Case managers, SWs cover the ED 24-7

Gatekeepers ensure level of care are correct

Faced with an influx of patients following Hurricane Katrina, North Oaks Health System in Hammond, LA, placed case managers in the emergency department, an initiative that ultimately led to 24-7 coverage by emergency department case managers.

The hospital has had social workers in the emergency department for 15 years. For the first 10 years, they staffed the emergency department from 11 a.m. to 11 p.m., the hospital's peak hours, says Sherri Lynn Hayes, RN, CCM, assistant vice president, case management at the 352-bed community hospital.

"When we had an influx of patients following Hurricane Katrina, we determined that we had to have somebody in the emergency department with the expertise to get patients into an appropriate level of care," she says.

At that point, the hospital placed social workers in the emergency department 24 hours a day, seven days a week.

The emergency department has 20 beds and an additional seven urgent care beds and sees more than 70,000 patients a year.

Until Hurricane Katrina, case managers covered the emergency department for 12 hours and were on call to screen admissions at other times. The emergency department charge nurse would contact the on-call case manager to make sure the patient was in the appropriate level of care. After Katrina, the case management hours were extended to 24-7.

"We knew that it was important for us to get patients in the right level of care at the time of admission. If not, we would lose ground. You start out behind if the patient is not at the right level of care. The emergency department case managers take a load off the nursing staff by working with bed control, processing admission orders, and making sure that the orders are complete," she says.

Today, one RN case manager and one social worker cover the emergency department and work 12-hour shifts, seven days a week, alternating weekends and holidays. The hospital has four full-time case managers and four-full time social workers who cover the emergency department and uses PRN staff for the extra shifts each week.

"Emergency department case managers are the gatekeepers for the hospital. The gatekeeper function has to be in place for the entire case management program to work. The emergency department case managers are the first domino in the treatment process, and depending on how they do their job, the next domino will either be missed or will fall right," she says.

At North Oaks Health System, all inpatient admissions and observation stays flow through the emergency department case managers, with the exception of pre-operative surgical admissions.

The hospital set up telephone lines for all physician offices and referring hospitals to call.

"They know if they call that number, they get a human, and that person will make arrangements to get the patient in," she says.

The case managers work in a central location in the emergency department in between the nurses' station and the physician area. They use an online system to enter all admissions into the hospital's electronic system and ensure that the initial review is completed and that the patient meets admissions criteria.

An electronic bed board shows the occupied beds in the emergency department, allowing the case managers to see every patient who comes into the emergency department and follow the procedures and treatment they receive in real time.

For instance, if a patient comes in with chest pain, the emergency department bed board shows when the labs are drawn, when the lab results are available, when the EKG is performed, and when the doctor sees the patient.

"Everything going on with a patient shows up on the bed board, allowing the case managers to track the patients as they come through," she says.

Once a physician makes the decision to admit a patient, the case manager reviews the record to ensure that the patient meets admission criteria. If a patient doesn't meet admission criteria, the case manager prints a copy of the criteria and talks with the physician.

"We try to educate the physicians at that point in time, whether it's the emergency department physician or the attending physician," Hayes says.

If the case manager is unable to come to an agreement with the physician on severity of illness and the services the patient needs, the case is referred to the medical director for review and a conversation with the physician.

The case managers look at the orders to make sure they're complete and contact bed control to get a bed assignment. They send the orders to pharmacy so the medication orders will be on the unit when the patient arrives and check the patient record to make sure the core measures standing orders have been issued. If not, they remind the physician.

If a physician in the community does not follow the protocol for direct admissions and sends a patient to the emergency department without calling the admissions line, the case manager calls the physician for clinical information.

"When patients come in with no clinical information, the case manager talks to them and tells them the hospital is waiting for information from the doctor. If they are in distress, we put them in an emergency department bed. If not, we ask them to wait while we get the information," she says.

When a direct-admit patient does not meet admission criteria, the case manager contacts the admitting physician.

"We make our best attempt to work it out. Sometimes the family is pressing the community physician because they can't take care of the patient at home. In those cases, we look for other options. If the physician insists on admitting the patient, we involve the medical director," Hayes says.

When a patient is slated for admission, the social worker performs an assessment in the emergency department and conducts an initial discharge planning screening using a discharge information work sheet developed by the hospital.

"A lot of time patients have family members with them in the emergency department but they might not come to the hospital during the patient's stay, or they might not come at a time when the unit case manager can talk with them," Hayes says.

By conducting an initial discharge planning screen in the emergency department, the social worker can get telephone numbers, pharmacy information, and information about what equipment the patient has at home, she adds.

"The validity of information is greatly improved. In the past, we've called the person listed on the face sheet and found out he or she was deceased," she says.

During the initial discharge screen, emergency department social workers also learn about social issues, abuse, or neglect and can conduct psychological evaluations when appropriate.

The hospital does not have an inpatient psychiatric unit and transfers psych patients to other hospitals. The emergency department social worker is responsible for the psych transfers, which typically involves an average of 16 phone calls to find an empty bed, Hayes says.

When the hospital instituted 24-7 emergency department case management, there initially was some resistance from the case management staff, Hayes says. Some case managers volunteered for the job, but others were assigned.

"As time went one, we were able to post additional positions and hire people specifically for this job," she says.

Today's emergency department case managers are specialists, Hayes says. Three were emergency department nurses before they became case managers. The fourth was a nurse in the intensive care unit, then a case manager.

"We look at emergency department case management as a specialized area. The nurses have experience with emergency and trauma cases and went through extensive training on InterQual," she says.

The case management department tracks admission avoidances, such as when the social workers or case managers work with families to get patients to a more appropriate level of care.

Last year, the hospital averaged nine admission avoidances a month.

"When you multiply the cost per day of an admission by the average length of stay, it's a significant number. These are people who might have been social admissions but are better served in a skilled nursing facility, those who just needed IV antibiotics set up with home health, or could be directly admitted to a long-term acute care hospital," Hayes says.

In addition, there are other outcomes that can't be measured, she adds.

For instance, she frequently gets letters complimenting the emergency department social workers for helping families through difficult times.

In one example, a social worker took care of two siblings while an injured child was being treated.

"The continuum of care is confusing for those of us in the health care field. You can imagine how confusing it is to patients and families who are encountering it for the first time. Our social workers are experts in human relations and guide the patients through the process. You can't measure that," she says.

[For more information contact: Sherri Hayes, RN, CCM, assistant vice president of case management, North Oaks Health System, e-mail: hayess@northoaks.org.]