Staffing for throughput
Semczuk sees the trend toward using more midlevels, nurses, PAs, and allied health professionals for patient care in EDs, and says, "I think it's a mistake." About a decade ago, he says that
Montefiore recognized that "Many of the people that were seeing sick patients in our ED were people who had full-time jobs as hospitalists or internists or nurse practitioners. [We felt that] those who were not trained in emergency medicine were not investing the time and effort to learn emergency medicine. What we needed to do was to staff our emergency departments with residency-trained emergency medicine physicians. Now patients know that if they come here, they're going to be seen by a board-certified emergency medicine physician who has dedicated his or her life to this field. They're not going to be seen by someone who happens to work a shift that day in the emergency department."
Nonetheless, 46% expect to invest in midlevel caregivers for their EDs within the next three years, nearly twice as many who expect to invest in physician staff (25%). Shafer, from Presbyterian Healthcare Services, offers this perspective: "Midlevels may not be able to see patients with quite the same acuity as a physician would, but by having them here, we can greatly extend the ability of the physician to cover more patients. Because it's going to be a cost savings, in healthcare we're going to see it more and more. The way the economics are, that's the future."
Semczuk reminds us, though, that those who have specific training can be very productive. "I encourage leaders to think about hiring more doctors at the expense of the midlevels. Doctors are incredibly productive when they're working in an emergency room setting if they're board-certified—they could easily see three or four patients an hour."
Another way to foster efficient throughput is to minimize the number of nonemergent patients who visit EDs. At the top of the list of tactics to minimizing avoidable ED visits is limiting prescriptions for opioids, a method used by 66%. In addition, nearly half (45%) track patients who visit EDs seeking opioid prescriptions. More than half (54%) help minimize avoidable ED visits through better coordination with primary care practices and clinics.
One quarter (24%) redirect nonemergent patients, and 29% say that they expect to begin redirecting nonemergent patients within the next three years. Care coordinators and patient navigators are one way to accomplish this. Shafer explains, "Not only do our navigators work within our system, but they also are in touch with all the other clinics in the city—low cost, no cost, or physicians starting up a private practice. They find out who's got any capacity to see patients and which patients they are taking." Shafer admits that referring nonemergent patients without insurance or who otherwise have no ability to pay for care presents a problem. "We have to be cautious," he says. "We might have to absorb that cost within our own healthcare system."