Preparing for Patient Demand Under Reform: Does Your ED Need an Overhaul?

MASSINGALE: I agree with Jonathan when he said something to the effect of, "We don't have a bed problem; we have a doctors-getting-patients-discharged problem." In many cases, there are a lot of patients who could leave the hospital if they could be discharged by somebody—the hospitalist or their primary attending physician. Where we have a hospitalist program, we're calling the hospitalist in on essentially all the medical patients, with a few exceptions. In a few of our hospitals, our hospitalists admit everybody except the cases going straight to surgery for trauma. If you're in a situation where you've concentrated all admissions into the hands of two hospitalists, for instance, that can be a bottleneck that needs correcting.

HEALTHLEADERS: Are the rest of you seeing the same sorts of problems with getting patients admitted even if you have space?

HUNT: We also face the challenge that essentially the entire volume of medical admissions has been concentrated on the backs of just the hospitalists. Some of the hospitalists are good about sorting through this load, but others struggle. I don't think dealing with mass triage is part of the typical internist's training. It is part of the ED physician training to deal with the truckload of patients just emptied into your waiting room at once. You can't see one patient and follow it to the end before going on to the next one. I think there is a different mind-set between the two specialties, and sometimes that causes friction.

DAVIS: One of the reasons we opened an express admission unit was to assist community physicians with direct admits, bypassing the ER and reducing the number of patients holding in the ER. The job of our EAU staff is to go to the ER and "pull" patients out of the ER. There shouldn't be a "push" effect because the ER physician and the staff are dealing with multiple patients and the last thing they need is patients holding in the ER. Additionally, if the ER physician knows a patient needs to be admitted, the hospitalist takes the patient and gets him or her admitted. That's teamwork, where everybody's successful together, not one at the expense of the other.

MASSINGALE: In hospitals where we have both ER docs and hospitalists, we have implemented aligned incentives. The ultimate goal is to transition patients from the ER to the floor more quickly, and so both parties are incentivized to work together to make this happen. A few cross-incentives that we have not yet implemented, but I think would be instructive, would be to provide a financial incentive for the hospitalist if the ER docs hit their left-without-being-seen and door-to-doc metrics. Likewise, you could incentivize the ER docs if the hospitalists hit their metrics through core measures—things like hospital length of stay and reduced readmissions.

WHITE: When I first came here, the hospitalist program was in its infancy. What was happening was that the ER docs were writing very comprehensive admission orders and actually were doing some chart reviews. A few times, only two orders were written past the ER admission orders because the ER docs were writing such comprehensive orders. That's great in a sense, but it's also bad. We've modified that considerably.

HUNT: Even before we consolidated, part of our volume strategy was moving patients who were waiting to be seen by hospitalists out of the emergency department into an admission unit. We also use that unit to place patients who have been directly admitted from an office or regional transfer if no inpatient bed is available. One of the unforeseen consequences has been that while we may get the patients out of the emergency department into an admit unit, it has created a buffer for the admitting physicians, resulting in even longer delays getting the patients into an inpatient bed. The patients are still backing up in the ED because the admit units are now overflowing with patients. It may just be an expensive solution to what is really a physician manpower or workflow problem.

DAVIS: Part of our challenge was when we looked at the process, we had our admit nurses floating throughout the house. It was disorganized. To further exacerbate the issue, at discharge time a floor nurse would have five patients. Three of those were being discharged, the ER would be sending up three more, and now the floor nurse might have eight patients. And they're doing paperwork on six of the eight. We took the admit nurses and moved them up to a designated admissions unit so they could own the entire admit process. We took much of the discharge process away from the floor nurses so they could provide care to patients.

MASSINGALE: There are very few cookie-cutter answers to this and people are out there selling some cookie-cutter solutions. It really takes hard work on an individual basis coupled with a lot of creativity and a lot of interim solutions. You have to live with some of that. There's no substitute for leadership. It takes a lot of hard work and a lot of leadership.

DAVIS: I felt our patient access team was not an acute fix to the ER's problems. It's a permanent team championing organizational throughput. We initially met once a month, now quarterly.

HEALTHLEADERS: Let's talk about the teamwork aspect of this work. All of these folks have to work together for the ultimate goal, which is to move that patient through in the most efficient manner possible. Are there ways to foster that kind of teamwork?

DAVIS: You can't just write an algorithm to it. The way I started it was to say, "I trust you with the patients who come here. I trust you to take care for our community and I trust that you are excellent providers." They need to hear that. Sometimes we as leaders get caught up in addressing the negative. That's the easiest part. It's important for us as leaders to pass along the compliments and celebrate the rewards, changes, outcomes, and all the wonderful patient experiences.

MASSINGALE: Good teamwork starts with selecting good people. There are some people who either aren't trustworthy or aren't going to engender trusting feelings, and it's important to figure that out in the interview and hiring process and take your time with your selection. People who are unable to engender trustworthiness or provide positive feedback are really hard to build a team around, especially if they're in a leadership role. We've invested in a lot of medical director training at TeamHealth because the medical directors are the linchpins. It's critical that we provide them with total support in order to ensure a successful relationship with our hospital partners.

HEALTHLEADERS: Technology is often a huge part of reengineering and making emergency departments more efficient. Often the ER is the first place hospitals introduce new technology. Is technology helping or hurting ED efficiency?

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