ED documentation system helps improve patient flow

Automation helps pass information along

At Sarasota (FL) Memorial Hospital, emergency department case managers have made a significant impact in reducing inappropriate admissions and assuring efficient patient flow, says Judy Milne, RN, MSN, CPHQ, director of integrated case management and quality improvement.

Sarasota’s "Assessment Team" consists of five RNs (clinical case managers) and four social workers (psychosocial case managers). Daily staffing includes two clinical case managers and two psychosocial case managers covering 15 hours per day, plus two clinical case managers covering the direct admission center and outpatient procedural areas. The team’s emphasis is appropriate utilization followed by discharge planning and placement to avoid admissions that may be unnecessary, Milne says. The clinical case managers also focus on assuring correct patient type assignment for patients who are admitted. In 2001, the ED saw 85,000 patients, about 22% of whom were admitted, and the hospital had inpatient admissions of 30,000.

Since more than half of all admissions to the hospital come via the ED or direct admits, "heavy resourcing of case management really starts efficient utilization off right," Milne says. The ED/outpatient case managers also assist inpatient case managers by documenting key findings and unresolved concerns in the case management database (TQ, produced by Boca Raton, FL-based Eclipsys Corp.).

"We have a very heavy emphasis on data, and all staff contribute by documenting their case management activities," Milne says. "We use these data extensively to support budget requests, to negotiate with community agencies, and to generally demonstrate our impact to the organization."

Benefits of case management

When a case manager in the ED reviews a case, "a couple of different scenarios could occur," she says. If the case manager notices unusual or pending findings, he or she would likely document in the database what those findings were and leave a note prompting the inpatient case manager to follow up on the case or "to keep an eye on a certain finding or a certain issue related to the care of the patient," Milne adds.

A similar scenario exists when the ED is busy and it’s important to keep patient flow moving. "They don’t really have all the results that they need in order to reach a conclusion about whether the patient is appropriate, but they’re getting some pressure to move the patient to an inpatient bed," she says. "They would document in [the database] what they did know about the patient and what was pending, and probably also what they were suspect about." For example, they would document if they weren’t sure that a particular patient would meet inpatient criteria.

Milne notes that, "if it’s a same-day kind of thing, and they really think someone on the inpatient team needs to be aware of it right away, they probably would follow up with a phone call to the receiving case manager."

For EDs without a sophisticated automated system, she acknowledges that getting good tracking data could be difficult. "Not impossible, but certainly very difficult, and you’d need good clerical support. You probably could design data-collection tools that went along with the flow of case management, but then you’d have to be able to hand off to clerical people to do data entry, run reports, and whatever."

Milne adds, "The other advice I would give is, even if it’s hard, try to do it. Because for us, the aggregate data and the way that we’ve used it has just been very powerful. . . . It’s just a lot of uses of the data that really help us manage our continuum and our patient flow."

She says one particular benefit of having a case management presence in the ED has been case managers’ ability to work collaboratively with ED physicians and teach them more about appropriateness of admission. "I think that, over time, our ED physicians have been much better at screening admissions more appropriately," she says. "So they’re helping us gate-keep at the front door to be sure that we’re using the facility correctly. From a clinical perspective, that’s definitely a gain, that we are diverting inappropriate admissions."

Social work contribution

The presence of social workers in the ED has had similar benefits. "Working collaboratively with the physicians and the RN case managers, [the social workers] can facilitate the placement or a reasonable discharge plan for a patient who maybe used to get admitted. So, in tandem with the clinical case managers, they help with the utilization from the perspective of being able to handle discharge plans pretty fast — to get placements done, to get paperwork filled out that’s required to get a patient to a facility or to get home care or whatever."

In 2001, Sarasota Memorial was named No. 1 in efficient management of Medicare patients by Milliman USA. "My own perspective is that many hospital leadership teams want the results that case management can achieve but frequently do not support the resources needed to accomplish the desired goals," Milne says.

"Our case management program is intensive and successful, but only because it has been resourced for success. Once the resources are committed, then it becomes the case management department’s obligation to achieve the results. Part of that obligation is to document what is being accomplished," she says.