Non-Emergent use of emergency department

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Non-Emergent use of emergency department

• Principal Investigator
• Tina Bacorn, RN

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Overcrowding in Emergency Departments

• Admission to ED numbers have been increasing.
  Implementation of the Affordable Care Act has
  increased the numbers considerably.
• Many of these admissions are not true emergencies
  
• Emergency department costs are the most expensive
  way to receive primary medical care

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Overcrowding in Emergency Departments

• Causes
• Sluggish processes for patient throughput
• Delayed care for patients with life threatening
  medical conditions
• Delayed relief of pain for patients who present
  with acute injuries or illnesses
• Contributes to the ever rising cost of healthcare
  in America

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Research Study Purpose

• To determine the population using the emergency
  department for non-emergent purposes
• To determine the reason for their choice in using
  the ED for non-emergent purposes
• To correct any identified obstacles to
  alternative primary care
• To re-direct patients to more appropriate
  facilities, the next time they have a similar
  complaint, by giving them alternative resource
  information
• To educate patients on their medical complaint
• ULTIMATELY Determine ways to reduce the
  non-emergent population of the ED

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Methodology

• Convenience sample of 100 patients was obtained
• Monday-Thursday
• Within hours of 0900-1500
• Genesis East Emergency Department-Fast Track
• During months of October and November 2014

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Methodology

• Inclusion criteria
• Must be triaged at level 4 or 5, based on
  standard ESI
• Practitioner to assess the patient and determine
  the condition to be non-emergent, could be
  treated else where, non-emergently, with equal
  care
• Exclusion criteria
• Non-english speaking patients, pregnant patients,
  and prisoners.

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Methodology

• Research candidates were presented with informed
  consent explaining the study
• Upon verbal consent, a series of questions were
  asked of the patient including
• age, gender, primary medical complaint, whether
  or not they had a PCP, insurance status, and
  reason for choosing the ED for their medical
  treatment
• Based on their answers, patients were given case
  specific resource handouts, treated by the
  practitioner, and then discharged

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Analysis

• Of the 100 patients interviewed
• 52 were female, 48 were male
• Median age was 24.5
• All 100 patients were residents of Iowa
• Answers were divided up into several categories
• Medical Insurance status
• PCP status
• Type of medical complaint
• Alternative resources given

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Analysis

• 100 of the patients could have been seen at an
  Urgent Care facility
• 86 of the patients could have been seen at PCP
  within next 3-7 days, with equal care, and with
  no additional harm
• 77 reported having a PCP. However, only 6
  reported having actually called their PCP to see
  if they could be seen. The other 71 stated they
  just assumed they would not be able to get in.
• -The difference between sick slots and routine
  check ups was explained.

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Analysis

• 30 of the patients were given ORA Orthopedics
  walk-in clinic information Open Monday-Thursday
  1700-2000
• 92 of the patients given ORA reference did not
  report severe pain or distress and could have
  waited an additional couple of hours to go here
  instead

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Analysis

• 23 of patients reported not having a PCP
• Given Genesis No Doc phone number
  (563-421-DOCS)
• Given contact information and hours of operation
  on the four community health care sites in the
  QCA
• 18 of the patients reported not having medical
  insurance
• Given information on how to sign up for the
  affordable care act, criteria requirements for
  Medicaid eligibility, contact information on
  Genesis Financial Counselor Representative,
  Rachel Pai for assistance in signing up
• Informed that Community Health Care also has
  assistance in signing up for the affordable care
  act insurance

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Analysis

• 12 of the patients were seen for chronic pain
  medication refills
• All of these patients had already established PCP
  care for their condition, but reported not being
  able to get into see the PCP before they either
  ran out of meds or the meds werent strong
  enough
• Given Genesis policy on chronic pain management
  in the emergency department
• Genesis policy is to not treat chronic pain with
  narcotics due to the national epidemic of
  narcotic substance abuse

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Analysis

• 3 of the patients were seen for dental pain
• Given 10 separate references for dental clinics,
  including the Community Health Care clinic that
  accepts walk-ins every morning, Mon-Fri, starting
  at 0715am
• Chronic pain policy also explained to those
  patients who reported the dental pain lasting
  longer than 6 months

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FAST TRACK not so much

• Fast Track is a common area of emergency
  departments, set aside for minor injuries and
  illnesses
• Fast Track is often overcrowded itself resulting
  in wait times of over 2 hours (ideal door-door is
  30 minutes)
• Sometimes it can take 30 min-hour just to get
  these patients triaged
• Convenience was the number one reason reported
  for why the patients chose the ED for their
  medical needs
• May 2015 West campus ED saw approx. 3,200
  patients and East campus ED saw approx. 3,000
  patients

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Systematic Reviews of Literature

• The most tested intervention to reduce the
  non-emergent use of EDs was case management
• Included a multi-disciplinary team of nurses,
  social workers, and physicians
• Locus of intervention not limited to the hospital
  and often extended into the community
• Strong evidence supporting a full time case
  manager for Fast Track. Case management was
  essentially what this research project turned
  into.
• In 2 before-and-after studies, the reduction in
  hospital costs was larger than the cost of the
  case management team. (Althaus et al., 2011, p.
  47)

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Fiscal Responsibility

• High Risk Population
• 68 had government funded insurance
• 18 were self-pay
• 4 had commercial insurance

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Fiscal Responsibility
Services and Supplies Eligible Populations by Family Incomelt100 FPL                 101-150 FPL                   gt150 FPL Eligible Populations by Family Incomelt100 FPL                 101-150 FPL                   gt150 FPL Eligible Populations by Family Incomelt100 FPL                 101-150 FPL                   gt150 FPL
Institutional Care (inpatient hospital care, rehab care, etc.) 50 of cost for 1st day of care 50 of cost for 1st day of care or 10 of cost 50 of cost for 1st day of care or 20 of cost
Non-Institutional Care (physician visits, physical therapy, etc.)   3.90   10 of costs 20 of costs
Non-emergency use of the ER 3.90 7.80 No limit
DrugsPreferred drugsNon-preferred drugs   3.903.90   3.903.90   3.9020 of cost
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Fiscal Responsibility

• Government insurance pays out based on a set fee
  schedule. The Iowa Medicaid Enterprise (IME) fee
  schedule is a list of the payment amounts, by
  provider type, associated with the health care
  procedures and services covered by the IME.
  Providers are contractually obligated to submit
  their usual and customary charges but accept the
  IME fee schedule reimbursement as payment in
  full. (Iowa Department of Human Services, 2014)

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Fiscal Responsibility

• Alternative interventions are now being
  implemented in EDs across America due to the
  financial loss associated with these unpaid
  bills
• ADVANCED TRIAGE

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Advanced Triage

• Nurse and practitioner in the triage room
• Practitioner determines whether or not the
  patient has a life threatening condition or if
  the potential is there for a life threatening
  condition to develop
• Patients deemed non-emergent are then given
  resource hand-outs for appropriate alternative
  facilities, and then discharged w/o treatment.
• Estimated door-door time on these patients is
  less than 10 minutes.

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Advanced Triage

• There are three criteria that should be met in
  order for this process to occur
• 1)The hospital has determined, after an
  appropriate medical screening, that the
  individual does not need emergency medical
  services.
• 2)An alternative non-emergency services
  provider is actually available and accessible in
  a timely manner to provide the services needed by
  the individual.
• 3)The hospital has provided the individual
  withthe name and location of an alternative
  non-emergency services provider (as described
  above) and a referral to coordinate scheduling
  of the individual's treatment by this provider.
  (Medicaid.Gov Keeping America Healthy, n.d.)

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Research Study Extensions

• Additional research for
• Exact amounts of money lost due to unpaid bills
  of non-emergent population
• Fast track case management trial, with follow up
  phone calls, to identify and address any hurdles
  the referred patients may have encountered
• Percentage differences of non-emergent to
  emergent patient populations
• The policy/procedure and community reactions to
  those hospitals doing Advanced Triage

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• References
• Althaus, F., Paroz, S., Hugli, O., Ghali, W. A.,
  Daeppenn, J., Peytremann-Bridevaux, I.,
  Bodenmann, P. (2011, July). Effectiveness of
  Interventions Targeting Frequent Users of
  Emergency Departments A Systematic Review.
  Annals of Emergency Medicine, 58(1), 41-52.
  http//dx.doi.org/10.1016/j.annemergmed.2011.03.00
  7
• Genesis Financial and Billing Services. (2014).
  http//www.genesishealth.com/patients-visitors/bil
  ling/assistance/
• Huang, Q., Thind, A., Dreyer, J. F., Zaric, G.
  S. (2010, July 9). The impact of delays to
  admission from the emergency department on
  inpatient outcomes. BMC Emergency Medicine, 10(),
  16-21. http//dx.doi.org/10.1186/1471-227X-10-16
• Iowa Department of Human Services. (2014).
  http//dhs.iowa.gov/ime/providers/csrp
• Kang, H., Black-Nembhard, H., Rafferty, C.,
  DeFlitch, C. (2014, October). Patient Flow in the
  Emergency Department A classification and
  Analysis of Admission Process Policies. Annals of
  Emergency Medicine, 64(4), 335-342.
  http//dx.doi.org/10.1016/j.annemergmed.2014.04.01
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• Medicaid.Gov Keeping America Healthy. (n.d.).
  http//www.medicaid.gov/Medicaid-CHIP-Program-Info
  rmation/By-Topics/Cost-Sharing/Cost-Sharing-Out-of
  -Pocket-Costs.html
•