Revisiting hospital emergency departments

911 For Emergency Care

Better data leads to better solutions to improve quality, efficiency of emergency care

As providers and payers search for ways to improve care and reduce costs, new data are suggesting that they turn their eyes to hospital emergency rooms as an opportunity to do both.

Conventional wisdom holds that hospital emergency rooms are overrun by patients who should be treated in less expensive settings. However, research is questioning that assumption by finding that the medical reasons patients seek emergency care are more complex. Consequently, hospitals need more sophisticated ways of dealing with emergency patients to ensure that the right care is given to the right patient with the result being better care at lower costs.

That approach helped Washington state reduce emergency visits by “high-utilizer” Medicaid patients by 23% in the first six months of its initiative, which is projected to cut Medicaid spending by $33 million in the current fiscal year.

“It turned out to work beyond our expectations,” says Stephen Anderson, M.D., immediate past president of the Washington chapter of the American College of Emergency Physicians.

The program uses an electronic data exchange to provide hospital emergency personnel at the point of care with information on a patient’s previous ED visits, latest test results and more. That information helps them decide whether a medical condition warrants emergency treatment. It was developed after Washington like other states tried—and failed—to reduce ED use by limiting payment for Medicaid patients treated in EDs if their discharge diagnosis suggests a non-emergency condition.

Dr. Anderson and his ED colleagues fought that because they suspected what a new study in the Journal of the American Medical Association has now shown: A patient’s discharge diagnosis is not a reliable indicator of whether a patient needed emergency care. Using an algorithm that attempts to determine whether a patient truly needs emergency treatment, researchers analyzed data from the 2009 National Hospital Ambulatory Medical Care Survey and found that 6.3% of visits could have been treated by primary care physicians. However, the chief complaints for that small subset of visits—abdominal pain, respiratory infections, chest pain and others—were actually the same chief complaints for the vast majority—some 88.7%—of ED visits.

Furthermore, nearly 14% of the “non-emergency” patients arrived at the ED by ambulance, 38% had high pain scores and more than 12% were admitted to the hospital, said lead author Maria C. Raven, M.D., an emergency physician at the University of California-San Francisco.

“The take-home is that when people come to the ED, whether or not the end diagnosis ends up being something that is an emergency, the reason they come is usually a pretty good reason,” Dr. Raven says.

Policy analysts at RAND Corp. cited that finding in their new report, The Evolving Role of Emergency Departments in the United States. They conclude that EDs today serve as a site for conducting complex diagnostic workups quickly and a source of care for patients who cannot get timely access to ambulatory care elsewhere. In light of that, they urge hospital administrators, policymakers and others to work toward effective integration of EDs into inpatient and outpatient settings.

“This can be facilitated through more interoperable and interconnected health information technology, greater use of care coordination and case management and more collaborative approaches to inter-professional practice,” according to the report.

That is what Washington State is doing in its “ER Is for Emergencies” program, which includes many of those best practices. Dr. Anderson, an emergency physician at MultiCare Auburn (Wash.) Medical Center, identifies three that are key:

  • Creation of the Emergency Department Information Exchange. A quick check notifies an ED physician how many times a patient has visited an ED anywhere in the state, whether a care plan (identifying, for example, a patient’s frequent request for narcotics or need for substance abuse services) is in place, and what diagnostic images and tests have been conducted elsewhere. By reducing duplicate tests, “it decreases dramatically the cost of the visit,” Dr. Anderson says. “It also has us upfront and openly talking to the patient: ‘You know, Joe, this is clearly an ongoing problem for you, and the solution isn’t another emergency department visit.’”
  • Case management for so-called Patients Requiring Coordination, or PRCs. Case managers contact high-utilizers after an ED visit to help arrange an appointment with a primary care physician.
  • Robust use of the state’s Prescription Monitoring Program. While most states have programs that alert ED physicians to the controlled substances that have been prescribed to a patient in the past year, use is spotty nationwide. In Washington State, 97 percent of ED physicians are using the program, Dr. Anderson says.

“By combining all these tools we are getting satisfied providers, better care for patients, and significant cost savings,” he says.