Staffing key to making ED patient-friendly, efficient

Experts offer billing, staffing advice

[Editor’s note: This month continues coverage of re-engineering the emergency department (ED) in Patient-Focused Care. This month’s coverage includes tips on how to hire midlevel practitioners and how to structure their jobs to make your ED more efficient while also boosting patient satisfaction in this critical department. In a future issue, PFC will focus on how your ED can set up an observation unit for chest pain patients that could save thousands of dollars in unnecessary care while ensuring that acute myocardial infarction cases are caught early enough to provide optimal care.]

Emergency departments nationwide are finding they can best serve patients by developing express care, fast-track, and urgent care centers staffed by midlevel practitioners who can provide full treatment to patients with less-critical illnesses and injuries.

But most importantly, urgent care services can boost patient satisfaction by providing cheaper, low-acuity treatment with shorter waits than patients would receive in the ED.

"Our intent is to convince [managed care companies] that it’s a whole lot cheaper to use our services rather than to have the patient come here and then ship him all over town," says Larry Mellick, MD, FAAP, FACEP, chairman and professor of the department of emergency medicine at Medical College of Georgia in Augusta. The 520-bed hospital’s ED has 44,000 patient visits each year.

"What people are recognizing is that the patients seen in the emergency department can be categorized and billed at a level consistent with their level of illness," Mellick says.

Mellick and other ED professionals who have set up express care or urgent care services offer these tips on billing, staffing, and setting up triage:

Create separate cost centers for the urgent care or express care services.

The Medical College of Georgia is moving toward developing separate billing for its pediatric and adult express care centers, Mellick says.

Making costs lower will be critical to winning managed care acceptance since so much of the focus in most health plans is on keeping patients out of the ED. But it is also critical to make sure patients understand the different cost structures and levels of care to keep them from being surprised by higher bills in the acute-care side.

Separate billing implementations

Currently, the centers are within the ED and are billed the same as the ED. However, there are plans to dedicate nine or 10 rooms to the express care centers, Mellick says.

To bill the urgent care centers separately from the ED, the hospital must provide the centers with their own space, staff, and accounting services, according to Medicare guidelines, explains Robert McVicker, CPA, FHFMA, senior assistant hospital director/finance for the Medical College of Georgia.

Medicare then would allow the hospital to charge patients urgent care center prices that differ from what they would have been charged in the ED.

McVicker uses physical therapy and occupational therapy services as an examples of how the urgent care center could be kept separate from the ED, even though the two are connected physically. "In most hospitals, the occupational therapy and physical therapy are in the same place, but they keep track of personnel and modalities separately," he says.

For instance, an injured patient arrives to see a physical therapist to regain strength in his arm. Once treatment is complete, the patient will walk into the next room to have the occupational therapist test his arm to see if he can use it for his job.

For the patient, the two services are conveniently next to each other, and they’re very similar. But for purposes of billing, it’s clearly defined which is physical therapy and which is occupational therapy, McVicker explains.

The ED should have a trained nurse or other professional perform triage in the waiting room so a patient’s illness or injury is classified before any treatment is rendered, he says.

Also, McVicker recommends EDs use the Medicare criteria in setting up billing because these typically are similar to Medicaid guidelines.

Hire physician assistants (PAs), nursing practitioners (NPs) as needed.

As more EDs open urgent care centers, there will be a greater need for midlevel practitioners who can supplement the care provided by ED physicians.

Cost-cutting measures call for NAs, PAs

Some experts say these services will be essential to EDs in the future if they want to survive managed care and health care cost-cutting. And the use of PAs and NPs can contribute to better patient satisfaction because since the additional staff will allow the urgent care center to see patients more quickly.

For example, at the ED at Loma Linda (CA) University Medical Center, patients often waited up to three hours to see a physician. Since the hospital opened the express care center, 98% of the patients are seen within 45 minutes of arrival in the ED, says Darlene Bradley, RN, MSN, MAOM, director of emergency and express care services. And those patients who are sent to the urgent care side are seen almost immediately, with waits typically no more than 15 minutes, she adds.

Loma Linda set up its fast-track or express care center three years ago, combining an industrial medicine clinic and urgent care center, says Brent Fisher, MBA, FACMPE, administrative director of the emergency physician group at the 797-bed hospital. The ED, express care center, and industrial medicine center see about 55,000 patients annually.

The ED and express care center had a 10% increase in the past six-months compared to the same period last year, Fisher says. From 1995 to 1996, the total hospital admissions from the ED increased about 2%. But a comparison of the first six months of 1996 and 1997 showed that admissions have increased by 8.7% this year because "we’re now seeing a higher acuity patient in our ED," Fisher says.

The Medical College of Georgia will hire pediatric nurse practitioners for its pediatric express care when the volume increases, Mellick says. Currently, he says, there is no standard formula for hiring in either the pediatric or adult express care centers. Mellick says they’ll use a mixture of a part-time physician and part-time PAs. The goal is to hire several full-time midlevel practitioners to run the express care center with supervision from ED physicians. (See story on how to hire midlevels, below.)

Mellick says the medical college has encountered one major problem with hiring midlevel practitioners — inability to bill separately for their services. The problem stemmed from federal requirements that midlevel practitioners have the same employer as their supervising physician, says Thomas Kelly, associate hospital director for financial services. "We are able to bill for PAs now. They’re considered physician’s employees," Kelly says.

Set up triage with trained nurses.

Loma Linda’s express care center has strict guidelines about who can perform triage. "Nurses have to demonstrate competencies; they have to work for a year in an ED, and they have to go through a training program," Bradley says.

The triage nurse classifies patients’ injuries or illnesses according to one of three colors: red, yellow, or green. The non-urgent or green go to the express care center. All yellows and reds are sent to the ED.

At first, Bradley says, the ED had specific criteria for which physical ailments would be sent to the express care center. But the criteria proved too rigid. So they changed the triage criteria to simply exclude from express care certain types of ailments, such as migraines and chest pains. This gives the triage nurse more flexibility in deciding whether a patient receives a green or yellow designation.

The triage training program lasts from four hours to a full day, and the nurses are mentored by experienced triage nurses.

Currently the ED has 85 nurses, 40 of them are trained triage nurses, Bradley says. The ED also has some trained triage technicians who provide backup support during the busiest time period of 3 p.m. to 11 p.m. A triage nurse is always on duty.

Loma Linda uses so many triage nurses because the work is stressful and nurses typically want to rotate the job, Bradley says.