3 EDs, 470,000 visits: Strategies to handle high ED volumes

The COVID-19 pandemic shuffled up trends in emergency department volume, but many systems are seeing hundreds of thousands of patients a year.

Jeffery Metzger, MD, chief of emergency services at Dallas-based Parkland Health, which had 210,152 ED visits in 2019, told Becker's 2019 was their busiest year, followed by low numbers during the pandemic. Since then, numbers have been steadily climbing back to their pre-COVID-19 volumes, which Dr. Metzger attributes to two factors: A growing Dallas-Fort Worth metroplex and fluctuations in insurance coverage.

Jimmy Lao, MSN, RN, director of nursing for Reno, Nev.-based Renown Regional's emergency department, which is on track to reach 110,000 ED visits this year, said the growing economy is bringing new clients into their hospital, but their expanding services have increased volume for patients who do not have other options.

With increased volumes come increased unnecessary utilization of the emergency department.

"For people who are working or need multiple tests or consults, they find that the emergency department can serve as that 'one stop shop,'" Nilesh Patel, DO, chair of emergency medicine at Patterson, N.J-based St. Joseph's University Medical Center, which had 150,615 visits in 2019, told Becker's. "While this is not the intention of an emergency department, volumes increase due to perceived flexibility and convenience."

Each hospital has a different strategy for optimizing their resources to treat the sickest, and healthiest, of patients.

Dr. Metzger said Parkland is working to eliminate barriers to care to prevent its community from needing emergency department services. They provide resources and education around other options for care, but, he said, "I think there's still a large amount of population that we just don't reach. They don't know until they access the system, and the emergency department is the obvious front door."

Parkland has created a system for low acuity patients that allows 25% of their volume to be cycled through 12% of its space. The system created a rotating process patients move through: Patients are seen in a room for one step of the process before moving to special waiting rooms while tests are performed and results are processed. The movement, Dr. Metzger said, helps the patients feel they are receiving care and frees rooms so more patients can be treated.

Renown Regional takes a different approach: focusing on keeping patients out of the emergency department after discharge. Mr. Lao said they focus on readmissions to the hospital within 72 hours. A multidisciplinary team reviews the cases and develops process improvements to prevent them from coming back while providing referrals that keep patients out of the hospital. 

They are also utilizing telehealth to provide patients care without requiring in-person resources. Mr. Lao also credits the hospital's interdisciplinary team of case management, social work and alert (behavioral health) teams with reducing volume by performing evaluations and assessments to ensure appropriate referrals are given.

Despite careful planning, there are still thousands of patients who enter the emergency department looking for nonmedical or unnecessary services. Both Renown and Parkland told Becker's they regularly treat patients who need something as simple as a prescription refill and members of the homeless population who come seeking shelter.

"We're sort of the one place that they can come to and get a roof over their head," since some of them have been banned from shelters due to behavioral issues, Dr. Metzger said.

But Dr. Patel argues there is no such thing as an unnecessary visit. "Whether a patient is at the highest or lowest level of acuity, that individual requires access to care providers for assessment and treatment. Quite simply, everyone who comes through our emergency room doors needs to be cared for."


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