Care management unit has broad LOS impact

Short stay, telemetry admissions, costs decreased

A new report from the Urgent Matters Learning Network titled Bursting at the Seams: Improving Patient Flow to Help America’s Emergency Departments, describes the experiences of 10 hospitals selected for an initiative to help hospitals eliminate ED overcrowding. Of the 10, four received a special $250,000 grant for "demonstrator projects." One such project, an innovative care unit at Grady Health System in Atlanta, yielded this impressive roster of results:

  • Decreased number of short stay admissions. During the period of the grant, the care management unit (CMU) cared for 1,147 patients, which is 1,147 hospital admissions diverted.
  • Decreased number of admissions to telemetry beds requested from an average of 11 per day (before the CMU opened) to an average of four per day at the end of the grant period.
  • Decreased congestive heart failure (CHF) costs. Actual costs per patient ranged from $616.28 to $1,061.62, with a total savings of $3,600 on average.
  • Decreased relapse rate. (The final numbers are being determined.)

"We went back and looked at what we thought were some causative factors [of overcrowding]," recalls Leon L. Haley Jr., MD, MHSA, deputy senior vice president of medical affairs, chief of emergency medicine, and vice chairman of clinical affairs for Grady Health System, and associate professor in the department of emergency medicine at Emory University, both in Atlanta. "One of the major impacts for us was patient bed availability," he continues.

Grady conducted a two-month study beginning in August 2002 to obtain a representative sample of volume in patients, the number of patients admitted, and how many patients were in the waiting room. "In the evening hours, especially 6 p.m. to midnight, it was not unusual for us to have 120 active patients in the ED and 25 to 35 admitted, so about 30% of ED capacity was being taken up by inpatients," Haley explains. "That’s a big deal for us."

Haley and his Urgent Matters team got together with the internal medicine service, as well as with the financial department, and asked them if addressing any particular condition(s) could make a difference in improving throughput. The finance department assisted with this analysis by assessing the admitted patients within the hospital that were identified as having a stay of less than 48 hours, months before the opening of the CMU.

The findings showed that three diagnoses stood out as potential candidates for the CMU (chest pain, asthma, and CHF). Hyperglycemia was identified as an additional candidate because patients with diabetes made frequent return visits to the ED.

"They were chosen because they tend to get bottled up in admissions," notes Haley. For example, most patients with chest pain or CHF were admitted to telemetry beds. Hyperglycemic patients generally went home, but they spent a lot of time in the ED first, as did the asthma patients. "They also tend to make repeat visits," Haley adds.

Haley identified the existing seven-bed chest pain center that was attached to the ED, so he proposed augmenting it to transform it into a CMU.

"At that time, I was the director of inpatient case management, and I knew we had all these case managers upstairs, so I suggested we bring them downstairs," Haley says.

The patients in the four identified categories were then sent to the new CMU. Funded by the grant, the new unit was open 24 hours a day, seven days per week. Additionally, the CMU had dedicated case managers seven days a week, 20 hours a day and was staffed by a nurse and a clinic assistant.

The case managers were responsible for patient and family disease education, getting the patients the proper meds, arranging for very specific primary care follow up, and follow-up with every patient.

"Our case managers were allowed to schedule primary care follow-up directly out of the unit to their primary care physicians’ [PCPs’] schedules," says Haley. "This included our downtown clinic, as well as a neighborhood center." The care manager could ask the patient, for example, "How is next Tuesday at 2 o’clock with Dr. Jones?" and the patients knew when they walked out the door that they would be seeing him, Haley notes.

"They also worked with cardiology to set up outpatient stress tests," he adds. "All of these targeted follow-up appointments were within 48-72 hours."

The case manager usually would call the next day, but definitely before their follow-up PCP appointment, then a week later, and after 30, 60, and 90 days. They would ask the patients how they were feeling and whether they were following up as they were supposed to.

In the seven- to eight-month-long pilot program, about 1,500 patients went through the new unit. "The vast majority went home," says Haley. "Perhaps 15% got admitted; but if they did, it was to a lower acuity bed." Chest pain patients did not have to go to telemetry unless they were very ill.

The average length of stay (LOS) in the CMU was about 13-14 hours, Haley notes. Under the old model, these patients would have been admitted. "The way to think of it is, those patients who went into the care management unit are a group that no longer would be adding an additional six hours to LOS, by going to an inpatient bed and then later being discharged," he observes.

In other words, in the past, patients with chest pain or CHF were admitted almost all of the time.

"They basically sat in the [emergency care center] five or six hours before they got to a bed, and then were here maybe 24-36 hours," Haley explains.

"By putting in the care management unit, chest pain patients went there and had a total stay of about 16 hours — but 85% of the group went home, as opposed to being admitted," he adds.


For information on the care management unit, contact:

  • Leon L. Haley Jr., MD, MHSA, Deputy Senior Vice President, Medical Affairs, Chief of Emergency Medicine, Vice Chairman of Clinical Affairs, Grady Health System, Atlanta; Associate Professor, Department of Emergency Medicine, Emory University, Atlanta. Phone: (404) 616-6419. E-mail: