One fact is non-negotiable when it comes to emergency departments: they must continue to deliver an excellent standard of care for patients with acute illness and injury.
However, the shift from volume-driven to value-based care and the need to balance quality, patient satisfaction, and cost of care, has forced hospital administrators and other industry professionals to reevaluate the role EDs play in the care continuum.
And though some consider the emergency department to be a necessary evil due to the significant overall expense, selected outcomes being the same or not better than other care settings, and costs that must be absorbed by the hospital, there are many reasons to value it as a strategic asset.
An article in the March/April 2016 edition of Spectrum, a publication of the Society for Healthcare Strategy & Market Development (a division of the American Hospital Association), written by Lisa Fry, chief business development officer for SCP, and Dr. Randy Pilgrim, SCP enterprise chief medical officer, lists the following as reasons:
- Fifty to seventy percent of all hospital admissions come through the ED, with significant downstream implications such as surgical procedures and diagnostic testing that contribute to the hospital's net revenue.
- ED visits account for 28 percent of first-contact care, despite the fact that ED physicians comprise only four percent of all doctors.
- A large proportion of quality measures, documentation, and patient experiences begin in the ED — metrics that have a growing impact on hospital revenues and public reporting of performance.
- Important diagnostic and treatment decisions are made in the ED, as is the decision to admit a patient or send him home.
- The payor mix is usually one-quarter each: Medicare, Medicaid, commercial, and self-pay, which is more than other practice types typically see.
- The ED serves as a rapid diagnostic center for unscheduled, undifferentiated conditions.
- Although it has a high fixed cost, it’s almost never an option to close the ED.
- It’s a main point of entry for the largest number of patients entering the hospital. In addition to driving admissions, the ED also accounts for a significant number of radiology and laboratory charges for the hospital.
Even though retail and urgent care clinics continue to serve patient care needs on an increasing basis, EDs remain a central component of hospital-based medical care. In fact, the rate of ED visits is increasing out of proportion to population growth, according to the article.
"Hospitals depend heavily on patients who are admitted through the ED,” Dr. Pilgrim said in a telephone interview responding to the article. “It's the entry point that sets the course for high-quality, cost-effective management for the majority of admitted patients and is foundational to the hospital’s well-being."
Squeezing the most value demands that EDs be "right-sized," according to Dr. Pilgrim. The core of this process requires laying a solid, stable foundation, which includes efficient utilization of space and equipment, effective provider staffing, and the assurance of quality care.
Right-sizing also means finding ways to maintain quality while reducing costs and length of stay. Two innovations the article mentioned were:
- ED observational, short-stay units, or rapid treatment units, which bridge the gap between an ED visit and a hospitalization.
- Rapid diagnostic units, designed to optimize diagnostic specificity and improve risk stratification. "[A] rapid diagnostic unit more closely matches a patient's needs with the resources required to treat his/her condition," the article said.
Other right-sizing measures include a focus on managing care after patients leave the ED — and even before they arrive.
Case management and patient navigator programs can help patients discharged from the hospital or ED to obtain a primary care physician, schedule follow-up clinic visits, and arrange for home monitoring or medication checks, the article said, with the ultimate goal being to reduce admissions, readmissions, and "super-user" visits.
In terms of managing patient care before the need for an ED visit arises, Fry and Pilgrim said that community-based services, such 24/7 nonclinical call centers, provider referral lines, employer health programs, community health fairs, and educational seminars can help to encourage wellness and ensure that, when patients do visit the ED, they get to the site best-suited to their needs.
From Fry and Pilgrim’s point of view, there are sufficient reasons to see the ED as a strategic asset rather than a necessary evil. Both assert that there are a number of important, cost-efficient alternatives that leverage emergency care in new ways, and establish an important role for the ED within the continuum of patient care.