NON-EMERGENT USE OF

EMERGENCY DEPARTMENT

Principal Investigator:Tina Bacorn, RN

Overcrowding in Emergency Departments

Admission to ED numbers have been increasing. Implementation of the Affordable Care Act has increased the numbers considerably.

Many of these admissions are not true emergencies

Emergency department costs are the most expensive way to receive primary medical care

Overcrowding in Emergency Departments

Causes: Sluggish processes for patient throughput Delayed care for patients with life

threatening medical conditions Delayed relief of pain for patients who

present with acute injuries or illnesses Contributes to the ever rising cost of

healthcare in America

Research Study Purpose To determine the population using the

emergency department for non-emergent purposes

To determine the reason for their choice in using the ED for non-emergent purposes

To correct any identified obstacles to alternative primary care

To re-direct patients to more appropriate facilities, the next time they have a similar complaint, by giving them alternative resource information

To educate patients on their medical complaint ULTIMATELY: Determine ways to reduce the non-

emergent population of the ED

Methodology

Convenience sample of 100 patients was obtained

Monday-Thursday Within hours of 0900-1500 Genesis East Emergency

Department-Fast Track During months of October and

November 2014

Methodology

Inclusion criteria: Must be triaged at level 4 or 5, based on

standard ESI Practitioner to assess the patient and

determine the condition to be non-emergent, could be treated else where, non-emergently, with equal care

Exclusion criteria: Non-english speaking patients, pregnant

patients, and prisoners.

Methodology

Research candidates were presented with informed consent explaining the study

Upon verbal consent, a series of questions were asked of the patient including:

age, gender, primary medical complaint, whether or not they had a PCP, insurance status, and reason for choosing the ED

for their medical treatment Based on their answers, patients were given

case specific resource handouts, treated by the practitioner, and then discharged

Analysis

Of the 100 patients interviewed: 52 were female, 48 were male Median age was 24.5 All 100 patients were residents of Iowa

Answers were divided up into several categories: Medical Insurance status PCP status Type of medical complaint Alternative resources given

68 %

18%

10%

4%

Medical Insurance Status

Medicaid/Medicare 68%

Self-Pay 18%

Private Insurance through employer 10%

Commercial (insured through a specific health care provider) 4%

29%

25%12%

7%

6%

6%

6%

4%3% 2%

Type of Non-Emergent Medical Complaint

Upper Respiratory Infection (cold/flu) 29%

Acute Minor Musculoskeletal Injuries 25%

Chronic Pain Management (Narcotic Rx refills) 12%

Skin Irritation (rash,insect bites) 7%

Laceration 6%

Eye Irritation 6%

Migraine 6%

Non-Pain Rx medication refill 4%

Dental Pain 3%

Non-Injury producing foreign body swallowed 2%

Analysis 100 % of the patients could have been

seen at an Urgent Care facility 86% of the patients could have been

seen at PCP within next 3-7 days, with equal care, and with no additional harm

77% reported having a PCP. However, only 6% reported having actually called their PCP to see if they could be seen. The other 71% stated they just assumed they would not be able to get in.

-The difference between sick slots and routine check ups was explained.

Analysis

30% of the patients were given ORA Orthopedics’ walk-in clinic information: Open Monday-Thursday 1700-2000

92% of the patients given ORA reference did not report severe pain or distress and could have waited an additional couple of hours to go here instead

Analysis

23% of patients reported not having a PCP Given Genesis “No Doc” phone number:

(563-421-DOCS) Given contact information and hours of operation on

the four community health care sites in the QCA

18% of the patients reported not having medical insurance Given information on how to sign up for the affordable

care act, criteria requirements for Medicaid eligibility, contact information on Genesis Financial Counselor Representative, Rachel Pai for assistance in signing up

Informed that Community Health Care also has assistance in signing up for the affordable care act insurance

Analysis

12% of the patients were seen for chronic pain medication refills

All of these patients had already established PCP care for their condition, but reported not being able to get into see the PCP before they either “ran out of meds” or the meds “weren’t strong enough” Given Genesis policy on chronic pain

management in the emergency department Genesis’ policy is to not treat chronic pain with

narcotics due to the national epidemic of narcotic substance abuse

Analysis

3% of the patients were seen for dental pain

Given 10 separate references for dental clinics, including the Community Health Care clinic that accepts walk-ins every morning, Mon-Fri, starting at 0715am

Chronic pain policy also explained to those patients who reported the dental pain lasting longer than 6 months

“FAST TRACK” – not so much

“Fast Track” is a common area of emergency departments, set aside for minor injuries and illnesses

Fast Track is often overcrowded itself resulting in wait times of over 2 hours (ideal door-door is 30 minutes)

Sometimes it can take 30 min-hour just to get these patients triaged

“Convenience” was the number one reason reported for why the patients chose the ED for their medical needs

May 2015: West campus ED saw approx. 3,200 patients and East campus ED saw approx. 3,000 patients

Systematic Reviews of Literature

The most tested intervention to reduce the non-emergent use of ED’s was case management

Included a multi-disciplinary team of nurses, social workers, and physicians

Locus of intervention not limited to the hospital and often extended into the community

Strong evidence supporting a full time case manager for “Fast Track”. Case management was essentially what this research project turned into.

“In 2 before-and-after studies, the reduction in hospital costs was larger than the cost of the case management team.” (Althaus et al., 2011, p. 47)

Fiscal ResponsibilityHigh Risk Population

68% had government funded insurance 18% were self-pay 4% had commercial insurance

68 %

18%

10%

4%

Medical Insurance Status

Medicaid/Medicare 68%Self-Pay 18%Private Insurance through employer 10%Commercial (insured through a specific health care provider) 4%

Fiscal ResponsibilityServices and Supplies Eligible Populations by Family Income

<100% FPL                 101-150% FPL                   >150% FPL

Institutional Care (inpatient hospital care, rehab

care, etc.)

50% of cost for 1st day

of care

50% of cost for 1st day

of care or 10% of cost

50% of cost for 1st

day of care or 20% of

cost

Non-Institutional Care (physician visits, physical

therapy, etc.)

 

$3.90

 

10% of costs 20% of costs

Non-emergency use of the ER $3.90 $7.80 No limit

Drugs

Preferred drugs

Non-preferred drugs

 

$3.90

$3.90

 

$3.90

$3.90

 

$3.90

20% of cost

Fiscal Responsibility

Government insurance pays out based on a set fee schedule. “The

Iowa Medicaid Enterprise (IME) fee schedule is a list of the payment

amounts, by provider type, associated with the health care procedures

and services covered by the IME. Providers are contractually obligated

to submit their usual and customary charges but accept the IME fee

schedule reimbursement as payment in full.” (Iowa Department of

Human Services, 2014)

Fiscal Responsibility

Alternative interventions are now being implemented in ED’s across America due to the financial loss associated with these unpaid bills:

ADVANCED TRIAGE

Advanced Triage

Nurse and practitioner in the triage room Practitioner determines whether or not

the patient has a life threatening condition or if the potential is there for a life threatening condition to develop

Patients deemed non-emergent are then given resource hand-outs for appropriate alternative facilities, and then discharged w/o treatment.

Estimated door-door time on these patients is less than 10 minutes.

Advanced Triage

There are three criteria that should be met in order for this

process to occur:

1)“The hospital has determined, after an appropriate medical screening, that the individual

does not need emergency medical services.”

2)“An alternative non-emergency services provider is actually available and accessible in

a timely manner to provide the services needed by the individual.”

3)“The hospital has provided the individual with…the name and location of an alternative

non-emergency services provider (as described above); and a referral to coordinate scheduling

of the individual's treatment by this provider.” (Medicaid.Gov Keeping America Healthy, n.d.)

Research Study Extensions

Additional research for Exact amounts of money lost due to unpaid

bills of non-emergent population Fast track case management trial, with follow

up phone calls, to identify and address any hurdles the referred patients may have encountered

Percentage differences of non-emergent to emergent patient populations

The policy/procedure and community reactions to those hospitals doing Advanced Triage

References

Althaus, F., Paroz, S., Hugli, O., Ghali, W. A., Daeppenn, J., Peytremann-Bridevaux, I., & Bodenmann, P. (2011, July).

Effectiveness of Interventions Targeting Frequent Users of Emergency Departments: A Systematic Review. Annals of

Emergency Medicine, 58(1), 41-52. http://dx.doi.org/10.1016/j.annemergmed.2011.03.007

Genesis Financial and Billing Services. (2014). http://www.genesishealth.com/patients-visitors/billing/assistance/

Huang, Q., Thind, A., Dreyer, J. F., & Zaric, G. S. (2010, July 9). The impact of delays to admission from the emergency

department on inpatient outcomes. BMC Emergency Medicine, 10(), 16-21. http://dx.doi.org/10.1186/1471-227X-10-16

Iowa Department of Human Services. (2014). http://dhs.iowa.gov/ime/providers/csrp

Kang, H., Black-Nembhard, H., Rafferty, C., & DeFlitch, C. (2014, October). Patient Flow in the Emergency

Department: A classification and Analysis of Admission Process Policies. Annals of Emergency Medicine, 64(4), 335-

342. http://dx.doi.org/10.1016/j.annemergmed.2014.04.011

Medicaid.Gov Keeping America Healthy. (n.d.). http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-

Topics/Cost-Sharing/Cost-Sharing-Out-of-Pocket-Costs.html