Success key No. 1: Taking pressure off the ED
For many hospitals, the time from the afternoon to the evenings is one of overcrowding and nervousness inside the ED, and it has been no different at the 713-bed Memorial Regional Hospital in Hollywood, Fla., and its 72-bed ED, says Maggie Hansen, RN, BSN, chief nursing officer.
"We have our saturation point [beginning] in the afternoon," says Hansen. "Usually, it is Monday through Thursday, from 3 p.m. to 1 a.m."
The hospital has launched special programs to deal with overcrowding and potentially dangerous situations. One of its most effective ways of reducing the number of patients using the ED has been working with local community centers that provide patient care beyond the hospital, says Hansen.
Like many healthcare systems, Memorial has a high percentage of patients—about 20%—who do not have a primary physician or medical home, Hansen says. While Memorial's ED volume increased rapidly from 2005 to 2010, Hansen says, it has "stabilized" in the past year, increasing from 91,000 in 2009 to 92,000 in 2011.
Hansen attributes the relatively small increase to the hospital's community health services ED discharge program, "which seeks to provide primary care in South Broward for residents who qualify," she says.
"We have also worked diligently with many providers in the community to partner with them regarding patients who are considered high ED utilizers to develop specific plans of care to meet their needs on an outpatient basis," Hansen adds.
The hospital has an ED discharge clinic that provides follow-up care for recently discharged patients. It also has an ED diversion clinic to establish "quick care" for patients who were unable to schedule an appointment with their primary care physicians.
"There are a lot of people who don't have a payer for healthcare. It's our mission to care for people regardless of their ability to pay," Hansen says. "But we don't want them to overutilize the ED services because they don't have a primary care physician. If they come to our ED for an illness—say, heart failure—we can refer them to a community health service so they can be followed up, so they have a medical home."
Having working relationships in the community must be connected with the hospital's own "patient flow team" that evaluates its staffing each day for the ED unit, which includes 62 acute care beds and focuses on patients who leave the ED without treatment, against the advice of hospital staff, Hansen says.
Hansen says that only 1.8% of ED patients leave without being seen, which is better than the national average of 2.5%.
The patient flow team, which includes physicians and nurses, "looks at all components that impact patient flow to identify challenges and barriers, and work on ways to remove them," Hansen says.
The hospital has a "split flow" design in which ED areas are separated into acute care, quick care, and "super-track," depending care the patient may need, Hansen says. The average treat-and-release time for all ED patients is 210 minutes, but for those seen under quick care the time is 110 minutes.
Quick care is a separate area within the ED staffed with a physician and nurses who see patients who "will not need a lot of resources and can be out soon," Hansen says. The super-track room, located outside the ED, where a physician extender sees patients having the "most minor of complaints," Hansen adds. "A patient can be out in 38 minutes," she says. "You can't even go to a doctor's office and be out that quickly."
To keep patients from returning to the ED, the hospital also has a disease management program "especially for those people who don't really have a primary care physician or payer source to have their healthcare managed by a physician or nursing staff. The idea is to help them care for themselves by showing them how to make appointments, take medications," Hansen says. "We help them with following appointments and answer questions they need."
The program is connected to the community health service "to avoid unnecessary ED visits, focusing on preventing readmission of congestive heart failure in particular," Hansen says.