For a hospital’s Emergency Department (ED), increasing financial efficiency largely depends on clinical throughput. This article segments the ED visit into three parts--arrival, in-room, and disposition--and discusses the financial ramifications of specific process improvements that increase patient flow and enable greater volume in each.

Before making any changes to ED operations, though, CFOs and ED leadership can capitalize on one area of opportunity that does not involve patient flow: documentation. At most EDs across the country, improving revenue can be achieved through better documentation practices.

Documentation and coding: common problems

The culture of emergency medicine, not surprisingly, perceives certain types of emergent situations as “routine emergencies,” downplaying the efforts necessary to stabilize acute patients. While this culture has evolved for good reason--namely, to help the ED team maintain cool-headedness in times of great stress--it is often responsible for the gap between the care documented and the care actually performed. That gap is perhaps the most common, and costliest, explanation behind lost reimbursement dollars.

A physician who fails to document the total amount of time she spends stabilizing a patient with an acute impairment to a vital organ system makes it impossible to accurately code for that critical care--one of the most commonly underused code sets. Say, for example, the physician documents the hour she spent stabilizing the patient but didn’t document the 20 minutes she spent an hour later reviewing the patient’s labs and radiographs, or the 25 minutes after review that she spent communicating the patient’s needs to the medical staff. Omitting documentation of those 45 minutes of critical care time means a lost opportunity to code for not one, but two segments of 99292--a loss that translates to about 20 percent less reimbursement.

Or take this more common example: An emergency physician treats a patient with asthma who is in respiratory distress. The patient receives life-saving treatments in the Emergency Department and improves significantly. Because this scenario is so routine for emergency physicians, the outcome (a stable patient, no longer in distress) can lead them to underestimate (and undervalue) the critical nature of the role they played. If a single physician fails to document his/her critical care time in that instance, the difference in reimbursement could be $75 or more. If a 50,000 annual volume ED is missing even 2% of their opportunities for appropriate critical care documentation and coding, that equates to a loss of $75,000 just on the professional fees. If we consider non-critical care charts that were similarly “down-coded,” it amounts to several hundred thousand dollars annually in missed professional revenue.

A meaningful gain in financial efficiency, then, comes from changing the “routine emergency” culture around documentation. The first step is to invite the scrutiny of a coding and billing expert, or to work in tandem with the hospital’s billing company to identify those gaps between care performed and care recorded. A coding expert will be able to quickly point out where a physician has documented one thing but the timing and other factors indicate another. The education piece is showing those discrepancies to the ED team, in this case emergency physicians, and explaining how that documentation costs the hospital money, which can in turn deprive the ED of much-needed resources. It is also crucial to provide similar documentation education to the nurses, as nurses do so much of the work on the facility coding side. In fact, we often find that the missed facility revenue is several times the professional amount. Just one example here: hospitals have been leaving money on the table for years due to faulty documentation around IV administration and medication injections, which require the recording of both start and stop times for billing.

While down-coding is the greatest area of opportunity for increasing revenue, there are gains to be made on the other end of the spectrum, too. Higher codes can be denied if the documentation does not satisfy prerequisite codes such as “review of systems” (ROS) and “past family or social history” (PSFH). Dismissing PFSH as “non-contributory,” for example, without also noting that the appropriate questions were asked, can mean the difference between a level 3 code and a level 5 (amounting to more than $100 loss per patient).

Clinical efficiency: arrival

While the full and accurate documentation of emergency services rendered is a simple first step toward greater financial efficiency, the real financial gains will come from strides in clinical efficiency. Arrivals--or more to the point, wait times--are notorious for souring patient satisfaction (which can, through word of mouth, drive down volume), and they are also the linchpin for improving patient flow in the ED. Additionally, the downside of poor arrival protocols is financially harmful; the penalties for “LWBS,” when patients are registered but then leave without being seen, constitute significant losses of potential revenue for the hospital. In fact, reducing the LWOBS by even one patient per day can mean an additional $50,000 or more on the professional side and several multiples of that on the facility side.

While there are a number of strategies for minimizing wait times and getting the patient in front of the right provider, there is one wrong way to do it, and it’s currently standard practice: linear processing. In this model, the patient endures one set of questions via the registration process, and then a second set of questions, first from a triage nurse and then from a primary nurse, before finally seeing the physician or advanced practice provider (APP) (who may ask the very same questions posed earlier!). The time spent in front of each of these clinicians and the time between them automatically draws out the arrival process unnecessarily, creating problematic bottlenecks for providers and frustration for patients.

Alternatives to linear processing:

  • Parallel processing, which eliminates interviews that do not add value from the patient's perspective and puts anyone necessary to the patient’s care in front of the patient at the same time. This may require reprovisioning space for patient intake and assessment. Because some clinician sees the patient immediately, non-emergent patients can be entered and discharged quickly, thus making room for higher acuity patients.
  • A “Care team,” which allows the ED to skip the triage step and put a provider and a dedicated team nurse in front of the patient as a first step. Speed is actually the second concern here: reducing hand-offs, and the errors that occur most often during transitions of care, is the first. Fewer hand-offs also translate into financial efficiency in terms of avoiding redundancies. At one hospital, the arrival-to-provider metric dropped from over an hour to 13 minutes with the implementation of the Care team model. 
  • “Pull to full,” a simpler adjustment, means that patients are drawn into the ED until all spaces are filled. This is crucial in addressing their satisfaction as they are being pulled into the treatment area sooner and able to be seen by the provider. By potentially moving the provider assessment earlier in the visit, ED teams are able to identify life-threatening illnesses right away and reduce the likelihood a patient will leave the facility before being seen.

Clinical efficiency: in-room

The in-room and disposition phases of the visit also need to move efficiently to realize gains. In this portion of the visit, space is the limiting factor. Moving patients out of beds they don’t need--which means getting testing completed and results in--is the key to improving patient flow.

Lab testing and radiology results cause the biggest drags on the in-room process, so improvements begin with measuring those turnaround times in relation to patient flow (i.e., the “end” of the measurement is not the time the lab exports the results, but the time the provider enters the system to obtain them). Some rules of thumb for increasing efficiency in these areas:

  • Set aggressive goals for turnaround times.
  • Monitor progress towards these goals (i.e., physician ordering, lab confirmation, lab results waiting, physician accessing results) automatically.
  • In monitoring lab, radiology, and ED physician performance around these goals, make sure to check the outlying times as well as the averages. 
  • Adjust focus, and resources if necessary, to bring even the outlying turnaround times into range.

A tougher shift is one of orientation: from the traditional “stabilize and treat” to “disposition [‘dispo’] first.” While stabilizing patients and providing appropriate care are indeed the governing principles of emergency medicine, it is also true that it is generally more efficient to disposition existing patients before bringing in new patients. Clearing the physical and mental space to treat a new patient is easier when a stable patient is safely en route home or to wherever in the hospital he needs to go.

Clinical efficiency: disposition

The in-room orientation toward disposition needs follow-through from the entire ED team in order to realize the efficiency gains that can allow greater a larger volume to be seen with the same amount of resources. As described above, even one extra patient seen per day without any additional resources could mean well over $100,000 per year between professional and facility revenue.

Physicians naturally focus on newer patients and those requiring care more urgently. But without the beds vacated by stable patients, those new patients can’t be treated properly--so adopting the “dispo first” mantra, across job description, is critical. If it’s possible, appointing a “bed czar” whose only responsibility is managing the beds in the ED, including predicting volume spikes, arranging bed readiness (i.e., housekeeping) as well as simply monitoring availability, and staying ahead of the needs of the ED, is ideal.

Somewhere between the culture shift toward disposition and the resource-reliant creation of a new position lies collaboration between the ED and the hospitalists who admit patients to the hospital. The intricacies of the power struggles and obstacles to collaboration between these two groups are too numerous and arcane to enter into here. But even this tricky area can be managed into greater efficiency, namely through the establishment, supported by both specialties, of specific protocols for admission. Establishing guidelines for the admission of certain specialist patients is one example: together the specialties could agree that the hospitalist service will admit for Gastroenterology with the understanding that those specialists will consult on all appropriate patients, for instance. These and other protocols avoid the need for stressful case-by-case negotiations, and minimize the time spent arguing, second-guessing a decision, or multiple phone calls by the emergency physician. They can also address those costly, dangerous errors that tend to occur around transitions of care.

Conclusion

Faster high-quality care leads to improved patient satisfaction, which in turn can lead to greater volume. Efficiently handling that volume can reap the very resources that help extend and sustain those gains. The story of financial efficiency in the ED is one that ends in more revenue for the hospital, then, but also, crucially, in greater quality care for a greater number of patients.