ED volumes have risen with expanded coverage through the Affordable Care Act and are likely to remain high, putting more pressure on hospitals for an efficient process for transitioning patients from the ED to the ICU. Tracking key metrics is a first step in improving that transition process, which includes ensuring that patients are not unnecessarily admitted to the costly ICU, where few guidelines exist to establish protocols for ICU admissions and their transition of care.
There are three common scenarios that lead to inappropriate admissions to ICU from the ED, says Joshua Johnson, a healthcare consultant with Novia Strategies in Powey, CA. In the first, physicians are unaware that they are over-admitting to the ICU because they do not receive data on a regular basis that help them understand how well they are managing patients from the ED, he says.
“If a hospital is admitting 25% to 30% of its ED patients to the ICU, that starts to become a red flag when the national average is around 20%,” Johnson says. “But if the physicians don’t have that information, there is no way for them to know they have a problem. Many organizations have protocols for admissions, which is a good start, but if you don’t have the data on the back end you’re missing the value of those protocols. It’s like having a posted speed limit, but no speedometer in your vehicle to know how you’re doing.”
In the second scenario, physicians know they are over-admitting, but continue because they see an ICU admission as the only way to be sure the patient will get the proper care, Johnson says. He recalls working with a hospital system recently that struggled with over-admitting to the ICU, and when the data were presented to ED physicians, they said they were not surprised but felt their actions were necessary.
“They shared with us that part of the reason behind pushing patients into the ICU was that if they didn’t, they couldn’t be sure when that patient would be seen by an attending physician,” he explains. “There was a real concern that if they put that patient on a med-surg unit they might not be seen for a day or two, and they were concerned that wouldn’t meet the needs for that patient.”
The hospital addressed the issue by working with hospitalist physicians to ensure more prompt attention on the med-surg unit, and by improving the lines of communication between the ED physicians and hospitalists. This mistrust sometimes can be identified through the overuse of condition code 44, the term applied when a Medicare patient is admitted to a hospital as an inpatient, but is changed to observation if the hospital determines the services did not meet inpatient criteria.
ED Focused on Throughput
The third scenario involves how hospitals incentivize ED physicians. There has been more emphasis in recent years on moving patients through the ED quickly, reducing the door-to-doctor times and ED stays to a minimum, he notes. Hospitals incentivized ED physicians and staff to reach those goals, aimed at improving patient satisfaction and decompressing the ED. Those were proper goals, but the improvements in ED throughput often come at the cost of other areas in the hospital, Johnson says.
He recalls one hospital where the ED physicians paid very close attention to their ED metrics, monitoring scorecards and times, meeting monthly to review the metrics and strategize ways to improve their performance. But the result was that there was a strong motivation to push people into inpatient status to bring down their ED throughput times.
“If I’m an ED physician and I want to keep my metrics looking good but not compromise the care of the patient, there’s an incentive for me to push that patient to a floor rather than holding him in the ED a while longer, after which he might be able to go home,” Johnson says. “The patient still receives proper care, but he’s someone else’s problem in terms of metrics.”
Hold Physicians Accountable
Case management also should be a strong component in the ED, helping patients use the proper resources outside the ED rather than returning for things like prescription refills, Johnson says.
While data and metrics are key to improving transitions from the ED to the ICU, Johnson cautions that it is not enough to simply dump information on ED physicians and wait for improvement. The information won’t improve anything unless the ED physicians understand how to use it and accept that they are not being punished, Johnson says. Expect a learning curve.
“It’s always critical that there is an opportunity for them to learn, so they understand. If you simply take them a scorecard and beat them over the head with data, you’re going to face a lot of resistance,” he says. “You have to acknowledge that physicians in most cases really are trying to make the best decisions for their patients, and use the data to help them understand when some decisions are not what’s best for the patient.”
For instance, ED physicians sometimes place patients in the ICU because they perceive that unit as offering a high level of care and attentiveness from physicians and nurses. What they often overlook is that the patient is now on a care trajectory that is going to require more days for the patient to move through the ICU and transition to med-surg or another step-down unit before ultimately being discharged, Johnson says. The ICU becomes an unnecessary detour that subjects the patient to risk of infection, loss of muscle mass, and other damage.
Data also must be shared regularly with ED physicians to create a sense of accountability, Johnson says.
“If I show them their transition metrics one time and it’s not good, they’ll say sure, they’re going to change their ways and fix it. There is very little chance that they actually will,” Johnson says. “But if they know that I’m coming back to show them that exact same metric every month at their physician staff meeting, and their performance is going to continue to be measured on ICU admissions, they’re going to hold themselves and each other much more accountable for maintaining that improvement.”
- Josh Johnson, Consultant, Novia Strategies, Powey, CA. Telephone: (858) 486-6030. Email: email@example.com.