Some of the most visible transformations in healthcare are taking place within the emergency department (ED) as hospitals seek not only to reduce the number of non-urgent visits but streamline care delivery and improve patient satisfaction.

Some providers are redesigning their operations to better track patients and increase throughput, while others are experimenting with cutting-edge technology like Google Glass to improve access to specialists. Washington State, in the meantime, is enjoying lower Medicaid costs and readmissions thanks to a comprehensive initiative to encourage ED use only for real emergencies.

ED Efficiency Takes Off

“Over the past several years, there has been much more focus on ED efficiency,” says Mark Reiter, MD, MBA, president of the American Academy of Emergency Medicine (AAEM) and residency program director for University of Tennessee College of Medicine’s middle Tennessee emergency physicians.

Even a few short years ago, “people weren’t measuring anything in a systematic way,” he says, but now “people are collecting a lot more data, which are being benchmarked for different metrics.”

As a result, the ED is a greater focus of hospital administrators, who are using quality data to improve processes and hone best practices. Also, as the front door of the hospital, administrators see a well-run ED as critical for overall performance and patient satisfaction.

More hospitals are executing programs of process redesign, Reiter says. “A lot of emergency department leaders and hospital leaders are deconstructing steps in the process and then looking at ways to reduce waste and improve efficiencies. There is a lot of focus on Lean and Six Sigma and performance improvement.”

Prioritizing Emergency Care

Many hospitals are implementing protocols in which high-risk patients follow a different stream than lower-risk patients.

“The lower-risk patients are not assigned a bed, and instead are evaluated by a rotating physician in a designated area,” Reiter says. “It really helps emergency departments with a smaller number of beds, especially as volume continues to increase.”

Reiter cites Baltimore Medical Center, a high patient volume center that utilizes a single routing system to improve the flow of patients through the ED.

Here, patients entering the ED are first evaluated by a “Quick-Look” nurse, who directs them to the most appropriate area. This facilitates the admission process and enables more attentive handling of seriously ill patients. The private exam rooms feature televisions, telephones and bedside computers for patient registration and improved medical care.

The Samaritan Medical Center in New York is another example cited by Reiter of an organization that invested significant resources into transforming its ED. In 2012, it underwent a process change called “Rapid Clinical Evaluation” that focused on getting the least acute patients through the system as efficiently as possible to free up staff and beds for true emergencies. “It has been dramatically successful,” Reiter says.

Another notable trend is the hiring of scribes to enter data into EHRs at the point of care. “A lot of hospitals are using less effective EHR systems, and it’s becoming burdensome for physicians and cuts into efficiencies,” he says. “Scribes are a way to offset that.”

15-Minute Wait Times

A part of Indiana-based Pioneer accountable care organization Franciscan St. Anthony Health, Chesterton Health and Emergency Center, which opened in 2012, has managed impressive efficiency.

During 2013, the center’s average wait time averaged less than 15 minutes and patient satisfaction hovered over 99 percent, earning it the 2013 Press Ganey Guardian of Excellence Award.

The Press Ganey surveys touch on several categories including nurses, registration process, lab tech, technology and patient perception. “To achieve that high percentile, you need to excel in all categories,” says Medical Director David Hunnius, DO.

The newness of the center has “allowed for the opportunity to set the tone for the culture in terms of who we hired and drill into everyone’s heads customer satisfaction from day one,” says Travis Thatcher-Curtis, RN, Franciscan St. Anthony Health’s ED manager. “Everything we do takes into consideration the patient, being respectful of their time and getting them their definitive diagnosis.”

At the emergency center, patients arrive and register, then are seen right away by physicians or nurses. Assessing patients sooner results in faster diagnoses, treatment and, ultimately, satisfaction, he says.

“The expectation is that we eliminate the redundancies of them telling their stories multiple times,” he says. The center’s EHR is linked to all providers within Franciscan St. Anthony Health (although some are still getting connected) so specialists and ED clinicians alike can access it. Users can see previous encounters and whether there are chronic conditions or previous surgeries.

Efficiency also is enhanced as the center includes an onsite laboratory, high-field open MRI, 64-slice CT, ultrasound, mammography and general x-ray services, along with primary care and specialty physician practices.

Hunnius advises other providers that want to improve their EDs to rally care teams around the importance of patient satisfaction and patient-oriented care. Meaningful communication with patients on best care options is essential to everything, he says.

A Statewide Effort

Some efforts to improve ED care are occurring at a state level.

To reduce low acuity Medicaid ED visits, better coordinate care and lower costs, Washington implemented “ER is for Emergencies” in July 2012. As part of this effort, the state’s 98 hospitals instituted a group of seven best practices designed to redirect care to the appropriate setting and reduce preventable admissions. These include:

Track ED visits to avoid ED “shopping.”

Implement patient education to encourage primary care visits in place of ED visits for lower risk conditions.

Institute an extensive case management program.

Reduce inappropriate ED visits by collaborative use of prompt (72 hour) visits to primary care physicians and improving access to care.
Implement narcotic guidelines that discourage narcotic-seeking behavior.

Track data on patients’ prescribed controlled substances by widespread participation in the state’s Prescription Monitoring Program.

Track progress of the plan to make sure steps work.

The hospitals all adopted an electronic information system that allows ED physicians to see patient visits from all hospitals over the past 12 months, and to know the diagnosis and treatment given during these previous visits. Moreover, 97 of the 98 hospitals utilized the same standardized care plan format for improved care coordination.

“We jumped into this right away to get all partners to take ownership,” says Steven Anderson, MD, practicing pediatric physician and board member at the Washington Chapter of the American College of Emergency Physicians, speaking at a media briefing.

It paid off. In March, the state attributed much of the $30 million in Medicaid savings to the program. ED visits dropped 10 percent in fiscal year 2013 and high utilizer visits decreased along with the rate of visits resulting in a scheduled drug prescription.

“This has improved care, reduced costs and made a significant impact across Washington,” says Carol Wagner, senior vice president for patient safety at the Washington State Hospital Association. “The strategies applied to all patients so savings are actually higher as estimates are only for Medicaid patients.”

Google Glass

In addition to process redesign, some hospitals are implementing wearable technology to improve access to specialists. 

Rhode Island Hospital, for instance, launched a six-month pilot earlier this year to utilize Google Glass for real-time consultations with dermatologists in its ED.

Paul Porter, MD, initiated the pilot after becoming a Google Glass Explorer. He felt the hands-free feature of the technology would allow for a more patient-centered focus.

“I saw the potential to have lower cost, higher value care and virtual medical homes to patients,” he says. Porter found a company to provide a HIPAA-compliant version of Google Glass, which strips away the ability to download images and access email or websites.

Tech savvy dermatologists, affiliated with the hospital and Brown University, volunteered to participate. Utilizing a tablet, they can see and hear everything through the wearable technology and engage in a conversation with the patient on his or her condition.

The pilot already is helping patients with limited access to dermatologists receive care. Porter plans to eventually launch a pilot with nine other hospital departments to utilize Google Glass to link primary care physicians to a virtual medical, or smart room, for seamless medical care.

A Bright Future

ED improvement initiatives are alive and well, but hospitals “must walk the walk,” says Thatcher-Curtis. “If you say you are about patient satisfaction and minimizing wait times, you need to own it and hold people accountable and show them that it is measurable. And, you need timely and constantly monitoring so you can interject when necessary to deliver better care.”