As is true of most of medicine, the use of emergency rooms is complex and costly, which is why St. Luke’s and other hospitals and health systems are intent on making sure use is appropriate and for the right patients. St. Luke’s has begun early efforts toward an end-to-end care redesign, in part to ensure appropriate emergency room use.
It will be challenging and difficult work, but there are great opportunities to reduce cost and make the care better for patients. Here, blog editor Roya Camp, St. Luke’s director of content and communications, looks at some of the factors and challenges involved in appropriate ED use.
- David C. Pate, M.D., J.D.
Emergency room care is not what it was when Dr. Matt Larsen started there more than a decade ago.
As a resident in Pittsburgh, and then in his early years in Twin Falls, Dr. Larsen treated people with heart attacks, victims of life-threatening accidents, children with severe injuries.
It’s not that Dr. Larsen, who is now St. Luke’s Health System medical director of acute care services and who continues to practice as an ER physician, does not still see those sorts of needs. It’s that he now also sees so much more – and so much more that should not be there.
In recent years, due to a combination of federal rules and regulations, economic conditions, the whipsaw that the health insurance industry continues to experience and a variety of lifestyle habits, people increasingly have used emergency rooms as drop-in clinics.
Medicine as practiced in emergency rooms in Idaho and across the country is not a form of care specially trained ER physicians are paid to practice. It is a form of medicine St. Luke’s is intent on changing.
Dr. Larsen and other physician leaders with St. Luke’s Health System are in the early stages of what may be a “back to the future” shift for ED care.
It’s a massive endeavor. Because fixing what’s wrong in the ED is to fix what’s wrong with everything around emergency care, not the emergency care itself.
“End-to-end care design is not an ER initiative,” Dr. Larsen said. “It’s about who is ending up in our EDs to be treated.”
Dr. Neeraj Soni has worked in Treasure Valley emergency departments for nearly two decades. Dr. Soni is also an emergency medicine physician and is president of Emergency Medicine of Idaho, which contracts with St. Luke’s for ED coverage in Boise, Meridian, Nampa, Fruitland and Mountain Home and urgent care coverage in Eagle.
He agrees that the profile of patients seen in ERs has changed in his years of practice and that improvements could be made to care design, but does not think the question of ED use is particularly problematic.
At a very broad level, conventional hospital medical care historically has followed two paths:
A patient is admitted for the sort of care that necessitates a hospital stay, or a patient suffering a sudden and traumatic event comes to the ER, is treated and is discharged.
ERs also can become the way station for all the care needs in the middle, however, and people use EDs for a variety of problems EDs are not designed for. So ED physicians and staffs may end up treating chronic diseases, such as hypertension, COPD or diabetes, for example. Or they see people with basic needs but who lack a primary physician.
Or they see people who, accustomed to immediate answers or solutions to their needs at fast-food restaurants and coffee houses, drop by the ED for all manner of relatively minor health concerns. As evidence, Dr. Larsen points to ED utilization patterns that show volumes peaking and spiking from 4 p.m. to midnight, when people are off work, out of school and available to get their care needs met. At the ED, rightly or wrongly, they can get timely care, all the tests they might need, answers to questions and medications.
“We’re seeing far more of the primary care complaints, chronic disease states,” Dr. Larsen said, “and I believe that’s an access issue and a convenience issue.
“If patients perceive that their only option is to go to the ED, then they’re going to go to the ED,” he said. “For them, it’s a one-stop shop.”
It’s not that patients with complex, chronic diseases are coming to ERs seeking treatment for those diseases, however, but for problems related to those illnesses, Dr. Soni said. Dr. Soni, who serves as St. Luke’s chief medical informatics officer, said the use of the system’s recently implemented common electronic health records system has been valuable in treating these complicated patients.
“They live on the medical edge, teetering on the edge of serious illness,” he said. “The patients are quite complex. The complexity of the patients has gotten significantly higher.
“Is that a good use of the ED or not?” Dr. Soni said. “Whether it is or not, it’s necessary, and it may not be that inefficient.”
It’s not to say highly trained ER staff members can’t do this care; it’s to say their skills are better applied to the traumatic and significant injuries, accidents and illnesses that they are best equipped to handle.
And while insurers, hospitals and patients are rightly concerned with costs, ED physicians are trained to look at “worst first.” Primary care, in contrast, is less expensive because it “works the person up. We work the person down.
“Our job is to rule out the worst of the worst. Once we rule out life-threatening issues, we look at, where should this person be?” Dr. Larsen said. By that point, of course, all the very expensive tests have been performed. And that sort of care runs smack up against accountable care contracts.
“I think it’s this perfect storm that’s been created,” Dr. Larsen said.
And because this level of care is not what ERs have been designed to deliver, there are no efficient, set processes to deal with the needs from a value-based perspective. Care as currently practiced in ERs across the country is very expensive, the logical result of the historic fee-for-service approach, and only relatively recently have health-care administrators begun to cast a critical eye on the type of care going on in the ER setting.
Dr. Larsen points to studies that indicate that globally, 47 to 51 percent of all medical contacts are happening currently in emergency room settings, and that 50 to 60 percent of what clinicians see in the ED is not what they would consider an acute medical emergency. He thinks the figures likely hold true for St. Luke’s and that St. Luke’s has only been somewhat lucky in that Idaho has a much smaller population than California and other states, where patients are waiting six to eight hours to be seen in EDs.
“It’s a global crisis,” he said. “What we see is not an uncommon event. It’s an epidemic.
“ERs have always been considered the safety net,” Dr. Larsen said. “The safety net has so much weight on it right now that it has the potential to crash.
“And what is the safety net after that?”
Dr. Soni has a different take. He notes that, given the several scales used to gauge the severity of the problem the patient is experiencing, assessment of the problem after the patient has been seen may be very different than it was assessed at when the patient arrived.
St. Luke’s ED patients also vary significantly among locations, he said. Based on the Emergency Severity Index, he said, Boise and Meridian EDs see sicker patients than do, in order, Twin Falls; Nampa (although Nampa ED patients are trending sicker); St. Luke’s Elmore, Fruitland and Wood River; and McCall and Jerome, with the least sick.
Dr. Soni said that in the aggregate, 93 percent of St. Luke’s patients seen in the ED required moderate to complex or critical decision-making by emergency medicine providers.
“Who else would have provided that?” Dr. Soni said. “Who is going to do anything but tell them to go to the ER to get evaluated?”
When Dr. Soni started with EMI, St. Luke’s Boise was the organization’s only hospital, with a two-track approach in the ER. Lower-acuity patients were seen by a nurse practitioner and a physician’s assistant and moved through quickly. The practice tapered off, he said, when urgent care clinics began to spring up in the area. He said St. Luke’s ED volumes in Boise and Meridian have stayed fairly flat over the past decade, in large part because those low-acuity patients continue to visit urgent care clinics and because St. Luke’s is meeting emergency needs closer to home for Canyon County residents than in the past.
St. Luke’s has begun to address the complicated combination of factors that has led to the current state. And while solving the problems that ultimately bring many to the emergency rooms who might appropriately be seen in other settings will take some time, physicians and other leaders know solutions are to be found in education, access and technology.
“Quick-care” clinics and services, for example, are more appropriate for acute but minor injuries, illnesses and mishaps such as cuts, fractures and upper respiratory infections. The same quality of care can be delivered, but in a far more cost-competitive way.
Connecting patients to primary care physicians is another aspect. If people don’t have doctors that they can readily access, their default will be to go where care is available; too often, that ends up being the ER.
Virtual care, electronically delivered and/or facilitated, is another promising piece of the solution. With virtual care, clinical decision units could be located outside the ERs but managed by emergency-trained physicians and hospitalists. St. Luke’s has begun to test this approach with chest-pain patients in Meridian. Additional after-hours care, patient education and stepped-up care of chronic conditions are additional parts that will need to find their way into end-to-end care design.
“The plan will be a global approach to this problem of access,” Dr. Larsen said.
“If we’re seeing patients with high rates of readmission, high utilizers, what are we not doing before they hit the ED? And that is such a big sweeping question.
“If the system were set up, I would love to see us reduce ED utilization,” he said. “I would love to see the EDs go back to what they did 30, 40 years ago, not as a 24-hour clinic.”
Keeping people out of the ED, Dr. Larsen and Dr. Soni agree, would show progress in terms of care delivery.
For Dr. Soni, it all hinges on one word: disposition.
“We talk in health care, especially in acute care, about the end event, disposition, basically what happens at the end of care,” he said. “There is no end to the patient’s care, just because they left the hospital or the emergency department. And the fact that we view it as disposition sets us up for the care to begin again.
“The notion of end-to-end care is good,” he said. “It might still be a little bit flawed, in that there is no end. It’s a web of patient care. It’s not a line.
“Reimagining what should be happening for patients and their families, for me, that’s the most important missing piece.”
Roya Camp works in the St. Luke’s Communications department.