emergency department, overcrowding, ambulance diversion, throughput, urgent care, Clinical Management, reform, coverage, primary care, admissionEmergency departments are bracing for an increase in patient visits when federal health reform's insurance provisions begin in 2014. The concern is fueled by the perceived impact Massachusetts health reform had on EDs.

"We're certainly aware that in Massachusetts there's been a crush on the emergency departments, and everybody is worried what would happen with expanded coverage," says Lee Sacks, M.D., executive vice president and chief medical officer for Advocate Health Care.

Although Massachusetts provides a cautionary tale, it also offers hope that hospitals can take steps to better handle emergency patient loads. And regardless of the ultimate fate of national health reform, ED visits are bound to grow because of the aging population and the shortage of primary care physicians. Hospitals need to prepare, says Sandra M. Schneider, M.D., president of the American College of Emergency Physicians.

When Massachusetts passed its health reform legislation in 2006, most experts assumed that expanding coverage would give more people access to primary care physicians. In theory, that would decrease comparatively expensive ED visits by patients with nonemergency complaints.

Instead, overall ED visits increased 4 percent after reform went into full swing in 2008, according to research published in the September 2011 Annals of Emergency Medicine.

Although the percentage of low-severity ED visits decreased among the patients most affected by the reform law, the drop was just 2.6 percentage points. The dip in the percentage of ED visits for ambulatory care sensitive conditions — those that could be addressed by good primary care — was even smaller at 0.6 percentage points among this group.

The reason: a dearth of primary care. "It's one thing to give people coverage, but it's another thing to give people access," says Stephen Epstein, an emergency physician at Beth Israel Deaconess Medical Center in Boston and instructor at Harvard Medical School. Newly insured patients faced long wait times to see a primary care physician or couldn't see the doctor when they needed to after business hours or on weekends. Many of those patients ended up going to the ED for nonemergency care.

The most eye-opening finding, Epstein says, is that the percentage of patients in the ED for ambulatory care sensitive conditions who then were hospitalized increased 6.7 percentage points in the group most affected by reform. "Suddenly people have insurance and feel like they can get this [condition] taken care of," he says. "They go to the ED, and we say, 'Wow, you really are sick,' and send them to the hospital."

How Hospitals Averted a Crisis

The Massachusetts case is further complicated by the state ambulance diversion ban enacted in 2009. The double-whammy of reform and the diversion ban could have been expected to cause an ED crowding crisis. But, Epstein says, that didn't occur. "It's not to say we don't have crowding problems. We do," he says. "It could have been a lot worse. The notion that you're going to have more patients coming to your ED because of health care reform and we're going to shut off this safety valve of diversion probably scared more than a few people to actually act."

Another reason a crisis didn't emerge was that before the ban went into effect, hospitals had access to materials describing best practices on how to mitigate ED crowding, including case studies published by Urgent Matters, a Robert Wood Johnson Foundation-funded initiative. Additionally, Massachusetts required hospitals to develop "Code Help" plans to use if their initial efforts ever fail. Code Help is an internal declaration that forces the hospital to take additional measures to alleviate ED backlogs. The measures range from opening a discharge lounge to temporarily canceling elective surgeries.

The reform law and diversion ban forced Massachusetts hospital leaders not only to look at how to make their EDs more efficient, but also to examine how hospitalwide processes impact patient flow in the ED. Any hospital hoping to address current ED crowding or to prepare for the anticipated nationwide increase in emergency patient caseloads will have to do the same because often the problems that cause backups are found elsewhere in the facility rather than the ED.

Those problems include a lack of inpatient beds for ED patients who need to be admitted, inefficient processes that slow ED patients' transfer to inpatient beds, health professional shortages and financial constraints, ACEP's Schneider says. "There are a wide variety of reasons why this is happening, but the end result is that you're waiting in the emergency department waiting room for treatment because inpatients aren't leaving," she says. "It's like a restaurant where people don't leave. Imagine people who come in for breakfast and then don't leave for two days."

Because these problems are hospitalwide, the solutions have to be, too. Tufts Medical Center in Boston instituted a number of initiatives to improve patient throughput to prevent ED crowding, says Matthew B. Mostofi, D.O., Tufts assistant chief of emergency medicine and president of the Massachusetts College of Emergency Physicians. They include an admissions, discharge and transfer center that coordinates those patient transitions; a centralized, hospitalwide bed board used to track patient throughput; new policies for turning around inpatient rooms; and streamlining patient handoffs by nurses.

Some problems, such as insufficient inpatient bed capacity, can be difficult and expensive to correct. Advocate Christ Medical Center in suburban Chicago has experienced a record number of ambulance bypass hours this year, Sacks says. The hospital, a Level I trauma center, runs at 95 to 100 percent occupancy, and there just aren't enough beds. "They back up in the ER. There are no critical care beds, so there is no room for the sickest patients. Pretty soon you get gridlock," Sacks explains.

In part to address ambulance diversion, the hospital is expected to break ground this fall on a $202 million, nine-story ambulatory care pavilion that will free up space to treat emergency patients and patients admitted to the hospital.

Addressing ED overcrowding requires a champion in hospital administration. "There are a lot of people out there who think that if we just shut off the patients coming to the ED we would solve the problem of emergency department crowding. Not the case," Epstein says. "You're really trying to make a hospital more efficient. Folks in the emergency department don't have control over the vast majority of the rest of the hospital." The team working on solutions should be multidisciplinary, including ED personnel, inpatient nursing, housekeeping, ancillary services, radiology and patient transport.

Some emergency departments are looking internally for ways to become more efficient. Earlier this year, Advocate Health Care placed care managers in its nine EDs. They work with patients — often those with behavioral health or chronic conditions — who have social issues that tie up emergency department staff and who frequently were admitted because ED physicians felt uncomfortable discharging them.

The care managers arrange physician appointments, home health care or placement in an appropriate health care setting. "These are things that can consume a couple of hours, and if the emergency department staff focus on that, it grinds the place to a halt," Sacks says. "We've found that [care managers] can improve throughput in the ER and avoid unnecessary admissions. The patients who get helped by it express a high degree of satisfaction that there is somebody special looking out for them."

Giving Patients Options Besides the ED

Some hospitals are recognizing the pressure the lack of primary care access has on emergency department volume and are developing ways to alleviate that strain. For example, Advocate Health Care in April entered into a clinical affiliation with MinuteClinic under which physicians affiliated with Advocate Physician Partners will serve as medical directors for 23 MinuteClinics. Many people find the nurse practitioner-staffed clinics convenient because they're open seven days a week and have weekday evening hours. The health system and the clinics will fully integrate their electronic medical record systems so that the nurse practitioners can access vital patient medical information and Advocate physicians will know what care was provided at the clinics, Sacks explains.

The organization also is piloting a call center to help prevent unnecessary after-hours visits to the ED, Sacks says. The center is staffed by nurses who can give medical advice when appropriate and who use protocols to determine whether patients who call in need to speak to their doctor, go to the emergency department or could wait until morning to see a physician. If the nurse helps a nonemergency patient arrange an appointment in the morning, "[he or she doesn't] have to run at midnight to the ER," he says.

Hospitals might want to accept the idea that patients are going to come to the hospital for nonurgent care but give them options other than the ED, says Randy Pilgrim, M.D., CEO and chief medical officer at the Schumacher Group, an emergency medicine staffing and management firm. For example, hospitals could adapt the Coumadin clinic model to conditions such as diabetes, chronic heart failure and chronic obstructive pulmonary disease. When patients present to the ED with one of those conditions, the staff must treat them, but then can offer patients a place for continuing care, he says. "In theory, you send them [to the clinic] once and show them how to access it in the future, and you've taken one unnecessary ED visit and limited it to one," Pilgrim says.

How Bad Is It, Really?

As the debate about national health reform and spiraling health care costs continues, though, some emergency medicine experts complain about what they perceive as an overblown perception of the cost of emergency care and the number of unnecessary visits. "Only 2 percent of the national health care budget is emergency costs — that's all costs, heart attacks, car wrecks and the 'unnecessary' visits," Schneider says. The Centers for Disease Control and Prevention reports that of all ED visits, 8 percent are nonurgent and two-thirds are after hours and on weekends, Schneider notes. "So if we got the unnecessary visits out of the ED, the cost savings would be one-third of 8 percent of 2 percent. I don't think that's going to save the health care costs of this country."

EDs have to be open 24 hours a day, seven days a week, 365 days a year so people with emergencies can get needed care, Mostofi says. If in the lulls they didn't see the less-severe cases, they couldn't cover their overhead. "If the place is empty and just waiting around for the severe cases to come in, it's not going to be cost-effective and EDs are going to close," he says.

Geri Aston is a contributing editor to H&HN.

Urgent Matters

Hospitals seeking to alleviate emergency department crowding can find a toolkit and other resources at Urgent Matters, a national initiative dedicated to the issue, at http://www.urgentmatters.org. Here are two case studies featured on Urgent Matters.

Full capacity protocol

Location: Stony Brook (N.Y.) University Hospital
Concept: Redistribute admitted patients boarding in the ED to acute care hallway beds when the ED is unable to evaluate and treat new patients in a timely manner.
Result: A substantial increase in patient safety and satisfaction. Of transferred patients, almost half were assigned a room immediately or in less than one hour.

Discharge resource room

Location: Regional Medical Center at Memphis
Concept: Create an eight-bed area dedicated to providing discharge instructions and resources for inpatients to assist in preparation for their home care.
Result: Use of the resource room freed inpatient beds more rapidly and significantly decreased ED throughput time.

Health Reform Concerns

A 2010 survey of emergency department administrators shows that many have concerns about the impact of national health reform on their EDs. Of the 6,075 respondents:

  • 70% said they believe Medicare, Medicaid and private insurance reimbursement will decrease under health reform.
  • 66% said health reform will cause ED patient volume to increase, while only 5 percent believe it will decrease.
  • 64% said that because of health reform their EDs will see more patients who cannot access primary care physicians in a timely matter, compared with 7 percent who said their ED would see fewer such patients.
  • 55% said that because of health reform their EDs will see more patients who cannot access specialists in a timely manner, while only 3 percent said their ED would see fewer such patients.
  • 43% said they believe reform will mean that their EDs will see fewer uninsured patients, while 22 percent believe they will see more uninsured patients.

Source: "Emergency Department Challenges and Trends: 2010 Survey of Hospital Emergency Department Administrators," Schumacher Group