A View of the ED's Integral Role within the Bigger Facility Operations Picture

As we look at the impact the emergency department has on facility operations, it's an undisputed truth that the majority of patient contacts in the hospital occur in the ED. Depending on a facility's surgical volume, 60 to 95 percent of patient contacts begin there for most hospitals; if you take surgery out of the equation, the range is closer to 80 to 95 percent.

Although the ED is sometimes inappropriately referred to as a "loss leader" for the enterprise, when you consider that 40 to 60 percent of admissions to the inpatient unit commence here, you begin to see what many hospital administrators already know — that the average ED functions as the "front door" to the enterprise and contributes significantly to overall net profits.

Setting your facility apart from the competition

It makes sense, then, to look at ways in which the ED can be both a customer service and cost differentiator for your hospital. If your facility is in a competitive marketplace, the ED can stand out as a center of excellence in a clinical specialty such as trauma, chest pain or stroke. It can also set your hospital apart by gaining a reputation for efficient patient throughput. Taking that thought one step further, if the ED becomes known among paramedics and ambulance services for moving patients off their stretchers quickly, they, too, will gravitate to your facility.

Patient satisfaction is another effective differentiator; by focusing on providing a higher level of customer service, you will attract more patients not only to the ED but to other hospital services as well.  

Improved customer service will yield additional benefits. How patients perceive their hospital experience — including care provided in the ED — is now factored into Medicare pay-for-performance reimbursement. Starting last October the CAHPS Hospital survey, which assesses patients' perspectives of care received, is among the measures used to calculate value-based incentive payments.

Aiding and abetting reporting requirements

The ED plays a crucial role in whether your facility complies with standards established for clinical quality measures and performance metrics. By identifying the appropriate patients, establishing care consistent with standards and initiating data collection, your ED staff can help ensure success in this regard.

Diagnostic decisions made in the ED, coupled with emergency physicians' compliance with documentation, also drive downstream success. For example, if a patient with community-acquired pneumonia seeks treatment in the ED, it's critical for the ED physician to determine whether the patient can be treated safely on an outpatient basis or should be admitted — a decision that must be rendered before an antibiotic regimen is chosen. If the patient is admitted, it's important that person be identified in the ED as a CAP patient, as there are additional CAP-related clinical quality measures to be followed during the inpatient stay. With so many admissions stemming from the ED, your emergency clinicians and staff hold the key to how well your hospital meets the Physician Quality Reporting System thresholds.

Reinforcing the network through patient retention

The ED can be an equally great source of ambulatory provider satisfaction. Oftentimes community physicians who send their patients to the hospital for care will refer them first to the ED, even if they need to be admitted. The manner in which the ED staff treats those patients (and the physicians themselves) makes a difference. Physicians who are satisfied with the way they and their patients are treated are more apt to continue using the same hospital. One key influencer of that perceived patient care quality is the communication of information from the ED to the community physician.

On the other hand, since approximately 80 percent of patients are discharged from the ED, you have a multitude of opportunities to retain many of them in your network by making appropriate referrals. In addition to strengthening your relationships with affiliated and independent primary care providers and specialists, you increase the likelihood that patients will receive appropriate aftercare. Improved continuity of care following discharge is in the patient's best interest and the hospital's, as it can help you avoid costly readmission penalties. In-network referrals for services such as outpatient testing or X-rays and other diagnostic procedures will further support patient retention.

A strategic component in cost containment

An emergency physician's decision to admit or discharge a patient can make an enormous difference in the healthcare costs for an individual — in many cases, as much as tens of thousands of dollars. Solutions such as information exchanges, data repositories and on-demand access to referential tools can be put in place to help physicians make better-informed decisions. Having access to data from the hospital's ambulatory network and other external sources gives physicians a more comprehensive patient history, allowing them to be more confident when deciding to discharge, monitor or admit. With insufficient information, they may be compelled admit the patient because none is available to support an alternative decision. Having more data on which to base decisions also reduces duplicate testing, eliminates unnecessary consultations and enhances patient throughput.

With hospitals already facing a 1 percent reduction if they exceed CMS' 30-day readmission levels, making a well-informed decision to admit is critical in avoiding penalties.

Cost considerations may be especially significant for hospitals participating in risk-sharing accountable care organizations. For hospitals designated as an ACO network provider, the ED physician's disposition decision becomes a powerful determinant of healthcare costs.  Identification of ACO patients on arrival and integrating the ED into care coordination processes are critical elements of ACO success.

I've only touched upon a few of the ways in which the ED affects the overall enterprise’s day-to-day operations. As the delivery of healthcare evolves, the impact of ED care is certain to grow. Like many ED physicians, I find the gratification of patient relief from reducing a fracture or incising an abscess is incredibly rewarding. The significant transformations underway in healthcare will allow me to experience gratification in ways not readily obvious today; the care I provide in the ED truly becomes part of the continuum of care the patient experiences in their life. We've always made a difference in the ED. Now, we are able to share that difference with others and see the long-term effects for the patients we serve.

As T-System's Vice President and Chief Medical Informatics Officer, Robert Hitchcock, MD, FACEP, is committed to advancing EHR adoption and healthcare IT public policy to improve the quality, safety and efficiency of emergency department medicine. Dr. Hitchcock has more than 20 years of experience in healthcare and has been a practicing emergency physician for more than a decade. He is an Emergency Department Practice Management Association board member.

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