Patient Flow Enewsletter
Volume 2, Issue 3
Thursday, June 16, 2005
When I began working in emergency medicine more than 30 years ago, the number of patients I saw in the ED who were not experiencing a medical emergency troubled me. For differing reasons, these patients were unable to access primary care providers and relied on the emergency department for routine medical attention. Through the years, the flow of these patients into the EDs where I have worked has increased, as has the percentage of patients who are not in acute condition.
My current job is to make sure that Denver's University of Colorado Hospital is ready at all times to provide the best emergency care for acutely ill patients. Up until 18 months ago, our ED was on diversion at least 120 hours a month. Our staff was stressed out. Our patients were experiencing long waits and over-crowded conditions, and we were straining to meet our community commitment to be open and handle their medical emergencies. We needed to manage the ED differently and try something bold.
Part of our solution has been initiating medical screening exams for patients who are not in an obviously emergent condition. The screenings help us determine if these patients really need the services of the emergency department or not. I know this topic has generated a great deal of discussion across the country. It is either celebrated or criticized, depending on one's perspective. I have received phone calls from reporters, ED directors, and chief financial officers at hospitals nationwide.
EMTALA calls for providing a medical screening for all patients who come to the ED. It does not require a hospital to provide medical care to those who are not in an emergent state. There is no prescriptive design for the medical screening in the law, so we carefully defined what it would look like here at our emergency department. For us, the changes we have made have been a step in the right direction.
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If our staff determines that the screened patient does not require emergency medical attention, we explain the findings of our assessment to the patient. We let the patient know that he or she can choose to use their insurance, or make other arrangements to pay for their care, if they plan to stay in the ED despite not having an emergency. If they do not wish to pursue treatment in the ED, they are given a comprehensive list of free clinics and community resources. Recent studies show that in Denver, a significant number of these patients do follow up and receive care at no or low cost.
In the roughly 18 months since we initiated this system, our diversion hours are down from 120 hours a month to just 10 hours. Our average length of stay for non-emergent patients went from 300+ minutes to just 54. Our patient volume in the lower acuity categories decreased, which suggests that our constituents understand that the ED is best used for medical emergencies. At the same time, the volume of higher acuity patients, which we are best equipped to serve, has increased and our revenue-per-patient figures continue to rise.
I am often asked to give advice on "how we did it." My most frequent answer is that we recognized that the influx of non-emergent patients into the ED is a community problem, and needs a community response. In every community, there needs to be an assessment of who can and will care for those who need primary care and are unable to access it. An important part of this discussion is the recognition that it is not solely the job of an acute care facility to provide this type of care.
I also counsel others to carefully deliberate the many ethical considerations of not automatically providing care, and to do so from many perspectives - patients, providers, administrators, and community residents. These discussions go to the heart of how we choose to use our talents and best serve our neighbors. At every turn, we need to listen to the softer side of people in order to determine if changes should - or should not - be made in a given hospital or a specific community.
Lastly, I think hospitals need to spend time discussing their thought process with the community and its media. We underestimated how our local paper would react to our decisions. We certainly missed an opportunity to explain our reasons for changing our procedures before the discourse became complicated.
Like my colleagues, I believe that we have an ethical obligation to provide quality care in America's emergency departments. Our obligation is to our community, to be open and available to treat critically ill and injured patients. I believe that when we are preoccupied with others who are not experiencing an emergency, when we are shut down and on diversion and not available to treat the father who is experiencing a heart attack, or the grandmother who has been stricken by a stroke, we break our commitment. I believe it is my ethical duty to provide an efficient environment for administering emergency care to people in Denver, whenever they need us, in a setting designed to treat acute illness.
Honoring this commitment is what I can do to help improve American health care.
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Lorna Prutzman, R.N., M.S.N.
Director, Emergency Services
University of Colorado Hospital
Denver, CO
