October 11, 2018

What’s New in the World

To help disseminate ED medical director-relevant research and help maximize our limited time, we will be offering recent literature reviews specifically applicable to the work that we do … leading busy ED’s.  For the inaugural newsletter, we wanted to provide a recap of the treasure trove of admin-related literature presented at ACEP’s Research Forum, held at the 2017 Scientific Assembly last October in Washington, DC.  Whether you have a similar project in mind and are not looking to reinvent the wheel or you are just browsing for new ideas, the following is a light-hearted one-liner summary of each the 31 abstracts presented in the “Administrative/Practice Management” category (grouped by un-official categories and listed in the order published in the October 2017 Supplement to Annals of Emergency Medicine.

Dollars and Cents/Throughput/ED Utilization Studies

  • Stop waiting for those urine pregs … using serum qualitative tests can save over an hour on average (73.6 minutes) for female patients with abdominal pain that require radiographic imaging. (16)
  • Clinical algorithms and educational initiatives can reduce kidney stone CT orders, and ultrasound can reduce renal colic patients’ length-of-stay (LOS). (19)
  • Changing the default CBC w/diff to a CBC w/o diff reduced the rate of differentials being ordered … leading to $180K in savings. (21)
  • Process improvement can lead to turn-around-time under 30 minutes for x-rays and non-contrasted CTs. (17)
  • Education and operations changes can reduce MRI orders, improve test appropriateness, and lead to a reduction in the rate of Medicare non-payments. (20)
  • If you “know” from the door you’ll be admitting, why wait? Call Dr. Admit. Partnering and coordinating diagnostic information expedited admission times for clinically-ill patients by an average of over two hours. (51)
  • My patient went where? Reporting of ED utilization to pediatric specialist physicians decreased ED visits. (78)
  • Truly helping high utilizers: the creation of individualized care plans for 145 high-utilizer patients reduced ED visits, inpatient hospital days, and costs (6-month savings of $1.6M). (79)
  • Reducing ED LOS for hemodialysis patients (a lot!!): creating an emergent dialysis process resulted in an annualized ED LOS reduction of 102,668 hours. (80)
  • Golden results for the “Gold Card” program: outpatient management was encouraged by giving discharged patients a “Gold Card” that guaranteed specialist follow-up within two business days.  Over 91% of the patients kept their appointment, and patient satisfaction was nearly 99%. (82)
  • The more you board, the slower your ED moves: for every boarder, overall LOS increased 1.55 minutes. And LWBS and walkouts changed by 0.07%. (108)
  • Ambulances, come one, come all: following ten years of process improvement, CMS metrics improved after implementing an ambulance diversion ban. (110)
  • Creating an interactive daily ED dashboard can improve ED management and data accessibility. (111)
  • Delineating for scribes precisely what information is required for each section of a chart can increase the level of service charges. (113)
  • Optimal schedules can be developed by analyzing data to optimize ED pharmacist presence to assist in decision-making and critical patient management while reducing pharmacist stress and burnout. (137)
  • Supply optimization could reduce medication waste by 60% and save thousands of dollars a year while saving nurses’ time. (138)
  • Excuse you, indeed: residents are interrupted nearly 12 times an hour for an average of 37.5 seconds per interruption. Interruptions are face-to-face with other healthcare team members, and the number of interruptions increased with resident seniority. (141)

Provider-Up-Front/Provider-In-Triage (PIT)

  • A doc upfront (concierge physician) performing a brief initial assessment did not reduce overall LOS, but decreased door-to-doc time and improved patient satisfaction. (46)
  • Maybe we know stuff … an all ABEM staffing model and improved front-end patient flow improved quality metrics and market share. (47)
  • Again, maybe we know stuff: docs upfront coupled with sub-waiting areas reduced LOS more than split-flow based on Emergency Severity Index score (ESIs). (49)
  • Is it worth it?  A doc upfront significantly reduced the LWBS rate, but the recaptured revenue did not offset the financial costs. (50)
  • Doc-up-front: after four years of a physician in triage, time to initial evaluation and LWBS decreased, while patients leaving without a completed evaluation and elopements remained the same and the time-in-bed and overall LOS increased. (109)
  • A provider in triage deceased the door-to-doc times but did not reduce overall LOS. (112)

Patient Quality

  • All those CTs are not decreasing admission rates: those physicians who order the most CTs also admit the most patients. (18)
  • Vitals are, well, vital: direct-to-room patient movement led to delays in obtaining vitals. Establishing a vital sign station in the waiting room decreased the delay. (48)
  • Choosing your observation (obs) patients: 48-hour ED obs reduced admissions for patients with chest pain, syncope, and anemia, but not for patients with sickle cell crisis (SCC), inflammatory bowel disease (IBD), and congestive heart failure (CHF). (76)
  • HEART scores did not change plan of care: with low risk chest pain, sites that had a compulsory HEART score versus a site that did not had no statistically significant changes to plan of care. (81)
  • Effectively managing ED-based HIV and HCV screening involved engagement of disparate groups, open communication, leveraging electronic medical record (EMR) processes, and creating progress reporting combined to successfully increase screening tests. (139)
  • Patients do not understand busy times: only 5% of surveyed patients identified the busiest day in an ED and 14% identified the busiest 6-hour time period.  (140)
  • The sickest get sicker: patients admitted to the floor got transferred to the intensive care unit (ICU) more when they met the criteria for septic shock (64% sent to the ICU) than for severe sepsis (28% transferred to the ICU). (142)

If you have any questions on the above recaps, the published abstracts are available on the Annals website.  In upcoming newsletters, we will continue to provide summaries of recent medical director-applicable research articles.  If you have any suggestions for must-read articles, please feel free to contact me.

Tom Spiegel, MD, MBA, MS
ED Medical Director and Assistant Professor
University of Chicago

[ Feedback → ]
LIVE CHAT