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Over the last several years, emergency department overcrowding has become a troubling issue, one that can become an easy scapegoat for the massive health care cost overruns we have become accustomed to hearing about.
But is emergency department overcrowding a cause – or a symptom – of something larger? And whether emergency department overcrowding is a cause or a symptom, how can healthcare organizations use new technology, including medical imaging, as a cure?
For answers, we turned to Dr. Sandra Schneider. An emergency medicine specialist, Dr. Schneider has been recognized several times for her leadership and service to the field of emergency medicine. A current professor in the Department of Emergency Medicine at the University of Rochester Medical Center, Dr. Schneider is also a past president of the American College of Emergency Physicians (ACEP.) Her views are based on her experience visiting emergency departments across the country.
In part one of my three part interview below, Dr. Schneider helps identify the root cause of emergency department overcrowding, shares how medical imaging technology can help to reduce the impact overcrowding can have on patient care, and helps to dispel some commonly held health care cost myths.
What role can medical imaging play in reducing hospital emergency department overcrowding?
Dr. Sandra Schneider: First of all, it is important to note that hospital crowding is the primary cause of emergency department crowding. It has become routine for hospitals to ‘board’ inpatients who are waiting for a bed in the emergency department. Because of tight finances, hospitals try to approach 100% occupancy. They may shut down (‘brown out’) inpatient units because of staffing shortages.
As the Emergency Department serves as the primary entry point for most medicine admissions, admitted patients remain for hours or even days (in some cases a week or more) waiting for a bed. Statistics show that boarding inpatients is common in 70-94% of hospitals and is particularly severe in urban settings. In some settings, boarders may routinely occupy 40-50% of ED beds. In some hospitals, when ICUs are full, inpatients currently in a floor bed may be brought to the ED if they deteriorate. Boarding inpatients is associated with delays in care for all patients in the ED, increased adverse events, and an increase in mortality and morbidity.
It is true that public hospitals often see patients who seek care for non-urgent conditions. Nationally we know that the CDC has identified that 8% of ED patients have non-urgent conditions (defined as needing care within 12-24 hours.) However 2/3 of these patients seek care after hours and on weekends, times when traditional medical care is not available. While urgent care centers offer an alternative, most will not accept patients without insurance or those covered by Medicaid because of low reimbursement. Many providers will not accept patients without insurance or those with Medicaid, again because of reimbursement. These patients have nowhere else to receive care, particularly on a weekend. Increasingly providers are even limiting the number of patients covered by Medicare that they will treat. The ED, which under Federal law must see all patients regardless of coverage, remains the only means of medical care for these patients. This Federal law is an unfunded mandate and a factor in the finances of nearly every emergency department.
Medical imaging plays a large role in overcoming several aspects of crowding. First, increasingly imaging helps us avoid admission to the hospital. Appendicitis is a great example. In the past it was appropriate for 30-50% of appendectomies to be performed on a normal appendix. Now that number is likely <10%.
The number of medical images ordered through the ED has skyrocketed. In part, this is because imaging provides more definitive answers (rules in or rules out disease.) In addition, many physicians see the ED as a portal to rapid testing. They can get same day results AND any necessary consultation for patients. ED has come under criticism for ‘ordering too many tests’. Some of these tests undoubtedly could be scheduled as an outpatient. However, few institutions have the ability to schedule patients after hours and fewer still can provide next day service.
It is important for the emergency physician, who is likely seeing the patient for the first time, to have rapid access to a patient’s history and previous test results. Emergency physicians need access to all recently acquired advanced imaging, whether it was done on site or at an outside facility on a 24/7/365 basis. In addition to preventing unnecessary repeat testing, this information allows the emergency physician to calculate and control the amount of radiation exposure of the patient.
Finally, ED efficiency is all about throughput. Unlike inpatient services, we monitor our care in minutes. Rapid turnaround time is critical, but so is having a formal final interpretation of medical images, particularly the more complex studies. To the extent that medical imaging can be done rapidly and the final interpretation by an attending radiologist can be available rapidly 24/7/365, emergency department flow can improve and length of stay can be reduced. Clearly there are issues for the radiology department which must manage multiple demands. In addition, in a field that is rapidly subspecializing, it is difficult to have an attending neuroradiologist available at all times. However, both patient safety and ED efficiency demand just that.
What are some ongoing efforts you’re making to educate people about when to seek emergency care?
SS: We feel patients should seek care when they believe they need it. We believe that all patients should have a PCP who is familiar with all aspects of their physical and mental health, and coordinates their care. We believe that the Patient Center Home Model will benefit those that can access it. However, we are concerned that a significant portion of the population will be unable to access that care, at least until there is greater capacity in primary care. We believe that good primary care, coordinated care for patients with chronic illness, and access to resources for all patients regardless of coverage will not only decrease ED visits, but will provide a cost savings and greater quality of life.
ACEP is a strong advocate for the Prudent Layperson definition of appropriate use of the ED. This definition is now part of the Affordable Care Act. Unfortunately many studies looking at appropriate use of the ED base their assessment on the discharge diagnosis, rather than the chief complaint. Until recently chief complaints were not coded and therefore not available in large insurance databases.
In addition, many authors have erroneously used the Billings Criteria for appropriateness, which Dr. Billings carefully states in his paper is not valid. When the discharge diagnosis is used, patients who come to the ED with chest pain and sent home with a diagnosis of GERD, are deemed to have used the ED inappropriately.
ACEP has developed patient education materials, many of which are available on EmergencyCareForYou.org. We provide a regular national radio show for both the public and emergency care workers covering topics that inform the public when to seek emergency care. Recently, the Washington State Chapter of ACEP has been collaborating with several other groups in their state to reduce the cost of emergency care. Their programs involve an integrated approach to patients who use the emergency department frequently and a network that allows providers access to pharmacy records. The very early results of this program suggest they have been successful in reducing costs.
Some EDs do care coordination centered within their department, while others have utilized the 24/7 availability of paramedics to monitor chronically ill patients in their home. The medical directors of many poison centers are emergency physicians. Over the past few decades their work has dramatically cut the incidence of childhood poisoning.
ACEP and emergency care workers have also developed public education programs for diseases where time-sensitive treatment is life saving. Media programs have highlighted emergency physicians discussing the early warning signs of stroke, myocardial infarction and sepsis. Rapid intervention in these diseases not only saves lives but improves the quality of life of the survivors.
Many EDs have fast track or urgent care centers embedded within the department. These function like urgent care centers in the community except that they see all patients regardless of coverage. While there is no obligation for the ED to treat non-urgent patients after initial assessment, deferral of care from the ED often is more problematic than there is cost savings. And without community resources to care for these patients, refusing to treat these patients who then have no other source of care is morally questionable, and in the long run likely increases costs.
There is a misconception that large amounts of money are wasted on these ‘unnecessary’ ED visits, and that the savings could be huge. The fact is that ALL of emergency care in this country represents just 2% of the total cost of health care. Again the CDC has identified that only 8% of patients have conditions that can wait, but only 1/3 of those occur during traditional business hours. We cannot count on the reduction of ED visits to save our healthcare economy.
Read part two of my interview with Dr. Sandra Schneider tomorrow to learn more about the impact the roll-out of health care reform will have on emergency department overcrowding.
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