Reducing the number of non-urgent patients in the Emergency Department
Reducing the number of non-urgent patients in the Emergency Department
This problem focuses on the Emergency Department (ED) of a public sector tertiary care hospital in a low-middle income country in South Asia. Comparative analysis indicates that this ED is the busiest nationally in relation to the average flow of patients per day (figure 1& 2). As compared to other EDs in the public sector hospitals that have an average case load of 200-250 patients/day, the ED of this hospital receives around 1600 – 1800 patients per day. A one month data analysis indicates that 80% of the visits are non-urgent patients. The magnitude of these statistics is compounded by an average of 4 to 6 relatives accompanying each patient as there is no policy of 1:1 ratios (patient: attendant). The high caseload of patients encompasses a myriad of patients suffering from minor acute problems to vital emergency conditions. Consequently, the presence of a large number of non-urgent cases and patient attendants not only affects the timely care of patients requiring emergency care but it also complicates the Utilization Management (UM) process; notably, the resources are either over-utilized or mis-utilized (misused).
This critical situation, data analysis along with interviews with key stakeholders reveals copious reasons for this patient overload. Firstly, the topographical location of the hospital; it is located at the entrance to the capital city, and its closeness to the main road makes it the first point of care for the severely ill and wounded patient coming from far-flung districts. Secondly, historically it enjoys a great acceptance among the inhabitants who have the notion that the hospital provides quality services with distinct specialties. Thirdly, due to a fragmented referral system in the primary and secondary level healthcare facilities hence patient do self-referral as far as a 200 kilometers distance. Furthermore, there is a cultural certainty among the population visiting the ED after the official working hours when the out-patient services are closed with the “belief” that they have the right to access these free services. These include “cold cases” that can be delayed without jeopardizing patients’ health and life. On the other hand, structural factors also contribute gravely to crowd the development; the ED and the outpatient departments (OPD) are located very close to each other. As a result, quite often ambulatory patients requiring outpatient services find their way to the ED. Finally, the healthcare workers habitually bring their relatives to access free of cost and faster health services in the ED. The current system allows the patients to be managed on ‘first come-first served’ basis and this puts severely ill patients at a great disadvantage.
Figure 1- February, 2018 patient caseload
Figure 2- March, 2018 patient caseload
The administration of the ED and the hospital are in dire of a strategy to control “ED crowding” and to develop a triage system to deliver timely, quality services to the patients who deserve it most. The target is to ensure that the ED is used only for emergency patients and that patients are provided the level and quality of care according to their clinical needs and to improve the UM process.
Perhaps the concept of an Urgent Care Center, in which non-life threatening conditions could be treated, may be an option with greater resources provided to your triage function so that only the most appropriate patients are then transitioned to access emergency services. In other urban settings that I have worked, a barrier to access of primary care services was transportation, so for a convenience factor, families would drop patients off at the Emergency Department when primary care clinic was more appropriate. We developed a transportation system of shuttling patients to the primary care clinic in town, once it was determined that they were not experiencing a medical emergency. The intent was to have them established in a primary care clinic and derive the benefits of appropriate site of service care, and the longitudinal benefits of being plugged into a primary care model for disease management.
Can’t speak to how it will work yet, but this is a project we are working on. We have found that, by and large, when our clinic patients come to the emergency department for lower level concerns, they generally present between normal clinic hours. We are working on introducing an ED Diversion program whereby through signage and the registration process, clinic patients will be made aware of their option to utilize the ED diversion program in lieu of the ED. To support the program, we will be putting a concierge in the ED to assist the patient in getting from the ED to the ED diversion program (should they choose), and augmenting our clinic staff with an additional APP to cover this volume. The intent is to have patients self-select as candidates rather than be identified through triage/evaluation. Our concern is that patients may learn that this is an easier and quicker way to get in for a clinic appointment, bypassing scheduling.
Our organization has opened several dozen “Urgent Care” centers in a geography that mirrors our hospital locations. These facilities were designed with patient convince and experience in mind so patients with lower acuity clinical problems have been highly motivated to make use of these facilities. As a result, we have seen declines in our total ED visit volume as patients with less severe clinical problems are seen first at these locations. The patients are typically managed at the time of presentation or referred for additional ambulatory services.
I think there are two problems indicted here
1) The Non emergency patients in ED
2) Accompanying family members
I may have a solution to the 2nd part. Do you want to share a simple, digital and easy to understand status for the family members so that they have an update on the patient and can step out of the ER. You may also create a designated space for them to relax and not crowd the ER.
The concept of “urgent care clinics” near the locations where most of your patients come from, should help reduce the flow in your ED. The next step is to develop clear guidelines and to enforce them.
Urgent care clinics nearby and a triage system to internist appointments during the day are helpful.
We have also opened up urgent care clinics in the community. We have also opened up a “fast track” in the ED department to move these non urgent patients into. This is a much more organized and efficient way to deliver patient care. Our turn around and wait times have decreased as a result of this method.
In the Netherlands we are allowed to send no show bills but only a few hosptials are doing it. In our hospital we recently debated again on this subject, as part as a “cut costs” project. In the end we decided not to send a bill for no show.
In our hospital it would bring up 400 k. But we also have to invest in administration and in the end send a summoner.
Experiences of other hospitals tells us that half of the people who do not show up won’t pay the bill. They probably are people with low income. So the trouble you have to make to get the money it huge.
And in the end, we are talking about health care and part of our patients our the fragile people who really need care and no bills so think about if it is really worth the trouble.
What we do is send a text message the day before the appointment as a reminder. Helpt a lot, worth the costs.
Good luck, Viviane
I think you are responding to another post.
A
This high number of non-emergent patients will not subside if politics are not involved.
In the Netherlands you pay for an emergency visit, but not if you go to the gp first and he/she refers you.
This way patients can choose between free of charge or charge service!
The GP’s however have to invest in same day visit options for patients.
Washington State Hospital Association claims success with their program. However, their statistics appear similar to what you have already achieved. http://www.wsha.org/quality-safety/projects/er-is-for-emergencies/
New Mexico ran a 24-hour free nurse triage hotline for several years, reportedly with some success. Ultimately it appears they couldn’t figure out how to fund it, as MCO’s went their separate ways. http://www.santafenewmexican.com/news/health_and_science/health-hotline-nurseadvice-new-mexico-at-risk-of-going-silent/article_edf26060-e5d0-549e-a396-199df3fed31f.html
Probably there will be no significant change until PCP’s provide an alternative (open access/walk in scheduling, telephone/internet nurse triage, extended office hours) that exceeds the value proposition experienced by patients who visit the ED. It is interesting that some countries require PCP’s to provide after hours access.
In the Netherlands patients with urgent health problems (in evenings, nights or weekends) can call the telephone number of a regional urgent care clinic (centrale dokters post) which are almost always located near and work closely together with an emergency post. They get a well-trained triagist on the line to provide the right care which can be medical advice via telephone, a meeting at a nearby primary care facility (e.g. with family physician), home consult of physician, ambulance or referral to emergency care. There is a website (thuisarts.nl) and an app (moetiknaardedokter.nl) which help patients with deciding when to go to a physician. The better the cooperation between the urgent care clinic and the emergency room the more patients the urgent care clinic is able to take over and the more the emergency room has capacity for complex urgent care (substitution of care). In the period between 2012-2015 the amount of patients going to the emergency room decreased with 5,8% nationally and the amount of patients moving to the urgent care clinics increased with 3,3% nationally.
(source: https://www.rijksoverheid.nl/documenten/rapporten/2017/09/01/monitor-samenwerking-spoedeisende-hulp-seh-en-huisartsenposten-hap).
This is a very complex situation. On the long run:
1. Public education
2. Improved community health care with family doctors. They can handle all non urgent cases and function as gatekeeper to the secondary helath care system.
3. Reforms to allow triage and selection at the door. And to stop the benefits of fast and high-quality of non-urgent cases in the ED setting.
On the short run, it may be possible to introduce some kind of selection by demanding a telehone call before showing up. This may not be feasible in the described setting.
Urgent care posts in the periphery, staffed with experienced nurses and GPs might work as filter. These outposts should have a fast track for referring patients who require urgent care at the ER or specialist care in a secondary/ tertiary setting.
some of the solutions we invested in on a national level is the patients’ hotline number. Where patients can call if they have any urgent or non-critical need and a family physician will respond and give the necessary advice. the other thing is the urgent care centers or clinics, it may work but depends on many factors. Your population demographics, admission rate, number of healthcare facilities in the region and other factors, so don’t take this solution as the magic one for all ed crowding problems.
This was also a problem in the Netherlands. Most E.R’s in the Netherlands now have a GP / PCP post (also staffed during out of office hours) at the hospital that liaises with patients own PCP via standardized PCP EMR. Patients are being triaged at the hospital gate by a triage nurse for the PCP post or E.R. There is also financial incentive for patients to go to PCP post. There is a copayment (own risk) for E.R. / hospital visits but PCP visits are fully reimbursed (also the PCP post at the hospital).
I agree with several others who suggested offloading lower acuity patients to a geographically distributed network of outpatient, urgent care clinic type facilities. Last year, our health system bought a chain of established urgent care clinics in our region rather than build our own. We rebranded the urgent care clinics so it is apparent they are affiliated with our healthcare system and put our EHR in all of the sites. The urgent care volumes have exceeded everyone’s expectations but there has been some interesting side effects.
Now, the acuity of the patients in our ED’s has increased significantly. This has led to problems with our staffing model (which relied on a combination of physicians and non-physician advanced practice providers). The APP’s used to serve as our front line ED personnel but now a much higher percentage of patients who come to the ED are seriously ill and require a higher level of medical management by a physician. We are now contemplating reversing this practice by using physicians in the front line, triage function so that interventions on the sickest patients begin quickly. After initial evaluation by a physician, less acutely ill patients who come to the ED could be routed to a lower acuity, fast track service embedded within the ED where there are managed by APP’s.
Also, we are finding that the ED shifts are more stressful for all of the personnel because patient mix has shifted to a significantly higher acuity level. The ED providers are all caring for extremely ill patients with fewer low acuity patients, who used to provide something of a breather for the ED staff.
The challenges we have seen should not deter you from exploring this model, but it is probably beneficial to anticipate these difficulties so you can anticipate and plan ahead to address problems like those we have experienced if and when they arise.
In our publically funded health care system, we have had some success with efficient urgent care clinics diverting patients with nonurgent conditions from the Emergency Room. There is much faster access to care through the urgent care clinics than the Emergency Department. The urgent care clinics can also provide much more cost efficient health care for patients with low acuity conditions.
This is a very complex problem and will require a multifaceted solution which include the suggestions above.
1. Our system established an urgent care network a number of years ago, including a few “Kids Care” clinics.
2. We’ve experimented with the hours of service, extending hours up until Midnight in areas where we had high volumes of ED patients.
3. We initiated a nurse triage line for the patients we assume risk for-the nurse triage line sends about 4% of callers to the ED, 35% get a PCP appointment within 24 hours, 15% are referred to our tele-health service, a high percentage are able to have their concern managed by the nurse.
4. We initiated a post-ED follow up phone call within 48 hours of their visit, those who accept the call have a significantly lower return ED visit within 5 days.
5. We’ve established a fast track process for the non-urgent patients in the ED
6. We’ve placed a significant effort on opening access and increasing the number of same day clinic appointments available in our Primary Care clinics. Our ED care managers have access to the primary care schedules and can get patients transitioned out to the PCP if appropriate.
7. Lastly, we’ve opened Behavioral Health Access Centers next to our largest Emergency Departments. Patients can present to the ED and be triaged to the Behavioral Health Access Center or present directly to the Access center for admission. The access centers are staffed with Mental Health APRN’s, RN’s and Behavioral health techs. They are able to assess and manage patients for up to 24 hours. This is reducing the burden of mental health patients in our ED’s who are awaiting disposition. Many do not need to be admitted because they’re crisis is managed and they can be set up for outpatient follow up.
With these efforts, less than 40% of our ED visits are for non-urgent/emergent care. These efforts have increased our % of high acuity patients and has made it difficult for benchmarking staffing levels but is supporting patients being cared for in the most appropriate setting.
Agree with Kim. While there is no silver bullet for controlling the flow of patients from various avenues and sources, it is imperative on the triage process and training at each source point with relevant triage experts along with post visit follow up.
1. Patient education is also critical to success here to ensure that they are made aware of the support services remotely or inperson when they walk-in to ED to keep them informed of the situation and also schedule appointment with relevant Care giver with follow up notes.
2. Also, leverage systems to Send ADT and Clinical notes to PCP for next day follow up