Novel strategies to handle nonemergent ED visits

Most patients who visit emergency departments (EDs) aren’t there for emergencies, according to a new report by the Evanston, IL-based health care information company Solucient.

The study examined more than a million commercial and Medicare ED claims nationwide. (To access the report, go to Solucient.com. Click on "News & Press," and scroll down for the report title "Hospitals Should Target Consumer Education to Relieve Emergency Department Overcrowding.")

Here are key findings:

  • Of the 106 million annual visits to EDs, 58% (about 62 million cases), are by patients who could have been treated in less-acute care settings.
  • About 75% of all pediatric ED patients could have been seen in a less-acute setting such as fast-track units or urgent care facilities.
  • Single females younger than 55 are the greatest users of nonemergent ED services. Based on these findings, the organization recommends targeting consumer education programs to single women, such as direct mailings and newspaper advertisements that educate patients on appropriate use of the ED, in an effort to reduce ED overcrowding.

However, some ED managers reject this conclusion. "We should accept the fact that we provide acute episodic unscheduled care," argues Larry B. Mellick, MS, MD, FAAP, FACEP, chair and professor of the department of emergency medicine at Medical College of Georgia in Augusta.

Some patients presenting to the ED will have emergencies, and some will not, explains Mellick. "Many of these patients will not have a clue as to actual severity of their illness," he says. "Consequently, any campaign to prevent patients with minor illnesses from coming to the ED may have an attached morbidity and mortality."

All EDs should be set up to handle less acutely ill patients, such as with urgent care centers or fast tracks, he adds. "The ED should see itself as being there for more than just patients with critical health conditions," he says. "We should reject this rigid construct that others are trying to impose on us and simply look at ways to provide better service."

Findings may be flawed

ED overcrowding is caused by a variety of health policy and financial issues, and it can’t be solved simply by educating patients about proper use of the ED, according to Robert Schafermeyer, MD, FACEP, immediate past president of the Dallas-based American College of Emergency Physicians and associate chair for the department of emergency medicine at Carolinas Medical Center in Charlotte, NC.

Schafermeyer points to increased boarding of inpatients due to a decreased capacity of available hospital beds. "Also, the nursing shortage leaves even fewer staffed beds to take care of a population that is growing older, has more chronic diseases, and is of a multicultural background," he says.

EDs must be the "court of last resort" for the insured when they can’t get timely access to their physicians, Schafermeyer stresses. "Crowding is not caused by the quick treatment that can be given to the less ill or minimally injured patients," he says.

The methodology of the study is suspect, explains Schafermeyer. "I do not trust any study that is not done with more than a review of discharge diagnoses," he says. "Yes, a laceration can be sewn in several clinical settings, but any one of us would want the wound evaluated and closed before infection or further injury occur."

Schafermeyer points to recent research that contradicts the study.1 "The researchers showed that critical and urgent visits have gone up significantly since 1990 and that there was an 8% decline in nonurgent visits," he says.

The study reported that intensive care units were full, with many critically ill patients waiting in the ED beds, Schafermeyer adds. "This was what I have seen at many EDs over the past three years," he says. "The boarding of inpatients and the lack of reserve or surge capacity is the culprit."

Mellick gives the following suggestions to provide better service in the ED:

Add a fast track or urgent care center to your ED.

These prevent patients with different acuities from competing for the attention of the ED physicians, Mellick says. Using the same physical location as the ED minimizes duplication of resources, he says. Less expensive, midlevel providers can be successfully used in these settings, he adds. "Paramedics or technicians or LPNs can adequately provide the desired nursing support," he says.

Consider using physicians to triage patients.

If a physician’s assistant, resident, or attending physician briefly screens patients and starts the initial orders, when the patient actually is placed in a room, the test results are already completed and can be immediately reviewed, explains Mellick.

"This allows the patient to be rapidly discharged, which significantly improves patient flow and patient satisfaction," he says. "Time traditionally lost while waiting for a room is filled with patient care activities."

Combine physician triage with urgent care.

There may be even greater benefit if physician triage is combined with urgent care activities, Mellick adds. "Often, patients seen in a physician triage setting are minor complaints that can be managed during the triage process, and the patient can be immediately discharged," he says.

This would need to occur in a location close to the main triage station, Mellick notes, and he adds that his ED will add three rooms for this purpose. "Additionally, [we] added a resident eight-hour shift during the busiest part of the day that is focused on physician triage, urgent care, or the observation unit," Mellick says.

Reference

1. Lambe S, Washington DL, Fink A, et al. Trends in the use and capacity of California’s emergency departments, 1990-1999. Ann Emerg Med 2002; 39:389-396.

Sources

For more information on nonemergent use of emergency departments, contact:

• Larry B. Mellick, MS, MD, FAAP, FACEP, Chair and Professor, Department of Emergency Medicine, Section Chief, Pediatric Emergency Medicine, 1120 15th St., AF 2036, Medical College of Georgia, Augusta, GA 30912-2800. Telephone: (706) 721-7144. Fax: (706) 721-7718. E-mail: LMELLICK@ mail.mcg.edu.

• Robert Schafermeyer, MD, FACEP, Department of Emergency Medicine, Carolinas Medical Center, 1000 Blythe Blvd., Charlotte, NC 28203. E-mail: Robert.Schafermeyer@carolinashealthcare.org.