Like its counterparts nationwide, the Emergency Care Center (ECC) at Grady Health System in Atlanta was facing increasing demands combined with decreasing resources - evidenced by strains such as ambulance diversion times that had increased 3000 percent within the last six years. A study conducted about 18 months ago by a medical student at Emory School of Medicine highlighted and validated a startling statistic that sparked the need for aggressive change. On average, at any given time of day, there were approximately 20 emergency department (ED) patients waiting to be admitted or "bordering" in the ECC. At peak times, there were as many as 40 to 50.

"In response, our thought was to target a specific group of ED patients who were historically clogging the admissions system and subsequently worsening the 'overcrowding' problem," explained Leon L. Haley Jr., M.D., M.H.S.A. , deputy senior vice president of Medical Affairs and chief of Emergency Medicine for Grady Health System. "Our thinking was that if we better managed this group, perhaps we could unclog the system overall."

This idea led to pursuit of an Urgent Matters demonstration grant and the eventual designation of a seven-bed Care Management Unit (CMU), directed by Dr. Varnada Karrieem-Norwood - designed to treat a core group of patients rather than admitting them to the hospital. Two key criteria were used to select the individuals who would be directed to the CMU - patients who typically have short lengths of stay (1-2 days) following admission and/or who tend to have frequent/return visits to the ED. Using these two criteria, the team identified four diagnoses that were appropriate for treatment in the CMU - asthma, chest pain, heart failure, and hyperglycemia.

See admittance guidelines.

Today's CMU has always been part of Grady Memorial Hospital's 12-year-old ED. Over the years the space has been used as storage, admissions, and as a designated room for asthma patients. One could argue that today's role as the facility's CMU is the best use of the space to date.

CMU patients receive a high-intensity level of care, including evaluation by a case manager who provides information about their disease and how to best manage it.

See case manager duties.

The team has also pioneered a 24-hour appointment access system that allows them to directly schedule follow-up appointments at five local clinics before patients even leave the CMU. And when they are ready to leave, transportation can be arranged for them, if necessary. They also receive home follow-up calls within the first 48-hours, as well as at the 30-, 60- and 90-days intervals, to monitor how well they are recovering.

See a chart of CMU patient disposition.

This level of attention and dedication to patients seems to have its rewards. CMU patients learn both how to better manage their disease and how to better access primary care to avoid becoming a repeat patient. In fact, of the 1,000 patients treated in the CMU since the project's initiation last summer, less than 30 have been repeat visitors.

Grady's Urgent Matters project director, Dr. Haley, attributes the success of the CMU largely to its nursing staff and case managers - four individuals who manage the unit - explaining that their dedication to this system has won the respect and trust of the faculty physicians who work in the CMU, as well as that of staff in other areas of the hospital.

"Our eventual goal is to be out of beds in the CMU nearly all of the time - seven days a week, 24 hours a day," explained Dr. Haley. "When we're regularly out of beds, we'll have successfully demonstrated how vital the unit is. If the beds are so in demand that we can't get people into the unit, we'll have proven the program's success and that we need more beds. We also hope that by constantly being full, we may not solve, but at least will significantly reduce the impact of admissions on the overcrowding' problem.

Click here to view a presentation from Dr. Varnada Karrieem-Norwood on the CMU.

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Leon L. Haley Jr., M.D., M.H.S.A.
Deputy Senior Vice President of Medical Affairs and Chief of Emergency Medicine
Grady Health System
Atlanta, GA