4
Improving the Efficiency of Hospital-Based Emergency Care

The emergency care system is but one component of the larger health care delivery system and of the even larger social safety net system. As such, it is subject to many forces far beyond its direct control. There is little that emergency care providers and advocates can do to alter such environmental factors as growing use of the emergency department (ED) by the uninsured; the increasing age and number of chronic conditions of patients; staffing shortages in many key areas, especially nurses and on-call specialists; malpractice insurance rates that grew on average more than 50 percent between 2002 and 2003 (AMA, 2003); and declining public and private reimbursements—not to mention disasters, both natural and man-made. There is, however, a great deal that the emergency care system can do to anticipate, prepare for, and manage the effects of these broader trends. This chapter explores strategies for improving the efficiency of hospital-based emergency care within the context of the broader health care delivery system, with a focus on the special issue of patient flow. The chapter also examines approaches to overcoming barriers to improved ED patient flow and operational efficiency. The committee emphasizes the compelling need for regulatory and policy changes to increase accountability and incentivize the efficient management of patient flow throughout the hospital and beyond.

THE ED IN THE CONTEXT OF THE HEALTH CARE DELIVERY SYSTEM

Medical science in the United States is arguably the most advanced in the world, but the organization and delivery of health care lags well behind



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Hospital-Based Emergency Care: At the Breaking Point 4 Improving the Efficiency of Hospital-Based Emergency Care The emergency care system is but one component of the larger health care delivery system and of the even larger social safety net system. As such, it is subject to many forces far beyond its direct control. There is little that emergency care providers and advocates can do to alter such environmental factors as growing use of the emergency department (ED) by the uninsured; the increasing age and number of chronic conditions of patients; staffing shortages in many key areas, especially nurses and on-call specialists; malpractice insurance rates that grew on average more than 50 percent between 2002 and 2003 (AMA, 2003); and declining public and private reimbursements—not to mention disasters, both natural and man-made. There is, however, a great deal that the emergency care system can do to anticipate, prepare for, and manage the effects of these broader trends. This chapter explores strategies for improving the efficiency of hospital-based emergency care within the context of the broader health care delivery system, with a focus on the special issue of patient flow. The chapter also examines approaches to overcoming barriers to improved ED patient flow and operational efficiency. The committee emphasizes the compelling need for regulatory and policy changes to increase accountability and incentivize the efficient management of patient flow throughout the hospital and beyond. THE ED IN THE CONTEXT OF THE HEALTH CARE DELIVERY SYSTEM Medical science in the United States is arguably the most advanced in the world, but the organization and delivery of health care lags well behind

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Hospital-Based Emergency Care: At the Breaking Point many other U.S. industries in terms of innovation, use of information technology, and management practices. Kleinke (1998, p. 6) described medical delivery in the United States as “…a miracle of disorganization, held together through the sheer collective will of overworked professionals tasked with managing tens of millions of patients by memory, pen scrawl, Post-It note, and telephone call.” It is a system that, to quote Berwick (1996, p. i3), “is perfectly designed to achieve exactly the results it gets.” The results, as documented by the Institute of Medicine (IOM) reports To Err Is Human: Building a Safer Health System (IOM, 2000) and Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001), include an estimated 98,000 deaths and more than 1 million injuries each year as a result of health care process and system failures (Starfield, 2000). According to the joint National Academy of Engineering (NAE) and IOM (2005, p. 1) report Building a Better Delivery System: A New Engineering/Health Care Partnership, “an estimated thirty to forty cents of every dollar spent on health care…a half trillion dollars a year…is spent on costs associated with: overuse, underuse, misuse, duplication, system failures…and inefficiency.” While confidence in American medicine remains strong, patients understand that the delivery system is failing. In a survey conducted by the Picker Institute (2000), 75 percent of patients described a system that was fragmented; difficult to navigate; and inconsistent in terms of information, evidence, and treatment. According to the NAE/IOM report, the U.S. health care system retains a “cottage industry” structure, with physicians and other health care providers operating semiautonomously. As a result, hospitals and other provider organizations lack the hierarchical control of the typical business enterprise, making it difficult to introduce efficiency principles to streamline flows in such areas as production, inputs, and inventory as in other industries. In addition, the prevalent payment structures in health care, which focus on individual encounters and practice settings, tend to reinforce silos, reward inefficient practices, and discourage investment in new technologies and process improvements. As a result, innovations that have swept through other sectors of the economy, including banking, airlines, and manufacturing, have failed to take hold in health care delivery—a sector of the economy that now consumes 16 percent of the nation’s gross domestic product and is growing at twice the rate of inflation. Health care information technology has advanced considerably in the last decade, but mainly in the administrative and financial arenas, as opposed to the core processes of delivering clinical services (NAE and IOM, 2005). Other industries have made use of a number of tools derived from engineering and operations research, which can be referred to collectively as operations management tools (see Box 4-1). Manufacturers, airlines, banks, the military, and others have adopted systems that employ a number of these

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Hospital-Based Emergency Care: At the Breaking Point tools. For example, Motorola’s Six Sigma process and the Toyota Production System combine statistical and process controls with worker empowerment and cultural change to minimize defect rates and achieve high levels of quality. Some of these approaches have been promoted and implemented by health care organizations, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Veterans Health Administration, Kaiser Permanente, the National Association of Public Hospitals and Health Systems (NAPHHS), the Agency for Healthcare Research and Quality (AHRQ), and several private hospital organizations. But adoption of such approaches has yet to become widespread (Gabow et al., 2005; National Association of Public Hospitals and AHRQ, 2005). A common thread among these tools is the systems concept, in which the dependence of every component on the others is recognized. To achieve the system’s maximum performance, each unit must not only achieve high individual performance, but also cooperate with interdependent units to optimize system objectives. The tools of operations management facilitate the understanding of complex systems and make it possible for managers to control and improve overall system performance. Nowhere is the interdependence among individual components more evident and the need for tools to manage complex systems more crucial than in the hospital ED. Taking care of emergency patients involves many discreet components, such as registration, emergency physicians, nurses, laboratory services, imaging, inpatient departments, and on-call specialists. These components are highly interdependent, such that optimizing the performance of any one without considering the broader objectives of the system is unlikely to improve the overall performance of the delivery of emergency care. For example, optimizing care in an inpatient department may slow admissions from the ED, worsen ED crowding, and create a host of associated problems. Indeed, that is what often happens. UNDERSTANDING PATIENT FLOW THROUGH THE HOSPITAL SYSTEM Crowding in the nation’s EDs poses a serious threat to the quality, safety, and timeliness of emergency care. While many of the factors contributing to ED crowding are outside the immediate control of the hospital, many more are the result of operational inefficiencies in the management of hospital patient flow. EDs receive an almost steady stream of patients. If an individual arriving by ambulance cannot be transferred quickly to an ED stretcher, efficiently triaged, and then rapidly evaluated, stabilized, and admitted or discharged, ED crowding will quickly develop, and patient care will be compromised.

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Hospital-Based Emergency Care: At the Breaking Point BOX 4-1 Operations Management Tools Many operations management tools could be applied to achieve better management of patient flow: Quality functional deployment. This iterative process links stakeholder needs to the resources required to meet those needs throughout the organization. Conflicting demands on the organization emerge and are resolved, with all relevant stakeholders examining the trade-offs from a systems perspective. The process has been used in a variety of industrial applications, including integrated circuit and automobile design. Failure modes and effects analysis (FMEA). FMEA is a formal process for analyzing failures that might occur under varying conditions so they can be avoided through design features. It has been used in manufacturing for more than 30 years and has recently been applied to health care. The Veterans Health Administration encourages its accredited hospitals to use FMEA or hazard analysis tools in a required annual proactive risk assessment of at least one high-risk process each year. Root-cause analysis is a qualitative, retrospective variation on FMEA that has been widely used to analyze industrial accidents. The Joint Commission on Accreditation of Healthcare Organizations requires accredited hospitals to use the method to evaluate sentinel patient safety events. Human factors engineering. This set of techniques attempts to integrate human behavior and limitations into process design. Human factors research has been widely used across industries and has had many recent applica Hospital administrators and policy makers have at their disposal a number of promising options for identifying and resolving the patient flow problems that contribute to ED crowding and its consequences. But these leaders must first be compelled to take action, something that will occur only when the causes of ED crowding are clearly understood, and administrators realize that the strategies required to address the problem go well beyond the ED itself. More than 15 years ago, Lynn and Kellermann (1991) described approaches to improving management of the ED in an overcrowded hospital. Key to their thesis, then as now, was the idea that crowding is an inpatient problem that manifests itself in the ED. Accordingly, measures to address crowding should begin on inpatient units, rather than with diversion of inbound ambulances. Moreover, administrators, policy makers, and the public must have the knowledge, incentives, and regulatory obligations needed to inspire change.

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Hospital-Based Emergency Care: At the Breaking Point tions in health care, such as medication administration, diagnosis, handoffs of patients between shifts, and telemedicine. Queuing theory. Queuing theory is used to determine the capacity of services that are subject to variable demand over time. It has been widely used in a number of service industries, such as banking and public transportation. It has had limited use in health care, but has been applied to optimize scheduling and staffing in primary care, operating rooms, nursing homes, radiology departments, and emergency departments (Huang, 1995; Siddharthan et al., 1996; Reinus et al., 2000; Lucas et al., 2001; Gorunescu et al., 2002; Murray and Berwick, 2003; McManus et al., 2004; Green et al., 2006). (See the detailed discussion in Box 4-2.) Supply-chain management. This set of techniques helps match resources with demand in highly complex production processes. Companies such as Dell, Toyota, and Procter & Gamble represent enormously complex systems that use supply-chain management tools, such as linear integer programs, to optimize performance. Airlines use these models to assign crews to thousands of flights per day across hundreds of cities. The techniques have revolutionized production in many industries but have had very little impact in the hospital environment despite substantial successes. For example, both Vanderbilt University Medical Center and Deaconess Hospital in Evansville, Indiana, have achieved substantial savings using these techniques. It has been estimated that the health care industry could save $11 billion by using supply-chain management (NAE and IOM, 2005). Statistical process control. This technique involves plotting the outcomes of a process over time to see whether variations fall within an acceptable range or fall outside that range and require corrective action. It is widely used in manufacturing. From arrival in the ED to hospital admission or discharge, emergency patients receive treatment at multiple points of the care delivery process. Patient flow, defined as the movement of patients through this system, is an important indicator of the timeliness, safety, and quality of the care received. Efficient patient flow ensures maximum throughput (the number of patients treated and discharged from the ED per day), minimizing delays at each point of the delivery process with no decrement in the quality of care. Impaired patient flow, on the other hand, results in bottlenecks that prolong delays for patients already in the system, as well as those awaiting entry. The input/throughput/output (I/T/O) model of patient care, based on engineering principles from queuing theory and compartmental models of flow, applies operations management concepts to patient flow within the acute care system (see Figure 4-1). The I/T/O model defines the acute care system as including unscheduled ambulatory care, urgent care, ED care and

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Hospital-Based Emergency Care: At the Breaking Point FIGURE 4-1 Input/throughput/output model. SOURCE: Reprinted from Asplin et al., 2003, with permission from the American College of Emergency Physicians.

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Hospital-Based Emergency Care: At the Breaking Point its ancillary services, inpatient care for those admitted through the ED, and out-of-hospital emergency medical services (EMS) care. In this way, the I/T/O model allows for the identification of all components of the health care system that contribute to or are affected by ED crowding (Asplin et al., 2003; Solberg et al., 2003). Under the I/T/O model, ED input, or demand, comprises three distinct categories of care: emergency care (treatment of seriously ill or injured patients), unscheduled urgent care (treatment of patients unable to receive needed care in a timely manner from other components of the acute care system), and safety net care (treatment of patients who experience substantial barriers to accessing unscheduled care from other components of the health care system). Variations in the demand for each of these types of care, both patient- and systems-driven, determine the input fluctuations in the ED. That is, ED input levels depend on both the volume of critically ill and injured patients and the ability of the overall health care system to care for nonemergent and safety net patients (Asplin et al., 2003; Solberg et al., 2003). The throughput component of the I/T/O model represents a patient’s length of stay in the ED and comprises two key phases: (1) triage, room placement, and medical evaluation, and (2) diagnostic testing and ED treatment. ED boarding is also included in the throughput component as it extends ED lengths of stay. The output component of the model represents the disposition of ED patients. It includes hospital admission, transfer to another facility, and patient discharge. It also includes the ability of the ambulatory health care system to provide timely and appropriate postdischarge care (Asplin et al., 2005). As designed, the structure of the I/T/O model allows hospitals to systematically identify and resolve impediments to patient flow across a spectrum of acute care settings. It also provides direction for researchers, policy makers, and hospital administrators seeking to understand and alleviate ED crowding as a way to improve access to and quality of care (Asplin et al., 2003; Solberg et al., 2003; Wilson et al., 2005). IMPEDIMENTS TO EFFICIENT PATIENT FLOW IN THE ED While hospitals are unable to control forces outside the facility that contribute to high levels of demand, they can understand the impact of those forces on operations and structure their organization for optimal response. At the same time, hospitals have direct control over a number of variables that affect operational efficiency, including such factors as inpatient bed capacity, ancillary service delays, the scheduling of surgeries and support staff, and provision of adequate physical space in the ED to permit evaluation and treatment (GAO, 2003). By applying variability methodology, queuing

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Hospital-Based Emergency Care: At the Breaking Point theory, and the I/T/O model, hospitals can identify and eliminate many of the impediments to patient flow caused by operational inefficiencies (Litvak and Long, 2000; Litvak, 2005). One of the most important factors currently outside the control of most hospitals is the regional flow of patients (see Chapter 3). Short of the need to go on diversion, there is typically little information sharing between hospitals and EMS regarding overloaded EDs and trauma centers and the availability of ED beds, operating suites, equipment, trauma surgeons, and critical specialists. Such information is needed to balance the patient load among EDs and trauma centers in a region, which requires that many elements within the regional system—community hospitals, trauma centers, and particularly prehospital EMS—effectively coordinate the regional flow of patients. In addition to improving patient care, coordinating the regional flow of patients is a critical tool for reducing overcrowding in EDs. Unfortunately, only a handful of systems around the country coordinate transport effectively throughout their region. Some examples were described in Chapter 3. Inpatient Admissions Bottlenecks The most commonly cited contributor to ED crowding is the inability to move admitted patients from the ED into inpatient hospital beds, in particular intensive care unit (ICU) beds. This lack of inpatient beds has the immediate effect of forcing ED staff to “board” admitted patients until an inpatient ICU or medical-surgical bed is available (see Chapter 1). Placing ED patients who require hospital admission in hallways or examination spaces temporarily until an inpatient bed becomes available is a poor substitute for inpatient care. EDs are not designed to provide privacy to hallway boarders, and staff are often too busy to meet an admitted patient’s needs in a timely manner. Moreover, boarding is the primary cause of ambulance diversion, a practice that delays access to emergency care and can send inbound patients to a hospital where the medical staff does not know them and has no access to their medical records. Ambulance diversion also contributes to reduced EMS capacity as ambulances seeking to offload patients are forced to find an open ED and once there, to wait until the ED staff are able to find an empty stretcher (Gallagher and Lynn, 1990; Thorpe, 1990; Andrulis et al., 1991; Derlet and Richards, 2000; Epstein and Slate, 2001; Derlet et al., 2001; Henry, 2001; Viccellio, 2001; The Lewin Group, 2002; McManus et al., 2003; Asplin et al., 2003; GAO, 2003; Schull et al., 2003; Solberg et al., 2003; Weissert et al., 2003; Eckstein and Chan, 2004; JCAHO, 2004; Kennedy et al., 2004; see also Chapter 1). By failing to manage patient flow effectively, hospitals allow the most time-critical access point in the facility—the ED—to become blocked and ultimately inaccessible.

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Hospital-Based Emergency Care: At the Breaking Point Financial Incentives In addition to contributing to an overall shortage of bed space, the current reimbursement structure discourages hospitals from making provision of inpatient beds to ED admissions a management priority. Within the hospital, ED patients compete for beds, staff, and services with patients who have been scheduled for elective admission, particularly elective surgical patients and those being admitted for invasive diagnostic or therapeutic procedures. When beds are scarce, elective admissions generally prevail because they pay better margins and promote loyalty among admitting physicians. ED admissions typically generate less revenue for the hospital, and may even cost the hospital money. Furthermore, since these patients are already in the system, they are unlikely to leave, whereas an elective admission can choose to go to another hospital. Finally, because hospitals benefit financially from increased volume (up to a point), there is a financial disincentive to hold vacant beds open for ED admissions. Delays in Ancillary Services Enhanced standards of care and improved medical technology mean that today’s ED patients routinely receive a number of complex diagnostic and screening services (McCaig and Burt, 2005). Whether complex or routine, the timely administration of these ancillary services and the prompt availability of test results are imperative for smooth hospital operations and efficient patient flow. Data suggest, however, that delays in diagnostic and screening tests for ED patients are both common and strongly associated with prolonged lengths of stay in the ED. In fact, nearly one-half of all ED service delays were related to wait times for radiology and laboratory results according to one survey conducted by the Emergency Nurses Association (Derlet and Richards, 2000; Weissert et al., 2003; JCAHO, 2004). Housekeeping also is frequently a problem, as most ED admissions occur in the late afternoon to early morning hours, while housekeeping staffs are usually reduced after 5:00 PM. Overuse of ED Services Physicians treating patients in the ED have access to a wide range of complex medical screening and evaluation tools, all within the confines of a single physical space—the hospital. This means that ED patients often also have access to the best technology in the community, as hospitals are frequently more able than local providers or smaller health clinics to purchase and operate expensive medical equipment. These factors have resulted in the dual effect of some patients opting to seek care in the ED and some primary or specialty care providers referring their patients to the

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Hospital-Based Emergency Care: At the Breaking Point ED as a means of streamlining the medical testing process. In short, the ED is assuming, by default, another new role—that of “one-stop shop” for complex medical workups, a phenomenon that improves the efficiency of office-based practitioners, but contributes to ED crowding and hinders the safety and timeliness of true emergency care. Also, because EDs often have limited access to patient records, redundant workups and diagnostic tests are often performed. Defensive Medicine The rise in the number and severity of medical malpractice claims, especially in high-risk fields such emergency medicine, has led to an increasingly defensive approach to providing care in the ED. Because emergency physicians have such a range of tests and diagnostic technologies at their fingertips, they are more likely to be blamed if they fail to use them and ultimately miss a diagnosis. For example, missed myocardial infarction has been the leading cause of malpractice claims in emergency medicine, yet definitively excluding the possibility of a myocardial infarction or acute coronary syndrome requires a minimum of 6–12 hours of evaluation and diagnostic tests costing more than a thousand dollars. Fearing potential litigation, ED physicians and on-call specialists may order additional tests or prolong monitoring periods, slowing patient flow and contributing to service delays. ED staff may also hospitalize patients in borderline condition rather than running the risk that a discharged patient will have an adverse outcome. This is even more likely to happen when the physician is concerned that the patient may not be able to secure outpatient follow-up care in a timely manner (Asplin et al., 2005). It should be noted, however, that it is difficult to quantify the increment over and above appropriate evaluation in emergency care that constitutes “defensive medicine.” Staffing Requirements In contrast to the strict nurse-to-patient ratios on many inpatient units and ICUs, most hospitals have declined to adopt nurse-to-patient ratios for the ED. As a result, an inpatient unit that has vacant beds but has reached its maximum ratio of nurses to patients may block admissions from an ED that may be caring for two or even three times as many patients per nurse. The merits of staffing ratios in general are discussed in Chapter 6. Inadequate Physical Space Unlike most high-risk enterprises, health care has been slow to embrace principles of ergonomics or human factors engineering in the design and

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Hospital-Based Emergency Care: At the Breaking Point maintenance of its various workplaces. As a result, ED providers often face limitations on the amount of space available in which to provide care, and they routinely encounter user-unfriendly spatial layouts and equipment placement and design. In many hospitals, for example, computed tomography (CT) scans, operating rooms, or ICUs are located a significant distance from the ED, requiring the staffed transport of patients across multiple hospital divisions or floors. Similarly, desktop-only registration, whiteboard tracking, and land-line phone paging systems routinely pull physicians and other staff away from the bedside, extending patients’ lengths of stay and leading to disruptions in the course of care. Fortunately, many of these design failures can be addressed through the adoption of new information technology tools (McKay, 1999; Chisholm et al., 2000; Derlet and Richards, 2000; Wears and Perry, 2002). Additional discussion of these tools is provided in Chapter 6. STRATEGIES FOR OPTIMIZING EFFICIENCY A number of initiatives now under way are aimed at improving patient flow in order to reduce ED crowding and its related effects. These include Urgent Matters, a $6.4 million, 10-hospital campaign supported by The Robert Wood Johnson Foundation that aims to eliminate ED crowding and improve public understanding of challenges facing the health care safety net; the IHI IMPACT Network, which, through its Improving Flow Learning and Innovation Community, seeks to increase patient throughput and minimize delays while ensuring that high performance in flow is not achieved at the expense of quality; and the University HealthSystem Consortium (UHC) Patient Flow Benchmarking Project, which targets in-hospital factors that impede or impair efficient patient flow. Recognizing the importance of managing patient flow to addressing ED crowding, JCAHO published a new standard for accredited hospitals: “LD.3.11.” “The leaders develop and implement plans to identify and mitigate impediments to efficient patient flow throughout the hospital” (JCAHO, 2004). Based on the above efforts, a wide range of tools have been developed and tested to address patient flow issues, generally with good success. While controlled studies have yet to be conducted, a growing body of anecdotal evidence suggests that by smoothing the peaks and valleys of patient flow (the movement of patients into and between various hospital areas for care), hospitals can reduce crowding while improving quality and reducing cost (JCAHO, 2004; Wilson and Nguyen, 2004). Boston Medical Center and St. John’s Regional Health Center in Springfield, Missouri, for example, reduced crowding by adjusting elective surgery schedules so they did not conflict with predictable peaks in emergency surgeries (Litvak and Long, 2000; Crute, 2005).

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Hospital-Based Emergency Care: At the Breaking Point Staff Buy-In Hospital clinicians, including those in the ED, tend to be conservative in nature and reluctant to embrace systemic change; efforts to identify and resolve barriers to patient flow through such strategies as those noted above are not likely to succeed without the early and strong support of hospital leaders, clinicians, and other staff. The recent failure of Cedars-Sinai Medical Center to implement a computerized provider order entry (CPOE) system demonstrates the magnitude and significance of this resistance. In November 2002, Cedars-Sinai began a 14-week, department-by-department rollout of its newly installed CPOE system. The rollout was called off and the system removed less than 2 months later following what has been characterized as a “staff revolt” (Chin, 2003; Cedars-Sinai Learns, 2004; Connolly, 2005). The selection of a well-respected, highly regarded individual to serve as a champion for improved patient flow is an important step in ensuring the success of flow improvement strategies. Among other responsibilities, this individual can help sell the necessary changes to medical staff and executive managers. He/she can also help exert the constant pressure needed to reshape the policies, processes, relationships, and cultural norms that have historically impeded patient flow throughout the hospital. Data Collection The collection and analysis of reliable, comprehensive data concerning all aspects of patient flow is imperative if hospitals are to understand and resolve the factors contributing to crowding in their EDs. Currently, however, most hospital data systems do not adequately monitor or measure patient flow. For example, few systems distinguish between when a patient is ready to move to an ancillary location for care and when that move actually takes place—a limitation that prevents the capture and analysis of data on ED boarding, as well as other ED throughput delays. Rigorous data collection and analysis is essential to the success of any patient flow improvement strategy. Using the I/T/O model, hospitals can identify key performance indicators for evaluating patient flow performance. Examples of such indicators used successfully by hospitals participating in the Urgent Matters initiative are time from inpatient bed assignment to bed placement, inpatient bed turnaround time, total ED throughput time, and time to thrombolysis for cardiac patients (Wilson et al., 2005). Other key performance indicators identified by the Government Accountability Office (GAO) as measures of ED crowding include the number of hours an ED is on ambulance diversion, the percentage of patients who board in the ED and for how many hours, and the number of patients

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Hospital-Based Emergency Care: At the Breaking Point who leave the ED after triage but before a medical evaluation as a percentage of ED visits (GAO, 2003). Systems Approach Research has shown that while the causes of ED crowding, boarding, and diversion are complex, the principal factors involved lie not in the ED itself but in inpatient departments to which ED patients are referred (Asplin et al., 2003). As a result, as noted earlier, it is increasingly understood that ED crowding is a systemwide issue that must be addressed across multiple hospital and acute care settings (Richardson et al., 2002; Asplin et al., 2003; Schafermeyer and Asplin, 2003; GAO, 2003; Magid et al., 2004). Thus it is not surprising that a key characteristic of successful patient flow improvement is the adoption of a systemwide approach to change. Such an approach includes, among other features, the development of a multidisciplinary, hospitalwide team that can work collaboratively to identify problems, propose solutions, and oversee the implementation and evaluation of various improvement strategies. (An example of a hospital team is shown in Figure 4-2.) Such an approach also includes timely collection and analysis of data at multiple points across several hospital settings to enable FIGURE 4-2 Sample hospital team structure. SOURCE: Reprinted, with permission, from Wilson and Nguyen, 2004.

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Hospital-Based Emergency Care: At the Breaking Point evaluation of patient flow and assess changes in operations. Results of these analyses and outcome measures should be shared within and outside the hospital setting. Such transparency increases ownership and accountability among hospital leaders and staff; it also improves patient understanding of the complex, multidisciplinary nature of emergency care. Alignment of Incentives The degree of crowding and boarding that occurs in the ED would not be tolerated in inpatient departments. The strategies discussed above have the potential to improve patient flow significantly; enhance the quality, safety, and timeliness of emergency care; and produce related cost savings. Yet history has demonstrated that little progress will be made toward achieving these goals unless hospitals are held accountable through regulatory and incentive-based policies. Without such policies, hospitals will continue to marginalize patient flow matters, relegating most of the related consequences to EDs and their patients through crowding, prolonged periods of boarding, and ambulance diversions. There are a number of steps that can be taken by hospital leaders to address these issues, as well as policy initiatives that should be considered to align payment incentives with the goals of enhanced efficiency and quality of care. Positive Incentives No major change in health care can take place without strong financial incentives, and today hospitals have almost no incentives to address the myriad problems associated with inefficient patient flow or ED crowding. Indeed, as detailed below, hospitals have a number of financial incentives to continue the practices that lead to these problems. Financial incentives must be instituted to ensure that hospitals act aggressively to eliminate ED crowding, boarding, and ambulance diversions. Rewarding hospitals that demonstrate efficient delivery practices that appropriately manage patient flow should be a consideration in reimbursement. All payers, including Medicare, Medicaid, and private insurers, should develop contracts that reward hospitals for efficient ED operations and penalize them for delays in hospital admission, for ED crowding, and for ambulance diversions. Through its purchaser and regulatory power, CMS has the ability to drive hospitals to address and manage patient flow and ensure timely access to quality care for its clients. Current CMS payment policies should be revised to reward hospitals that manage patient flow appropriately; conversely, hospitals that fail to do so should be subject to penalties. Finally, CMS should evaluate the potential effect of existing diagnosis-

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Hospital-Based Emergency Care: At the Breaking Point related group (DRG) payments on the relative priority assigned to elective patients and emergency admissions. Patients admitted from the ED are more likely to have a higher severity of illness, to be uninsured, or to have lower rates of reimbursement. Results of research undertaken at a small group of hospitals indicate that patients transferred to inpatient units and ICUs from the ED are more costly than elective patients for selected surgical DRGs (Munoz et al., 1985; Henry et al., 2003). A similar study found that patients transferred acutely to tertiary surgical ICUs were significantly more costly than elective admissions (Borlase et al., 1991). A disincentive to admit ED or transferred patients over elective patients may contribute to crowding and boarding in the ED. If such a disincentive exists, CMS should identify alternative payment methodologies to eliminate it. Negative Incentives Hospitals face virtually no reimbursement-related disincentives for operating a crowded ED. Indeed, they may benefit financially if this situation reduces Emergency Medical Treatment and Active Labor Act (EMTALA)-mandated admissions and preserves their capacity to admit elective patients. In 2004, JCAHO instituted new guidelines that would require accredited hospitals to take serious steps to reduce crowding, boarding, and diversion. This action followed a July 2002 alert that linked treatment delays to more than 50 deaths. Under pressure from the hospital industry, however, these requirements were withdrawn (Morrissey, 2004). They were replaced in January 2005 with a patient flow standard—Managing Patient Flow—that applies to the entire hospital. Among other things, this standard requires that hospitals develop plans and implement ways to monitor and manage patient flow that will reduce ED overcrowding and its consequences and ensure acceptable quality of care. Joint Commission Resources, an arm of JCAHO, has published a document aimed at educating hospital leadership about the new standard and providing guidance on how to comply with its provisions (JCAHO, 2004). While the new standard correctly acknowledges that patient flow is a system-level issue that must be addressed on a hospitalwide basis, it allows hospitals to continue using the ED as a holding area. Therefore, the committee recommends that the Joint Commission on Accreditation of Healthcare Organizations reinstate strong standards designed to sharply reduce and ultimately eliminate emergency department crowding, boarding, and diversion (4.4). Not only do hospitals face no financial penalties for crowding and boarding, but there are several financial incentives that promote the practices that lead to these problems. First, a hospital benefits financially from increased volume (up to a point). Operating at high capacity is risky for any business because it means there is limited capacity available to deal with

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Hospital-Based Emergency Care: At the Breaking Point spikes in demand. But the ED provides a convenient escape valve for hospitals operating at or near capacity. During periods of peak demand, patients can be cared for in the ED in relative safety because of the highly skilled and interdisciplinary staff that are available to deal with any exigency, staff that are used to a high-volume, high-pressure environment. Second, according to a recent GAO report, one reason patients back up in the ED is that, as noted earlier, elective admissions for surgery or other procedures tend to be more profitable than emergency admissions through the ED (GAO, 2003). While many hospitals may not intentionally favor scheduled over ED admissions, which would potentially constitute an EMTALA violation, the GAO report found that only a minority of hospitals that diverted ambulances took other measures, such as postponing or canceling elective admissions. Third, as discussed previously, patients admitted through the ED are more likely to be uninsured—indeed in many private hospitals, the only way an uninsured patient can be admitted is through the ED—and ED crowding has the effect of slowing the influx of uninsured and underinsured patients admitted through the ED. Fourth, when hospitals hold emergency admits in the ED and instead give an available bed to the next elective patient, they essentially receive two inpatient reimbursements for the price of one because ED staff (a fixed cost) provide inpatient care at no additional cost to the hospital, while the elective patient gets the bed. Giving the ED admission priority over the elective one forfeits that advantage. Also, if the elective admission does not get the bed, the patient’s admitting physician may look to another hospital for admission. By contrast, ED admissions are “captive” in that they are already inside the facility and are too sick or injured to go elsewhere except in extreme circumstances. Finally, when EDs are crowded in a community, especially if ambulances are being diverted and patients are walking away from the local public hospital or nonprofit equivalent, it can be financially perilous under EMTALA to have a “wide open” ED because uninsured and low-reimbursement patients are likely to flood the available ED. Although there is a paucity of data on the practice, some hospitals have been known to adopt “defensive diversion” to shield themselves from receiving diverted ambulance patients from the local public hospital. Further, some hospitals divert on a case-by-case basis—meaning they accept ambulances if the patient’s doctor is on the medical staff and refuse otherwise. While this practice constitutes an EMTALA violation, it is difficult to identify and pursue. In the absence of external regulatory mechanisms, monitoring of diversion status, and independent verification of how crowded the ED and hospital really are, it is impossible to limit this sort of practice.

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Hospital-Based Emergency Care: At the Breaking Point The committee would like to see improved monitoring of hospital admission patterns by CMS to ensure that hospitals are not regularly using diversion while continuing to accept elective admissions. Such a practice would be in violation of EMTALA, and its prohibition should be strictly enforced (Medical Advisory Committee and Pennsylvania Emergency Health Services Council, 2004). Furthermore, the committee concludes that the practices of boarding and diversion are so antithetical to quality medical care that the strongest possible measures must be taken to eliminate them. Therefore, the committee recommends that hospitals end the practices of boarding patients in the emergency department and ambulance diversion, except in the most extreme cases, such as a community mass casualty event. The Centers for Medicare and Medicaid Services should convene a working group that includes experts in emergency care, inpatient critical care, hospital operations management, nursing, and other relevant disciplines to develop boarding and diversion standards, as well as guidelines, measures, and incentives for implementation, monitoring, and enforcement of these standards (4.5). Public Awareness A final step in implementing the changes recommended by the committee is to make the public understand what is going on; appreciate the seriousness of the situation; know what questions to ask; and realize that the problem affects each individual, rich or poor, old or young, black or white, urban or rural. In short, the public needs to know what good performance is and understand who does and does not experience it. Hospitals should be required to measure key indicators of ED crowding and make those measures available to policy makers and the public. This could be accomplished through a variety of mechanisms, including patient flow performance report cards, public notices regarding diversion, and educational efforts focused on the unique and critical role served by safety net hospitals. For example, a community could provide “diversion alerts,” similar to storm alerts, to inform the public about EDs unable to accept new patients. The reliance of EDs on other hospital units to eliminate ED crowding and its consequences through the effective management of patient flow demands a systemwide approach supported by hospital leaders and staff, policy makers, and the American public. Without immediate intervention, the quality, safety, and timelines of emergency care will continue to experience strain under the pressures of ED crowding, boarding, and diversion. Eliminating these pressures is no longer just a matter of convenience; it is a matter of life and death.

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Hospital-Based Emergency Care: At the Breaking Point SUMMARY OF RECOMMENDATIONS 4.1: The Centers for Medicare and Medicaid Services should remove the current restrictions on the medical conditions that are eligible for separate clinical decision unit payment. 4.2: Hospital chief executive officers should adopt enterprisewide operations management and related strategies to improve the quality and efficiency of emergency care. 4.3: Training in operations management and related approaches should be promoted by professional associations; accrediting organizations, such as the Joint Commission on Accreditation of Healthcare Organizations and the National Committee for Quality Assurance; and educational institutions that provide training in clinical, health care management, and public health disciplines. 4.4: The Joint Commission on Accreditation of Healthcare Organizations should reinstate strong standards designed to sharply reduce and ultimately eliminate emergency department crowding, boarding, and diversion. 4.5: Hospitals should end the practices of boarding patients in the emergency department and ambulance diversion, except in the most extreme cases, such as a community mass casualty event. The Centers for Medicare and Medicaid Services should convene a working group that includes experts in emergency care, inpatient critical care, hospital operations management, nursing, and other relevant disciplines to develop boarding and diversion standards, as well as guidelines, measures, and incentives for implementation, monitoring, and enforcement of these standards. REFERENCES AMA (American Medical Association). 2003. National Physician Survey of Professional Medical Liability. Chicago, IL: AMA. American College of Healthcare Executives. 2004. Hospital CEO Turnover: 1981–2004. Chicago, IL: Health Administration Press. Andrulis DP, Kellermann A, Hintz EA, Hackman BB, Weslowski VB. 1991. Emergency departments and crowding in United States teaching hospitals. Annals of Emergency Medicine 20(9):980–986. Asplin BR, Magid DJ, Rhodes KV, Solberg LI, Lurie N, Camargo CA Jr. 2003. A conceptual model of emergency department crowding. Annals of Emergency Medicine 42(2):173–180.

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