Non-Emergent use of emergency department

Non-Emergent use of emergency department

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 nonemergent 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 nonemergent, 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 Medical Insurance Status 4 10 Medicaid/Medicare 68% Self-Pay 18% 18 Private Insurance through employer 10% Commercial (insured through a specific health care

provider) 4% 68 Type of Non-Emergent Medical Complaint 2.00% 3.00% 4.00% 6.00% Upper Respiratory Infection (cold/flu) 29% Acute Minor Musculoskeletal Injuries 25% Chronic29.00% Pain Management (Narcotic Rx refills) 12% 6.00% Skin Irritation (rash,insect bites) 7% Laceration 6%

6.00% Eye Irritation 6% Migraine 6% 7.00% Non-Pain Rx medication refill 4% Dental Pain 3% 12.00% Non-Injury producing foreign body swallowed 2% 25.00% 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: (563-421DOCS) 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 werent 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 EDs 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 Responsibility

High Risk Population 68% had government funded insurance 18% were self-pay 4% had commercial insurance Medical Insurance Status 4 10 Medicaid/Medicare 68% Self-Pay 18% Private Insurance through employer 10% Commercial (insured through a specific health care provider) 4% 18

68 Fiscal Responsibility Services and Supplies Eligible Populations by Family Income <100% FPL 101-150% FPL >150% FPL Institutional Care (inpatient hospital care, rehab 50% of cost for 1st day 50% of cost for 1st day 50% of cost for 1st

care, etc.) of care of care or 10% of cost day of care or 20% of cost Non-Institutional Care (physician visits, physical 10% of costs 20% of costs therapy, etc.) $3.90

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

$3.90 20% of cost Drugs 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 EDs 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 withthe 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 nonemergent 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

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