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MAY 2015
THE EXCEPTIONAL ED:
Telemedicine, Navigation, & Behavioral Health
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THE EXCEPTIONAL ED:
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•Find out how Lehigh Valley Health Network has
cut two-and-a-half hours of dwell time in the ED by
reducing the use of oral contrast before CT scanning
•Learn how telemedicine can improve behavioral
healthcare while reducing ED bottlenecks
•Find out how the Brigham & Women’s Faulkner
ED determines and implements a patient’s care
plan faster by placing a diverse care team in the
ED during initial examination and subsequent in-ED
rounding
•Discover how the proliferation of retail clinics and
increased patient sophistication will affect the future
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MAY 2015 | The Exceptional ED: Telemedicine, Navigation, & Behavioral Health
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About the Premium and Buying Power Editions
This is a summary of the Premium edition of the report. In the
In addition to this valuable survey data, you’ll also get the tools you
full report, you’ll find a wealth of additional information. For
need to turn the data into decisions:
each question, the Premium edition includes overall response
information, as well as a breakdown of responses by various
•
Chair of the Department of Emergency Medicine at Lehigh
factors: setting (e.g., hospitals, health systems), number of beds (for
Valley Health Network in Allentown, Pennsylvania, and Lead
hospitals), number of sites (for health systems), net patient revenue,
Advisor for this Intelligence Report
region, and assigned bed time (less than 2 hours or more).
Available separately from HealthLeaders Media is the Buying Power
A Foreword by Alex Rosenau DO, FACEP, CPE, Senior Vice
•
Three Case Studies featuring initiatives by Brigham and
Women’s Faulkner Hospital in Jamaica Plain, Massachusetts;
edition, which includes additional data segmentation based on
Seton Healthcare Family in Austin, Texas; Lehigh Valley Health
purchase involvement, dollar amount influenced, and types of
Network in Allentown, Pennsylvania
products or services purchased.
•
A list of Recommendations drawing on the data, insights, and
analysis from this report
•
A Meeting Guide featuring questions to ask your team
MAY 2015 | The Exceptional ED: Telemedicine, Navigation, & Behavioral Health
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Table of Contents
Locked items are available in the Premium and Buying Power editions.
Fig. 6: Operations Techniques to Increase ED Throughput
Foreword Methodology
5
Respondent Profile
6
Analysis
7
Fig. 7: Operations Techniques to Optimize ED Throughput
Fig. 8: Team Composition to Optimize ED Throughput
Fig. 9: Team Composition to Improve ED Throughput Next
Case Studies
Next Three Years
Three Years
Multidisciplinary ED Team Improves Behavioral Patient Care
Fig. 10:Status of ED-Related Investments
Bedside Strategies to Speed Emergency Department Throughput
Fig. 11: Status of IT/Analytics Usage
Dedicated Psychiatric ED: Improved Throughput and Patient Care
Fig. 12:Expected ED Area Increases Next Three Years
Survey Results
15
Fig. 1: Annual Visits to ED
Fig. 2: Greatest ED Challenge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Fig. 13:Tactics to Minimize Avoidable ED Visits
Fig. 14:Most Effective Care Continuum Providers/Services in
Helping Patients Make More Appropriate Use of ED
Fig. 3: Biggest Bottleneck Problems for ED Flow
Recommendations
Fig. 4: Average ED Wait Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Meeting Guide
Fig. 5: Average Time Between Decision to Admit and Assigned
Inpatient Bed
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MAY 2015 | The Exceptional ED: Telemedicine, Navigation, & Behavioral Health
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Methodology
The 2015 ED Strategies Survey was conducted by the HealthLeaders Media
Intelligence Unit, powered by the HealthLeaders Media Council. It is part of
a series of monthly Thought Leadership Studies. In February 2015, an online
survey was sent to the HealthLeaders Media Council and select members
of the HealthLeaders Media audience. A total of 274 completed surveys are
included in the analysis. The bases for the individual questions range from 217
to 274 depending on whether respondents had the knowledge to provide an
answer to a given question. The margin of error for a base of 274 is +/-5.9% at
the 95% confidence interval.
Each figure presented in the report contains the following segmentation
data: setting (hospital or health system), assigned bed time setting (less than
2 hours or more), number of beds (for hospitals), number of sites (for health
systems), net patient revenue, and region. Please note cell sizes with a base size
of fewer than 25 responses should be used with caution due to data instability.
ADVISORS FOR THIS INTELLIGENCE REPORT
The following healthcare leaders graciously provided guidance and insight in the
creation of this report.
Luis Lobon, MD
Chief of Emergency Medicine
Brigham and Women’s Faulkner Hospital
Jamaica Plain, Massachusetts
Kari Wolf, MD
Vice President of Medical Affairs
Seton Healthcare Family
Austin, Texas
Alex Rosenau, DO, FACEP, CPE
Senior Vice Chair of the Department of
Emergency Medicine
Lehigh Valley Health Network
Allentown, Pennsylvania
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Respondent Profile
Respondents represent titles from across the various functions
at hospitals and health systems.
Title
Type of organization
Number of beds
Base = 274
Base = 194 (Hospitals)
Hospital71%
1–19949%
Health system (IDN/IDS)
200–49934%
29%
500+17%
Base = 274
50
Number of sites
40
Base = 80 (Health systems)
1–520%
30
6–2033%
21+48%
20
10
0
41%
Senior
leaders
34%
Clinical
leaders
16%
Operations
leaders
5%
Marketing
leaders
3%
Financial
leaders
1%
Information
leaders
Senior leaders | CEO, Administrator, Chief Operations
Officer, Chief Medical Officer, Chief Financial
Officer, Executive Dir., Partner, Board Member,
Principal Owner, President, Chief of Staff, Chief
Information Officer, Chief Nursing Officer, Chief
Medical Information Officer
Operations leaders | Chief Compliance Officer,
Chief Purchasing Officer, Asst. Administrator, Chief
Counsel, Dir. of Patient Safety, Dir. of Purchasing,
Dir. of Quality, Dir. of Safety, VP/Dir. Compliance,
VP/Dir. Human Resources, VP/Dir. Operations/
Administration, Other VP
Clinical leaders | Chief of Cardiology, Chief of
Neurology, Chief of Oncology, Chief of Orthopedics,
Chief of Radiology, Dir. of Ambulatory Services, Dir.
of Clinical Services, Dir. of Emergency Services, Dir.
of Inpatient Services, Dir. of Intensive Care Services,
Dir. of Nursing, Dir. of Rehabilitation Services,
Service Line Director, Dir. of Surgical/Perioperative
Services, Medical Director, VP Clinical Informatics,
VP Clinical Quality, VP Clinical Services, VP Medical
Affairs (Physician Mgmt/MD), VP Nursing
Financial leaders | VP/Dir. Finance, HIM Director,
Director of Case Management, Director of Patient
Financial Services, Director of RAC, Director of
Reimbursement, Director of Revenue Cycle
Marketing leaders | VP/Dir. Marketing/Sales, VP/Dir.
Media Relations
Information leaders | Chief Technology Officer, VP/
Dir. Technology/MIS/IT
Region
WEST: Washington, Oregon, California,
Alaska, Hawaii, Arizona, Colorado, Idaho,
Montana, Nevada, New Mexico, Utah, Wyoming
19%
20%
27%
34%
MIDWEST: North Dakota, South Dakota,
Nebraska, Kansas, Missouri, Iowa, Minnesota,
Illinois, Indiana, Michigan, Ohio, Wisconsin
SOUTH: Texas, Oklahoma, Arkansas,
Louisiana, Mississippi, Alabama, Tennessee,
Kentucky, Florida, Georgia, South Carolina,
North Carolina, Virginia, West Virginia, D.C.,
Maryland, Delaware
NORTHEAST: Pennsylvania, New York,
New Jersey, Connecticut, Vermont, Rhode
Island, Massachusetts, New Hampshire, Maine
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ANALYSIS
Addressing Flow, Inside and Out
Finding solutions for emergency department patient flow requires internal and external approaches.
MICHAEL ZEIS
In addressing ED flow problems, one can look at the demand side (ED
WHAT HEALTHCARE LEADERS ARE SAYING
visitors), the supply side (inpatient beds, usually), and the efficiency of
what happens within the ED itself. Of course, there are circumstances
where approaching the demand side of ED volume makes sense, but efforts
to stem patient flow should be undertaken while recognizing the patient’s
role in the decision to seek treatment, and the patient’s self-appraisal of
the urgency.
Alex Rosenau, DO, FACEP, CPE, is senior vice chair of the department of
emergency medicine for the Lehigh Valley Health Network of Allentown,
Pennsylvania, which includes five hospitals, five emergency rooms, 17
community clinics, 12 health centers, and 10 ExpressCARE locations.
He notes that it is not known whether a patient is nonemergent until
that patient has been seen by physicians or other qualified medical
professionals and a disposition has been made. The patient determines the
need to be seen, and the ED staff determines the patient’s condition and
makes decisions about what steps to take to stabilize the patient.
“If you feel you need to be seen, I’m happy to see you,” Rosenau says. “We
are the masters of unscheduled care, in the end. And most unscheduled
care is a perceived emergency on the part of the patient.”
“We have a dedicated social worker, a dedicated case manager, and dedicated pharmacists. We have tight relationships with FCHQs and community
health clinics. We provide initial prescriptions and use a program to directly
schedule patients into a clinic or physician office for follow-up to avoid readmissions.”
—CEO for a medium hospital
“For those with responsible family members or who are personally accountable, we offer education regarding cause of their current visit to minimize
return. For those patients who are not reliable or are transiting through the
area, we provide educational materials and hope they read/understand them.”
—Chief financial officer for a small hospital
“We use our EHR to track follow-up and make calls post-care.”
—Chief operations officer for a small health system
“We use discharge phone calls. There is discussion of the obligation of an on-call physician to see a patient at least once, regardless of ability to pay.
We have conversations at medical executive and department meetings. There
is direct feedback to department chairs if there are violations.”
—Chief financial officer for a small hospital
“In addition to referring patients back to their primary care physician, we are
planning on opening an ED follow-up clinic where the ED can send a patient
to be seen in 1–2 days. The clinic will assess the patient and make sure they
get to the right specialist or PCP.”
—Director of emergency services for a large hospital
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Analysis (continued)
Special attention for behavioral health. One-third of survey respondents
(33%) say that patient flow is their greatest ED challenge, making it No.
1 among nine choices. Patient boarding is a top challenge for nearly
as many: 29%. These 29% are broken into 10% who are challenged by
boarding generally, and 19% who say their top challenge is boarding
behavioral health patients.
specialized behavioral health ED.
“Daily I would get data on the
number of patients sitting in EDs
across our entire community
waiting for a psych bed,” she says.
“Usually it ranged from 15 to
“We are the masters of
unscheduled care, in the end.
And most unscheduled care
is a perceived emergency on
the part of the patient.”
Although there are a range of causes of patient flow problems, boarding
20. We weren’t discharging that
is almost always caused by the lack of inpatient beds. Behavioral health
many people every day, so we were
patients present particular challenges. First, inpatient beds for behavioral
never going to win that battle.”
health patients are scarce. Second, providing care for behavioral health
Wolf and Seton Healthcare
patients places uncommon stress on ED resources—diagnosing and
Family established a specialized
stabilizing ED patients often requires specialized skills. And in the ED
behavioral health ED and increased patient access to behavioral health
and on the inpatient floors, behavioral health patients often need hazard-
medical specialists via telepsychiatry; both are targeted at improving in-
free rooms. Some have difficulty tolerating the normal hustle and bustle
ED patient flow.
of inpatient floors, to say nothing of the intensity that one sees in EDs
now and then. Finally, behavioral health patients often need heightened
monitoring by staff.
—Alex Rosenau, DO, FACEP, CPE
Especially after hours, telepsychiatry brings expertise to bear, often
hastening a determination. And with a specialized behavioral health
ED in the system, the other 10 EDs are freed from having to dedicate
When it comes to behavioral health patients, the arithmetic works
ED beds and staff to behavioral health patients, because EMTs deliver
against the ED. Kari Wolf, MD, vice president of medical affairs for
behavioral health patients to the specialized ED. But neither activity
Seton Healthcare Family, an Austin, Texas–based health system with
addresses demand, and neither addresses inpatient bed shortages.
five medical centers, three community hospitals, and two rural hospitals
serving 11 counties in central Texas, describes the behavioral health
demand and supply the organization was facing prior to establishing a
Inpatient beds: Influence from the ED. It’s not just behavioral health
patients, of course, that create flow challenges. ED-to-inpatient transfers
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Analysis (continued)
is cited by 69% of respondents as a top factor causing bottlenecks. But
range of care, often provided by
only 26% say they optimize ED throughput by ensuring the availability of
the inpatient care team. In such
inpatient beds.
a way, delays for an inpatient bed
do not delay receiving post-ED
Luis Lobon, MD, is chief of emergency medicine at the not-for-profit
stabilization care.
Brigham and Women’s Faulkner Hospital, a 138-bed community
hospital that merged with the 779-bed Brigham and Women’s Hospital
Best to take a system approach.
in 1998. He says the survey data might suggest a domain issue.
The challenges presented by
“To decongest our
emergency department, it
is important to know when
patient discharge occurs.”
—Luis Lobon, MD
behavioral health patients and the
“To decongest our emergency department, it is important to know
bottlenecks caused by transfers to
when patient discharge occurs. We have control over those treated and
inpatient beds demonstrate how EDs are part of a broader system, and
released from the ED, and we have become extremely efficient with our
resolutions to ED problems need to take that systemwide view.
throughput for ED patients treated and released. But we frequently really
are unable to expedite the departure of those patients that require an
Says Rosenau, lead advisor for this Intelligence Report, “In order for a
inpatient admission.”
complex adaptive system such as a hospital, together with an ED, to work
well, you have to look at the entire system. It’s about facility capacity
Says Wolf, “An ED medical director may have little ability to impact the
and process, regulating your costs, living up to department of health
availability of inpatient beds. And so I wouldn’t spend my time or effort
regulations, the adoption of adequate outpatient infrastructure, and
trying to move that needle.” But informal leverage can work. For patients
flow considerations. We know that what you’re doing in the ED is very,
who have been admitted but still occupy an ED bed, Wolf says, “Have the
very important because 68% of all patients admitted to the hospital come
nurses come down from the floor to the ED to round on the patient while
through the ED now.”
they’re waiting for their [inpatient] bed upstairs, and all of a sudden the
bed opens up upstairs.” Seton Healthcare Family’s EHR supports in-
Demographic impact on ED patients. With the lack of inpatient beds
ED rounding; in fact, it uses an “overflow-admitted-bed” classification
contributing so much to boarding problems and ED bottlenecks, why do
on the record. That classification allows the patient to receive a broader
69% say that they are making or expect to make structural improvements
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Analysis (continued)
to their EDs as a way to improve throughput? Look at the demographics,
as Rosenau describes it, one would
Rosenau suggests.
not consider and implement a
particular improvement technique
“When I started 27 years ago in the ED,” he says, “one ED bed was good
by rote. The implementation must
for 2,000 visits a year. Most people would say that today it’s somewhere
be attempted with individual
around 1,200 to 1,400 visits per year per bed.” Rosenau says EDs are
circumstances in mind, given a
seeing people with higher acuity levels, as well. “They’re older, they have
fair trial, and modified or rejected
more problems. Something like 10,000 Americans turn 65 each day, from
as appropriate.
now through 2029. Considering those above 65 and especially above 75,
that’s a group of people that needs medical care more often.”
Efficiency and involvement. Construction can address capacity or out-of-
Observation areas, for instance,
“Have the nurses come down
from the floor to the ED to
round on the patient while
they’re waiting for their
[inpatient] bed upstairs, and
all of a sudden the bed opens
up upstairs.”
contribute to ED throughput
efficiency for 39% of respondents,
—Kari Wolf, MD
date facilities. But much of the action necessary to improve ED patient
and another 23% expect to pursue
flow is related to ED operations. While we can identify which tactics
observation areas within three
are most common and which will get the most attention, near term, we
years. But the ED at Brigham and Women’s Faulkner Hospital does not
should remember that most operations-enhancement techniques are
have an observation area, and Lobon likes it that way. At Brigham and
being considered or have been considered by virtually all who manage
Women’s Faulkner, patients who require observation are admitted.
emergency departments. Fast-track or split flow for low acuity patients
(80%), streamlined registration (73%), and direct ED bedding (63%)
“We try to transfer the patients that require admission of any type from
received the highest mentions of tactics used now or expected to be
the emergency department to the inpatient units as fast as possible,”
pursued within three years. Says Lobon, “We take all of those as part
he says. According to Lobon, not offering an in-ED cushion such as an
of the same, which is basically the redesign of operations within the
observation area has fostered commitment to ED throughput issues
emergency department.”
from other components of the hospital. He says, “Relationships have
developed, agreements and guidelines have developed, accountability
Especially if one accepts that the ED is part of a complex adaptive system,
has been developed. Communication between ED leadership and the
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Analysis (continued)
rest of the community hospital leadership is very fluid, very dynamic. All
beyond inpatient bed, solutions
parties are extremely involved, invested on this emergency department
in psychiatry, day care treatment
throughput issue.”
centers, crisis intervention units,
nursing home, rehab facilities.
The observation designation is used for a patient about whom a
There are so many good things
determination or care plan has not yet been made. But because an
that they do, but they have not
observation patient needs at least monitoring and often needs care and
decreased our boarding.”
other advanced support, some EDs are making their observation areas
“In order for a complex
adaptive system such as a
hospital, together with an
ED, to work well, you have
to look at the entire system.”
more efficient. Says Wolf, “Historically, people who are going to stay in
That is because the constraints
the ED for a 24-hour observation pending a decision on whether they
that affect the organization
need to be admitted have stayed in whatever ED bed they were assigned
overall affect the case managers,
to. Now EDs are starting to cohort observation beds together, because
as well. Lobon explains, “Some of our emergency departments have flow
you need to think about things like ordering meal trays and helping
managers. At the end of the day, flow managers end up reaching the same
patients with bathroom breaks, things that you don’t necessarily think
bottlenecks that everyone does. They, too, are told no, there are no beds
about for standard ED patients.”
upstairs. So you still have to board those patients. I think the role of
—Alex Rosenau, DO, FACEP, CPE
nurse navigator in the ED becomes quite diluted because of that.”
Case managers or nurse navigators are used to improve throughput by
51% of respondents, and another 24% expect to pursue case managers
But case managers or nurse navigators can build and enhance
or nurse navigators within three years. Advisors suggest that one should
relationships with outside social services, which in some EDs will help
have realistic expectations about the degree to which a case manager can
throughput by directing ED visitors to other venues for care or help.
resolve ED flow problems.
Wolf explains how that helps. “A lot of homeless people come into the
ER when it gets cold, or when they’re hungry, or if it’s raining. As much
“We have a case manager on the day shift in our ED,” Rosenau says.
as you can, you coordinate with other entities to get people access to
“The case manager gives you the opportunity to look at other solutions
food, access to shelter, or access to their medications. That’s going to
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Analysis (continued)
keep them out of your ED. Those folks don’t tend to get admitted, so
telemedicine works well when
the inpatient side doesn’t have to deal with them. But the EDs deal with
an intensivist can sit in front of
them a lot.”
a bank of computers and screens
Telemedicine earning attention. Telemedicine can streamline the process
and get information. And as
long as there’s somebody at the
of obtaining a determination, and is now in use by 28% of respondents.
home hospital who can do the
Over the next three years, an additional 27% expect to pursue
procedures, they know that they
telemedicine in their EDs, resulting in a combined 55%. For psychiatric
can give advice to many intensive
patients in particular, telemedicine can bring expertise to bear and allow
care units.”
a patient to proceed instead of wait.
ED visits: concurrent factors.
“Communication between
ED leadership and the rest
of the community hospital
leadership is very fluid,
very dynamic. All parties
are extremely involved,
invested on this emergency
department throughput
issue.”
In the case of Seton Healthcare Family, telepsychiatry was brought in to
More than three-quarters (78%)
reduce unnecessary admissions—admissions that were ordered by ED
of healthcare leaders expect ED
doctors who may not have had the specialized training or experience to
patient volumes to increase.
order alternate care for psychiatric patients. Says Wolf, “On the inpatient
Because several factors are
side, we knew that we were getting a lot of people admitted who really
pushing and pulling at the same
didn’t need to be admitted. We implemented telepsychiatry because we
time, ED leaders are not always able to attribute change to one thing
knew that if we had some expertise in the EDs doing assessments, we
or another. Nonetheless, survey results and comments from report
would be able to divert admissions.”
advisors point to several industry shifts to be aware of and be prepared to
The applications for telemedicine are just emerging, and the healthcare
—Luis Lobon, MD
accommodate.
industry is uncovering the areas where the care model will contribute.
First, the growth and success of urgent care and convenient care settings
“Telemedicine has a bright horizon,” says Rosenau. “We really don’t
give patients choices, and they are making them. A portion of patients
know what it’s going to do for us, in my opinion. But we know certain
who visit urgent care centers actually need hospital-based services,
things. For instance, it works very well with psychiatry. We also know
though, and their visit to an urgent care center probably delays the
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Analysis (continued)
hospital-based care they should get. But urgent care centers are popular
Countering the shift to
with patients because they address the access-to-care portion of the
alternatives such as urgent care
population health management concept, and address the value portion
centers is the behavior of legions
of population health management by (presumably) providing care at a
of newly insured who, while they
lower cost.
nominally have access to primary
care, find that they must depend
An urgent care center provides an alternative for the portion of patients
on an already-strained primary
who otherwise visit the ED because they have difficulty getting a near-
care delivery system. If they visit
term appointment with their primary care physician, or cannot get a
the ED because they cannot get
primary care appointment at a time of day that makes sense for them.
a timely appointment with their
Lobon says cost of care might be behind the choice for some, as well.
primary care physician, they find
“At the same time that we saw healthcare reform in Massachusetts, we
saw the emergence of stand-alone urgent care centers,” Lobon says. “We
have seen a diversion of low-acuity patients to those urgent care centers.
We believe that perhaps convenience has played a role in this. But we also
believe that the … presence of copayments for emergency department
usage … has encouraged people to seek less-expensive care.”
A consequence of patients seeking alternatives is that EDs are seeing fewer
lower-acuity patients, which is probably a good thing. Lobon asks, “Are
those lower-acuity patients truly seeking urgent care centers, possibly
with low copayments? Or are they not seeking care at all? Although one
could say, ‘Yes, they’re being diverted to less costly clinical environments,’
we don’t know that. We don’t have the facts to prove that.”
that their insurance coverage
comes with copay responsibilities,
and they are now responsible for
paying for a portion of their ED
“Now EDs are starting to
cohort observation beds
together, because you
need to think about things
like ordering meal trays
and helping patients with
bathroom breaks, things
that you don’t necessarily
think about for standard ED
patients.”
—Kari Wolf, MD
care. Says Lobon, “Now they are
also being held responsible for a
copayment that—when they go to an emergency department—they were
not responsible for prior to having any healthcare coverage at all.”
Back door/front door. The chief culprit in creating ED throughput
problems is, as Rosenau calls it, a problem with the back door—the
lack of inpatient beds to receive patients who have been evaluated and
stabilized by the ED.
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Analysis (continued)
“The prime causes of boarding,” he says, “is no longer inefficiencies, but
expensive, most appropriate
it’s the lack of hospital inpatient capacity and the lack of outpatient
place that gives similar outcomes.
infrastructure.” While periodic surges in demand mean that boarding
If it’s something as simple as
problems caused by lack of inpatient beds may never be eliminated,
your poison ivy rash, it could be
organizations can and do implement systems to accommodate, which
primary care, it could be an urgent
generally includes activities such as closer teamwork with the inpatient
care, it could be a retail clinic. But
team responsible for patient discharges, or boarding in inpatient
certainly if you have chest pain
halls instead of in the ED. Some ED directors are in a better position
that you think is a heart attack, we
than others to help other groups recognize that ED crowding is an
want you in the ER.”
“Telemedicine has a bright
horizon.”
—Alex Rosenau, DO, FACEP, CPE
organizationwide problem.
A challenge going forward is to encourage patients to seek care in the best
While attention must be paid to the back door, the front door is getting
venue for their conditions, while at the same time knowing that, without
additional attention, as well. Because the ED has experts who can provide
a screening exam, the patients may not know what the best venue is for
sophisticated care for a wide range of ailments, it attracts those with
their conditions. Rosenau says bring ’em on, because then he knows that
serious problems, those who don’t know whether their problem is serious
patients are getting the right care.
or not, those for whom the ED is their only choice, and, as Wolf noted,
those who need to keep dry when it is raining.
When it is determined that a patient’s visit to the ED may have been
unnecessary, information can be provided so the patient can make
ED teams are confident in their ability to make a determination about
a better choice next time. The industry is on the path to improving
the severity of a patient’s problem, and seem somewhat uncomfortable
accessibility, and access to ED care should not diminish as access to care
delegating that determination to others. “If we really expect a large
in other settings increases.
increase of nonemergent ED patients,” says Rosenau, “then we have
to think about what’s the best way to send those patients to the least
Michael Zeis is senior research analyst for HealthLeaders Media.
He may be contacted at [email protected].
MAY 2015 | The Exceptional ED: Telemedicine, Navigation, & Behavioral Health
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CHARTS
FIGURE 2 | Greatest ED Challenge
Q | What is the greatest challenge regarding your ED?
Total responses
33%
Patient flow
19%
Boarding of behavioral health patients
12%
Wait times
10%
Patient boarding generally
4%
Interaction with other departments
• Uninsured and self-pay patients, which was the challenge
mentioned most frequently last year (by 24%) in a similar
question, is the top challenge for 13% this year. That
includes 20% of those located in states not participating in
Medicare expansion, compared to 8% of those in Medicare
expansion states.
3%
Physician adherence to quality goals
Patient diversion
• Wait time is the leading challenge for 19% of health systems,
and only 10% of hospitals. Within the hospital setting, a
higher percentage of large hospitals (24%) than small (4%)
or medium (11%) say that wait time is their greatest ED
challenge.
13%
Uninsured and self-pay patients
1%
4%
Other
TAKEAWAYS
• One-third (33%) of respondents say patient flow is their
greatest challenge. Although we see slight differences by
setting (35% of hospitals, 28% of health systems), patient
flow is the challenge mentioned most frequently across all
settings.
Base = 274
WHAT DOES IT MEAN?
Is there a problem area that is more fundamental to
operating an ED than patient flow? We should not be
surprised to see one-third citing patient flow as their greatest
challenge. And because providing emergency care to those
with behavioral health problems requires specialized
clinicians and often specialized facilities, we see that as the
top challenge for 19%.
DATA SEGMENTATION
Click on these icons
to dig deeper
VIEW BY
ASSIGNED BED TIME
VIEW BY
SETTING
VIEW BY
NUMBER OF BEDS
VIEW BY
NUMBER OF SITES
VIEW BY NET
PATIENT REVENUE
VIEW BY
REGION
MAIN CHART AND
TAKEAWAYS
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FIGURE 2 (continued) | Greatest ED Challenge
Q | What is the greatest challenge regarding your ED?
Information technology
30%
Patient flow
19%
Boarding of behavioral health patients
14%
Uninsured and self-pay patients
BUYING POWER
VIEW BY
PRODUCTS/SERVICES
Who controls the money?
Click on the icons to learn
how they think
Indicates the type of goods or services
the respondent is involved in purchasing
VIEW BY
DOLLARS INFLUENCED
VIEW BY
INVOLVEMENT
Indicates the role of the respondent in
making purchasing decisions
10%
Wait times
11%
Patient boarding generally
7%
Interaction with other departments
Indicates the total dollar amount the
respondent influences
3%
Physician adherence to quality goals
Patient diversion
0%
5%
Other
PRODUCTS/SERVICES
Base = 135
Clinical products
33%
Patient flow
19%
Boarding of behavioral health patients
12%
Wait times
3%
1%
7%
Interaction with other departments
5%
Interaction with other departments
5%
Physician adherence to quality goals
Patient diversion
0%
Base = 179
Outsourcing services
32%
Patient flow
14%
Boarding of behavioral health patients
13%
Wait times
12%
Patient boarding generally
27%
Patient flow
13%
22%
Uninsured and self-pay patients
16%
Wait times
11%
Patient boarding generally
Interaction with other departments
4%
Interaction with other departments
4%
Physician adherence to quality goals
Base = 103
Other
0%
Patient diversion
4%
Base = 79
13%
Patient boarding generally
Physician adherence to quality goals
Patient diversion
19%
8%
Wait times
3%
4%
21%
Uninsured and self-pay patients
3%
1%
23%
Patient flow
Interaction with other departments
Other
4%
Boarding of behavioral health patients
Physician adherence to quality goals
Patient diversion
1%
Legal services
Boarding of behavioral health patients
19%
Uninsured and self-pay patients
7%
6%
Base = 82
Base = 59
Consulting services
12%
Other
2%
Other
10%
Patient boarding generally
15%
Physician adherence to quality goals
Patient diversion
4%
Other
15%
Uninsured and self-pay patients
Wait times
Patient boarding generally
4%
Interaction with other departments
Physician adherence to quality goals
24%
Wait times
8%
Patient boarding generally
17%
Boarding of behavioral health patients
20%
Uninsured and self-pay patients
28%
Patient flow
22%
Patient flow
Boarding of behavioral health patients
15%
Uninsured and self-pay patients
Patient diversion
Executive search
Financial services
6%
4%
0%
6%
Other
Base = 48
MAY 2015 | The Exceptional ED: Telemedicine, Navigation, & Behavioral Health
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FIGURE 4 | Average ED Wait Time
Q | What is the average time patients spend in the emergency department before they are seen by a healthcare
professional?
TAKEAWAYS
• Patients at nearly one-quarter (23%) of hospitals are
being seen by a healthcare professional in 14 minutes or
less, almost twice the percentage at health systems (12%).
Similarly, 21% of EDs at low-revenue organizations see
patients in 14 minutes or less, compared to 13% of highrevenue organizations.
Total responses
33%
24%
20%
• Within the hospital setting, the average wait time to be seen
by a healthcare professional for more than one-quarter
(28%) of large hospitals is an hour or more, compared to 7%
of small hospitals and 11% of medium hospitals.
16%
8%
0–14 minutes
15–29 minutes
30–44 minutes
45–59 minutes
• The mean time to be seen at large hospitals is 54 minutes,
compared to 33 minutes at small hospitals and 30 minutes
at medium hospitals.
WHAT DOES IT MEAN?
Generally speaking, larger organizations have longer wait
times than smaller organizations. For instance, 28% from
health systems report average wait times of an hour or more,
compared to only 11% from hospitals. Of course, larger
facilities tend to have more ED patient visits and often more
complex operations to manage, but they also tend to have
more resources.
60+ minutes
Base = 225
Mean = 38
DATA SEGMENTATION
Click on these icons
to dig deeper
VIEW BY
ASSIGNED BED TIME
VIEW BY
SETTING
VIEW BY
NUMBER OF BEDS
VIEW BY
NUMBER OF SITES
VIEW BY NET
PATIENT REVENUE
VIEW BY
REGION
MAIN CHART AND
TAKEAWAYS
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