TRENDS IN EMERGENCY DEPARTMENT UTILIZATION AND OPTIMIZATION: PART 2 OF 3

My Experience Working on the Frontlines (Article 2 of 3)

Hello, and thank you for reading part 2 of my three-article series. To quickly recap, this series outlines: 1) current trends, 2) most significant challenges, and 3) methods for implementing sustainable improvement in the Emergency Department (ED)—based on my research, clinical work, and administrative experience.

The first article discussed current ED utilization trends and the key role the ED plays in our healthcare system. This article defines some of the key challenges and barriers for operational excellence in the ED.

As previously discussed, when Americans seek medical attention, over 50% of the time they head to the emergency room. While this level of utilization may feel high and is often presented as an indication of a poorly functioning system, the reality is more nuanced. A study conducted at the University of Maryland School of Medicine found myriad reasons for this high, and increasing, utilization level. Some reasons, such as lack of insurance coverage or limited access to alternative care settings, fit the prevailing narrative of high ED utilization being a “problem”. However, there were several positive factors associated with rising ED utilization, including “appreciation for the comprehensive care delivered by emergency departments”, and the “ability of emergency departments to fill a critical gap with regard to care delivered to vulnerable populations.”¹

Whether appropriate or not, rising ED utilization is a root cause for some of the key problems the typical ED faces. Most EDs were not built nor staffed to handle their current demand. Imagine a booming suburb being served by the same two-lane country road built 20 years ago. The road was not built to accommodate a heavy influx of new residents. Think of the ensuing traffic jams and associated frustrations. A similar dynamic occurs in the typical ED.

Key Challenges In the Emergency Department:

1. Overcrowding and Capacity Limitations

EDs are crowded, getting more crowded, and capacity is not keeping up. There are many factors: our aging population, high levels of uninsured or underinsured patients, increased patient acuity level, individual preferences for care access, or some combination of these and other reasons. Patients coming into the ED often encounter long wait times and other delays that equate to more time spent waiting and wondering why. There are many potential bottlenecks where delays can snowball: access to physicians or nurses, turnaround time for diagnostic testing, the discharge process, admission to a hospital bed, the practice of boarding, that collectively result in patient dissatisfaction and “LWBS” (i.e., left without being seen). These are all symptoms of a system that is bursting at the seams.

What I find interesting is that this problem is not unique to our healthcare system. While we are quick to point fingers towards our own perceived inadequacies, inequalities, or policy errors, it appears over-utilization, overcrowding, and wait times in other countries’ EDs is no better and often worse. According to Mohammad H Yarmohammadian, et. al., “Overcrowding in emergency departments (EDs) is a concerning global problem and has been identified as a national crisis in some countries,” with associated consequences of treatment delays, increased mortality rates, increased hospital length of stay (LOS), and unnecessary hospital readmissions.²

2. Inadequate Staffing Rates or Skill Level

There has been significant technological progress made towards optimizing staffing with predictive modelling and other sophisticated techniques. Still, the problem of tailoring staff count and skillset continues to persist. Historically, this was a “Goldilocks” problem of either understaffing—leading to long wait times and overcrowded EDs—or overstaffing, putting undue pressure on the hospital’s financial margins with no long-term sustainability. Organizations are getting better at optimizing staffing based on time of day, day of week, and seasonal impacts, etc. The perhaps greater emerging challenge is sufficient access to personnel with the correct skills. Emergency department staff, from doctors to nurses, have scarce and unique skills and, unfortunately, these staff are some of the most vulnerable to burnout.

3. Declining reimbursements

Ongoing trends of declining reimbursement, shrinking margins, and rising uninsured or underinsured populations means hospitals must do more with less. Emergency departments have been especially singled out in the last few years with reimbursement squeeze from all directions. Insurers such as Anthem and UnitedHealth are ratcheting up scrutiny on both low acuity patients deemed ineligible for ED care and the warrantedness of high-level care. The result is either reimbursement reduction or, in some cases, flat out denial of any payment.³

A confluence of reimbursement declines, rising demand, insufficiently skilled labor, rising cost of ED interventions, and of course EMTLA (Emergency Medical Treatment and Labor Act)—which assures that nobody is refused care regardless of ability to pay—collectively presents a significant challenge for emergency departments.⁴

Conclusion

There are still other material challenges in the emergency department and for the people who work in them. Some are highly individualized. The specific patient mix, management style of administration, work culture, geography, and other factors work in tandem to create a unique environment for each ED. What makes one ED function better than the next? That is a complicated question, and one that is at least partially explained by how well the ED adapts to the challenges described above. Please join me next month, for the third article in this series, where I will describe some of the most effective solutions and approaches that I have used in my work as an ED physician and administrator.

References

TRENDS IN EMERGENCY DEPARTMENT UTILIZATION AND OPTIMIZATION: PART 2 OF 3

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Jonathan Rogg, MD, MBA

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