4% of an­nual health­care ex­pen­di­tures. “You sim­ply can’t save enough money by try­ing to di­vert away low-acu­ity pa­tients,” Fields said. “There sim­ply aren’t that many of them. It doesn’t make sense to treat those pa­tients out­side that hos­pi­tal set­ting.”

One thing that re­designed emer­gency de­part­ments have in com­mon is that pa­tients see a physi­cian al­most as soon as they walk in the door. Tests are or­dered right away, and triage is a thing of the past. Physi­cians also work along­side a “scribe” who han­dles doc­u­men­ta­tion.

The Univer­sity of Colorado Hos­pi­tal even has a 24-hour re­tail phar­macy so that pa­tients can have a “pro­duc­tive wait­ing” ex­pe­ri­ence, Zane said. Colorado’s ER re­design was part of a larger $400 mil­lion pro­ject to build a new 12-story in­pa­tient tower—with the first floor largely ded­i­cated to an ER that is now more than dou­ble the size of the old one.

At­lanta’s 660-bed Grady Me­mo­rial Hos­pi­tal is also in the midst of its own “eight-fig­ure” pro­ject that will in­clude an ex­pan­sion and re­design of the emer­gency depart­ment. “It’s a dou­ble-edged sword,” said Dr. Leon Ha­ley, chief of emer­gency medicine for the Grady Health Sys­tem. “Ev­ery­one wants peo­ple not to come to the emer­gency depart­ment un­less they have an emer­gency. We know that’s not a re­al­ity.”

The ur­ban fa­cil­ity is still the ma­jor safety net hos­pi­tal for the unin­sured. But its emer­gency depart­ment has ap­peal for com­mu­nity physi­cians by speed­ing up the process of see­ing spe­cial­ists and get­ting test re­sults. “It’s rel­a­tively ex­pe­dited (com­pared to) if you try to do the same thing in a pri­mary-care set­ting,” Ha­ley said.

And some­times it leads to ad­mis­sions, the hos­pi­tal’s bread-and-but­ter. “When a pa­tient ex­hibits se­ri­ous symp­toms, the ED can be the most di­rect and op­ti­mum way to take care of the pa­tient and most con­ve­nient method of ad­mis­sion,” said David Gans, a se­nior fel­low at the Med­i­cal Group Man­age­ment As­so­ci­a­tion. It may even elim­i­nate some costs. “For many, the cur­rent in­sur­ance sys­tem does not bill an ED visit if the pa­tient is ad­mit­ted, so there may be no ad­di­tional cost to the con­sumer or the in­sur­ance com­pany.”

An­other com­mon theme among re­designed emer­gency rooms is larger ob­ser­va­tion units. Not ev­ery pa­tient needs to be set­tled into an emer­gency depart­ment’s most valu­able real es­tate: the mon­i­tored crit­i­calcare bed. “It’s one of the most ex­pen­sive beds in the hos­pi­tal,” said Dr. Bryan Gargano, as­so­ciate chief of emer­gency medicine at Rochester (N.Y.) Gen­eral Hos­pi­tal. “It’s your most valu­able re­source.”

Rochester Gen­eral first took a hard look at its emer­gency depart­ment four years ago. At the time, pa­tients com­ing into the ER were wait­ing an aver­age of 80 to 90 min­utes to see a doc­tor, and a frus­trated 4% to 5% left with­out be­ing seen. The hos­pi­tal first tried to tackle high vol­ume and long wait times with a big­ger space. But “it was pretty ob­vi­ous that build­ing a new space won’t solve op­er­a­tional prob­lems,” Gargano said.

By mid-2010, the hos­pi­tal had done away with the typ­i­cal mea­sures used to sort and process pa­tients. It cut triage and fast track. It fun­neled ev­ery pa­tient to a physi­cian, nurse or tech­ni­cian im­me­di­ately so that workups could be­gin right away. De­spite a huge in­crease in vol­ume—ER vis­its rose from 89,000 pa­tients in 2009 to 119,837 last year—the me­dian wait time fell to 19 min­utes.

How? A 30% in­crease in pro­duc­tiv­ity ac­com­pa­nied the in­creased fo­cus on serv­ing the im­me­di­ate needs of its ER pa­tients, Gargano said. TAKE­AWAY: Physi­cian re­fer­rals and in­sured walk-ins are crowd­ing emer­gency rooms, which are now the lead­ing source of hos­pi­tal ad­mis­sions.

More pri­mary-care physi­cians are send­ing pa­tients to emer­gency de­part­ments.

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