Patient Flow Solutions

Appointment-setting in the ED pleases patients, helps clinicians manage patient surges

EDs push back on suggestions the approach may encourage inappropriate utilization

One of the ways busy EDs are attempting to manage long wait times is by enabling patients who do not need immediate care to make an appointment to be seen in the ED one or two hours in advance. Critics worry that this type of approach will only encourage patients to use the ED inappropriately for problems that should be seen in a primary care setting. However, hospitals utilizing the approach counter that it is helping them to better manage volume, and that patients tend to be much more satisfied with their care when they don't have to sit in the waiting room for hours, not knowing when they will be seen.

"What this allows us to do is if we see there are 10 or 20 patients who show up in the triage area, there is a way of essentially taking out all the available appointments for the next five or six hours or until we catch up," explains Robert Steele, MD, division chief for adult services in the ED at Loma Linda University Medical Center in Loma Linda, CA. "The beautiful thing about this is that for the first time in my life, we have some control over the patient surge."

Include safeguards

Loma Linda University Medical Center is one of more than 20 hospitals in eight states taking advantage of the online, appointment-setting service offered by InQuickER, a cloud-based, software-as-a-service vendor based in Nashville, TN. Most of these hospitals are charging a fee to patients to use the service, although Steele anticipates that his hospital will eventually drop the $25 fee that it currently charges.

Steele stresses that it was the ED physicians who wanted to make the service available, based on feedback they received from neighbors in the community and hospital employees. "We are the big tertiary care trauma center. People want to come see us. They feel we provide a very high quality level of service," he says. "But the problem is that they don't want to wait, and they also don't want to feel that they have been put into a waiting room that is filled with people they don't know and don't recognize. They feel uncomfortable in there, so we took those two variables out."

There are safeguards built into the process so medical problems that need immediate attention get picked up, explains Steele, noting that patients input information about their medical problem when they make their appointments online. "The triage nurse looks at that information, and there are actually times when [he or she] will call up the patient and say that based on the information provided, we think you should come in right away," says Steele. "Our ability to evaluate those patients is only as good as what the patients include ... although I experience the same thing when I am face-to-face with a patient. If the patient doesn't give me the information that I need, it is difficult for me to make a good decision."

Sandra Schneider, MD, FACEP, president of the American College of Emergency Physicians and a professor in the department of emergency medicine at the University of Rochester School of Medicine and Dentistry in Rochester, NY, has looked into the practice of appointment-setting in the ED, and believes that it can fulfill a need. "It has to be done right. We don't want patients being told to wait when they shouldn't wait," she says. "If a person has cut himself and needs a few stitches, that is one thing, but the person who is having chest pain shouldn't be waiting, so there is concern that this needs to be done well."

Use approach to optimize resources

Steele takes strong issue with any suggestion that patients are using the ED inappropriately, or that the ability to make online appointments encourages such behavior. In many cases, he says, the ED is the only source of care available to patients who have been injured or become ill during the evening or night time hours. "The ED is [in operation] at all times, so why wouldn't patients use it? And from a cost standpoint, we're already there. Adding another doctor and another clinic to a system that already has a doctor and a clinic actually increases costs," he says.

Schneider agrees, noting that even in communities with a strong primary care system such as Rochester, NY, access to care can be difficult. "In general, primary care physicians don't have the time or ability to take care of patients with unscheduled care needs in their offices," she says. "They're just too busy. They can't get people in to be seen in a reasonable period of time."

Furthermore, Steele stresses that oftentimes, patients don't know that they are low-acuity until after they have been seen. For instance, he suggests that a patient who has suffered an ankle injury on the basketball court is a good example of a non-life-threatening issue that nonetheless merits emergency care. "The patient can make it for a few hours with the swelling and the pain, and that's okay, but he is going to need X-rays and some crutches, and it may not be a sprain. It may actually be a fracture," says Steele. "Many urgent care centers don't take X-rays, and aren't open after hours, so for many people, we are the only resource."

By enabling such patients to make online appointments, they can wait to be seen in the comfort of their homes, and know that they will be seen right away when they arrive in the ED. "What I can do is shift some of these patients out of the busy time when the ED is overcrowded to the non-busy time, and then I can be more efficient to the patient," says Steele. "They will have an expectation that I can meet, and I will know what services they need when they get here."

Steele says that while the hospital has offered the online appointments for about a year, there has been limited advertising for the service thus far. Still, he says the ED sees three to five patients a day who have scheduled appointments through the service, and many of these individuals are hospital employees or neighbors. "We would like to increase our volume of these patients by 10% to 20%," he says.

Schneider expects more EDs to adopt similar practices, and thinks that the approach could prove helpful in optimizing resources. "Most of the time, these appointments are not tomorrow, they are in a couple of hours," she says. "I think it is a very intriguing idea, if done right and professionally."

Sources

  • Sandra Schneider, MD, FACEP, President, American College of Emergency Physicians, and Professor, Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY. Phone: 585-275-8762.
  • Robert Steele, MD, Division Chief for Adult Services in the ED, Loma Linda University Medical Center, Loma Linda, CA. Phone: 909-558-4344.
  • InQuickER, LLC, is a cloud-based, software-as-a-service vendor based in Nashville, TN. Phone: 877-221-7981. Web: www.inquicker.com.