Staff ED at peak times for admissions

Cross-train other staff to review for criteria

If you have the emergency department volume and the staffing, covering the emergency department 24 hours a day, seven days a week is optimal, according to Joanna Malcolm, RN, CCM, BSN, consulting manager, clinical advisory services for Pershing, Yoakley & Associates in Atlanta.

"People do come in at 3 a.m. and in some areas, the emergency department volume tends to ramp up after midnight," Malcolm says.

Most hospitals don't have the case management staff to screen every single patient or cover the emergency department 24 hours a day, seven days a week, says Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and partner and consultant in Case Management Concepts, a case management consulting firm based in Dallas. If that's the case in your hospital, analyze your emergency department volume and staff accordingly to cover peak hours of admissions, she advises. Case managers should not be temporary personnel who float down to the emergency department when they are needed, Cesta says. They should be dedicated personnel who are assigned exclusively to the emergency department.

If your hospital can't afford 24 hour coverage in the emergency department, look at your peak hours for admissions and staff accordingly. Cesta recommends 12-hour shifts for RN case manager positions, supplemented by social workers who put in eight-hour shifts. For instance, if the social worker comes in at 8 a.m. and the case manager at noon, the emergency department is covered from 8 a.m. to midnight. This means the emergency department is covered a good portion of the time without 24-hour-a-day staffing. Cross-train emergency department staff on the basics of admission criteria so patients can be reviewed at the time of admission, rather than waiting for someone to review the cases the next day.

If your hospital isn't large enough for a full-time case manager in the emergency department, develop a process so emergency department admissions are screened, either by cross-training the house supervisor or charge nurses, or by calling a case manager to come down and review any cases where there are questions about admission status.

Malcolm suggests that when you develop your emergency department case management process, make sure you have some kind of coverage seven days a week. "Having case managers on call may work for discharge planning, but it's difficult to determine by telephone if a patient meets admission criteria or is in the right status. You need to see the chart and have access to InterQual criteria," she says. "It's not a good idea to admit just using the diagnosis."

For example, it's essential for a case manager to review the chart to determine admission status when a physician wants to admit a patient for chest pain. Many patients with chest pain don't meet inpatient criteria, but there might be a little nuance in the doctor's note that indicates the patient does indeed meet criteria.

Many hospitals don't have the case management staff to screen every single patient. In those cases, Cesta recommends analyzing emergency department admissions to determine which diagnoses are at greatest risk for inappropriate admissions and develop a triage mechanism so those patients are referred to the case manager for review. Other referrals might come from the emergency department staff or the inpatient case manager who might alert the emergency department case manager that they think a newly discharged patient might come back.