Trends in Emergency Department Utilization and Optimization: Part 3 of 3

In the midst of the COVID-19 crisis, I would like to briefly address how ongoing challenges in the ED intersect with our current reality. For the past several decades, ED utilization has outstriped overall population growth in the United States. This trend in demand is conflated with hospital consolidations and closure of smaller community hospitals, reducing access to ED services in some communities across the United States. The undesired consequence is decreased access to care in rural and poor urban areas—places where there is already inadequate access.

With the spread of COVID-19, I shudder thinking about the challenges we face in unprecedented demand on a system that is already maxed out in many communities. While it is encouraging to witness an increasingly coordinated federal response to this crisis (i.e., funding and resources), our ability to appropriately meet demand will likely vary across our communities.

Because there is little choice at this stage and it fits my overall life outlook, I am going to take the optimistic position and assume that we will get through this COVID-19 challenge, likely bruised but far from beaten. It will be a learning experience for our national emergency medicine system. However, once COVID-19 is behind us, it would be foolish to assume that it will be the last time such a surge in demand will occur. As population increases, lives in closer proximity, and absorbs the unpredictable impacts of climate change, the possibility of such events will remain. Up until now we have been mostly spared, yet in addition to COVID-19, outbreaks of SARS, MERS, and Ebola underscore the perennial reality of these threats.

The constant in these various outbreaks is that people with access to timely testing and quality care did much better than those who experienced barriers, shortages, and delays. As a nation, we must have a proactive plan for additional capacity when we experience intermittent and unpredictable surges in demand. 

With our current situation as a backdrop, I here offer several evidence-based approaches for how the ED can provide more care with less resources, decrease wait-times and boarding, and absorb a certain level of demand surge—all while improving the patient experience.

1. “Fast Track” Service Line in the Emergency Department:

The central idea behind the “Fast Track” approach is to triage patients into separate, acuity-based, cohorts immediately at presentation to the ED. Low acuity patients (fever, sore throat, skin rash, UTI, minor injuries, etc.) are treated in a separate part of the ED, with its own set of dedicated resources. Essentially, a dedicated fast track area places an urgent care center within the ED environment. The less acute patients do not compete for attention and resources with the more complicated cases coming into the ED. This approach typically offers a separate examination area for the lower acuity patents, with more appropriate staffing and supplies, allowing for much quicker ED throughput.^1,2

The impact of the “Fast Track” approach has been well studied across many different regions, patient populations, and ED types, with benefits for both low acuity patients and more severe patients:

• Decreased overall patient wait times
• Increased throughput of lower-acuity patients
• Reduced LWBS (left without being seen) rates
• Decreased overall hospital admissions
• Decreased testing and, in some cases, costs
• Increased available provider time for higher acuity patients
• Shortened overall ED length of stay
• Improved patient satisfaction³

Like any significant structural or process-related change, transitioning to this approach will have its challenges. The opportunity cost of implementation, the stress, and sense of upheaval for the staff could be substantial. While there might be “down-the-line” financial benefits, upfront investment in staffing, equipment, and added physical space may be required. Other aspects of the ED would have to be carefully rethought to gain all of the potential benefits. For example, unless a hospital dedicates an imaging department and a lab specifically for the fast track, benefits could be eroded if fast track patients have to wait for their results with the higher acuity patients in the main ED.

2. Implementation of Advanced Triage Protocol

Advanced triage allows for immediate and more proactive intake of patients presenting to the ED. It allows parallel processing of ED patients instead of a traditional serial process. The typical approach is implementation of a quick patient assessment, with diagnostics and treatments all being ordered quickly and delivered simultaneously. Advanced triage can be implemented by empowering nurses and/or mid-level practitioners, such as physician assistants and nurse practitioners, to initiate order sets based on the patient’s presenting complaint, or with an emergency physician as part of the intake team. While there is evidence that physician-led advanced triage may be incrementally more effective, it appears that both are superior to the traditional intact model.³ 

Physician triage is an area of personal interest for me, and my previous work has shown that a physician-led model provided significant and sustained results.⁴  The benefits of this approach and other advanced triage models include: 

• Decrease patient length of stay
• Decreased LWBS rates
• Improved patient throughput
• Decreased time to pain treatment
• Increased patient comfort
• Decreased time to antibiotics in patients admitted with pneumonia
• Decreased delays in performing ECGs and administering thrombolytic agents for MI
• Decreased costs associated with patients requiring one-to-one monitoring
• Indication of decreased medical errors
• Improved employee satisfaction⁴

Perhaps the most significant benefit is an increase in the amount of patient volume that an ED can handle by reducing boarding and improving overall patient throughput. With an increased sense of empowerment, clinical staff are able to manage larger volumes while mitigating the sense of being overwhelmed or “burned out”.

3. Emergency Room Information Systems, Tracking Systems, and Communication Technology

While the influx of new technology can feel overwhelming and disruptive to many clinicians, these tools have an undeniable and material positive impact. Many recent studies confirm the benefits of technology designed to improve quality, communication, throughput, and patient satisfaction in the ED.⁵

Computerized tracking systems are increasingly able to predict and improve patient flow, shorten patient wait times, decrease LWBS rates, improve revenue, improve patient satisfaction, improve provider engagement, and facilitate communication. The increased use of mobile technology to both deliver information to clinicians and improve overall ED communication is showing real value. One use case for mobile technology is to facilitate bedside registration and the immediate bedding of patients as they enter the ED. With this approach, patients bypass the front desk entirely, minimizing administrative bottlenecks and documentation needs.

Concluding Thoughts

There are many other promising approaches for improving performance and facilitating “doing more with less” in the ED. Those herein highlighted methods consistently offer significant value.

I would like to leave you with two additional thoughts when designing a more effective ED structure for your organization. 

• These approaches offer the most benefit when implemented together. For example, advanced triage in an ED with Fast Track service lines can ensure that patients get proper care, in the most appropriate setting, as quickly as possible. Thoughtfully implemented technology can improve communication, documentation, and staffing through predictive modelling. All these tactics together facilitate speed and alignment across clinical staff.
• While these approaches are well substantiated, there must be a constant effort to improve and revise processes. In fact, what research exists on the topic suggests that the benefits tend to dissipate if there is not a way to continuously engage the ED staff with additional education and data that supports the value of their efforts.³ Barriers can include lack of staff buy-in, cultural resistance, and misalignment of staff incentives with change management initiatives. It is imperative for organizations to implement a widely accepted education and feedback mechanism to ensure that clinicians see the benefits of their work in a transparent fashion.

Emergency care is currently top of mind as we are on the frontline of the largest global health challenge in a generation. During normal times the average person rarely thinks about the ED unless they find themselves or a loved one in acute distress. Faced with a collective crisis such as COVID-19, the importance of having access to high quality emergency care in the midst of limited resources becomes crystal clear. Not only are more resources needed to drive improvements in emergency care, we must also be smart about how we deploy them.