“The aim is to have every patient seen by a physician within 20 to 30 minutes of ED arrival, no matter how acute,” Conn says, allowing, of course, for trauma, stroke, or acute pain patients who would be seen immediately.
This usually entails a quicker registration process, often called parallel process or bedside registration, to get the basic patient information necessary to generate a medical record.
Another strategy being tested at MGH through a Centers for Medicare & Medicaid Services demonstration project involves prompt computer notification of specially designated case managers whenever a an enrolled “frequent flier” comes into the ED, and sometimes even before that, when paramedics are called to the patient’s home.
“Basically, there’s 10% of the population who devour 70% of the healthcare resources, but we’ve shown that with this kind of aggressive case management, we can decrease those costs by 15% to 20%. Nationally, that’s huge—billions of dollars a year,” Conn says.
Another strategy to grapple with the coming throngs of patients, says Kirk Jensen, MD, MBA, the chief medical officer for BestPractices, an ED management and staffing company based in Fairfax, VA, is to understand the hospital’s peak flow periods, which he says are really quite predictable: “On Mondays, Saturdays, and Sundays, they’re usually full from 10 or 11 in the morning until the late evening hours.”
With that knowledge, Jensen says, “you can model the demand for physician or clinical service hours. ED managers are now taking a scientific approach to management, off-loading some patients to midlevel practitioners, such as physician assistants or nurse practitioners. And many departments are using EMTs in a supportive role.”
Less critical patients, “the ankle sprains, the acute bronchitis, and limited cases of the flu—those patients can clearly be seen just as effectively by physician extenders,” he says.
Parker says that at EmCare practices, “we’re using scribes, which are individuals who take notes, document, and help coordinate care, making sure that labs come back. And after following our productivity, I’d say we’ve seen a 15% increase in physician productivity,” which means physicians can see more patients. “We need fewer full-time equivalent physicians, and the physicians love it. It’s made their lives so much better.” The scribes cost in a range of $15 to $20 an hour, Parker says.
One element to consider in the emergency room of hospitals is the behavioral health needs of a large percentage of their patients. Not only do psychiatric patients not mingle well with other patients with physical illnesses or injuries, but they can be disruptive, as well.
Conn says that at MGH, “we had a number of emergency visits from psychiatric patients who were basically using the emergency room as a regular psychiatrist’s office, either as follow-up or to get medication refills. So in order to decrease the number of those patients, the psych department opened up a special acute psychiatric outpatient clinic.”
But that hasn’t fixed the problem, he says. “Our issue is that there are not enough acute care psych beds in the commonwealth to manage those patients, so they tend to stay a long time in the ED. It’s a disgrace.”