Thursday, July 9, 2009

OSF and ED Overcrowding and "Where the Money Is"

Keith Steffen, OSF's CEO, photo at right.

When I wrote Keith Steffen and OSF's ED Attendings the letter in September, 2001 about OSF's Emergency Department overcrowding, I had no idea that for the majority of the coming decade, this would be the "hot topic" in Emergency Medicine literature.

I thought then that OSF's ED leadership and OSF's Administration were not giving the ER patients a fair chance for improved care. I thought that we were putting our patients at risk.

OSF, like many medical centers across the nation, are "bottlenecking" patients in the door for profit. Patient safety is on the back burner.

Here is a good article that was published this month in Emergency Medicine News that describes OSF's (and many other medical centers) problem very well.

Emergency Medicine News Vol 31 (7) July, 2009

Emergency Department Crowding

(Beginning in the middle of the article):

Dr. Ackroyd-Stolarz found that older people who stayed longer in the emergency department were more likely to have adverse events.

In her retrospective cohort study, she included 982 patients 65 and older. The average age was 77.8 years, and 75 percent of them experienced a prolonged ED stay of six hours or more. Studying the records, she found that 140 had adverse events. Adjusting for total ED stay, she found that long stays in the emergency department were associated with a higher risk of adverse events.

Those who suffered an adverse event stayed in the hospital twice as long as those who did not (20.2 days versus 9.8 days). Because the patients stayed in the hospital longer, they occupied acute care beds, an increasingly scarce commodity that exacerbated ED crowding.

Even when there are readily available beds, elderly people tend to stay longer in the emergency department because they come in with more complex illnesses and require a longer workup.

But by far, the lack of inpatient beds is the most significant contributor as to why they are waiting, Dr. Ackroyd-Stolarz said. There is evidence that the elderly are more likely to be admitted to the hospital. They don't want to go to the emergency department unless they are really sick because they know they will wait, she said.
The higher risk for these patients often comes from a decreased physiologic reserve. They are often sicker with comorbid conditions, she said. In the future, we need to demonstrate that this association holds true in other hospitals.

Fixing the problem requires a system approach, said Dr. Ackroyd-Stolarz, not just focusing on the emergency department. People outside of emergency medicine will say, 'If we just fix how they do their business,' but it goes beyond the doors of the emergency department, she said, noting that hospitals need to investigate bed management and what occurs in the community, such as whether services are available to help avoid ED visits.

If we provide more primary care services to nursing home residents, we may prevent that transfer to an emergency department in the middle of the night because there is no physician in the nursing home, she said.

For those who must come to the ED, Dr. Ackroyd-Stolarz said it is important to recognize that the crowding and long waits can be distressing. Often, people end up being admitted for something that could be managed in the nursing home if the services were available.

We need a coordinated, systemic look at every part of the system to figure out where we can make changes to improve the flow, she said.

The extended length of stay for those with adverse events presents a special issue, she added. They take up extra acute care bed time, and the medical literature says hospitals do not have acute care beds because patients are waiting to be transferred to nursing homes.

By preventing the adverse event, EDs could reduce the length of stay. We do not know which came first, she said. Did they have an adverse event because they were in the hospital longer, or did the adverse event contribute to the length of stay?

In fact, profitability creates a mixed message. Studies published in the past five to 10 years show that crowding is associated with lower quality care, but a wave of studies in the past year or so has associated crowded EDs with higher profits for the hospital.

Arguing that crowding is profitable, that it hurts patients, and that it is associated with lower quality portends a tough solution where the federal government disallows crowding. They could implement a solution like that in the United Kingdom or Australia where they won't pay for emergency department patients who stayed there longer than a certain time, Dr. Pines said. It's certainly a possibility. How long should it take to evaluate a patient? Four hours is too short; eight hours might be more reasonable.

Dr. Pines said another solution would be not to pay for admissions until they get to the floor. Hospitals now bill from the time of the bed request, and this solution would not allow the hospital to bill a DRG for an ED patient. Even if they spend 24 hours in the emergency department hallway, Medicare gets a bill for a whole hospital day, he said.

Alternative solutions will likely prove more effective, he said, such as creating incentives for doctors to see patients in their offices during what are now off-hours. Could we pay primary care doctors to see patients after 5 p.m.? Dr. Pines asked. Could we pay surgeons more to operate toward the end of the week or even on weekends? That could smooth schedules and make primary care available when patients actually need it. Essentially, we need a system of acute care that reflects the physiology of how people get sick, which is at unexpected times.

The issue boils down to how patients get medical care in the United States, Dr. Pines said. The system is built around where the money is. The money, for whatever reason, is in specialty care and procedural services. We have a lot of specialists in this country for that reason.

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