In 2012, the Centers for Medicare and Medicaid Services (CMS) rolled out its first emergency department (ED) core measure set. This was the start of a new era in which EDs played a key role in helping their organizations meet national quality goals. A high-performing ED was suddenly necessary in order to maintain accreditation, compete for patients and receive full annual update payments under CMS' Hospital Inpatient Quality Reporting (HIQR) program. New ED measures have been added to the program each year.
Effective Jan. 1, 2014, CMS added two new core measures to the program. Hospitals must now report:
- Median time from emergency department (ED) arrival to ED departure for admitted patients
- Admit decision time to ED departure for admitted patients
In many ways, these measures are an extension of throughput measures for discharged patients, which were added in 2013. However, to expedite admissions from the ED, patient flow must be efficient not only within the ED itself but across the entire hospital. Therefore, some hospitals will need to increase collaboration between ED providers, hospitalists and inpatient departments to improve their performance.
To help hospitals excel under the new measures, MedAmerica's practice management team recently reviewed several CEP America EDs that have already achieved significant success in improving turnaround time to admission (TAT-A). Their goal was to identify success factors and best practices.
The team found some interesting commonalities among these high-performing hospitals:
- Executive champions. At all of the hospitals studied, the impetus for improved TAT-A started at the executive level. Hospital administrators worked closely with the ED medical directors to design and implement new processes.
- Process focus. Specifically, successful hospitals emphasized processes that decreased ED length of stay (LOS).
- Collaboration. Leaders at these hospitals charged providers and nursing leadership to work together on solutions.
So how are successful hospitals tackling the problem? Here are a few case studies.
Advocate Sherman Hospital (Elgin, Ill.)
At Advocate Sherman, a throughput group led by the patient advocate director (who reports directly to the hospital president, ED medical director and director of nursing) identified processes to prevent ED holds. These included:
- Setting ED admit targets for each patient care unit
- Posting results on the hospital scorecard
- Discussions of throughput data at monthly leadership meetings
As the following chart shows, these process changes decreased TAT-A from an all-time high of over 160 minutes in late 2012 to around 70 minutes by late 2013. Gains were maintained even during times of high patient census.
The team at Advocate Sherman has continued its improvement work by adding a safety huddle and refining the patient handoff process. ED medical director Dr. Steven Zahn continues to champion the project and collaborates with the hospital administration to promote the team's success.
Northwest Community Hospital (Arlington Heights, Ill.)
At Northwest, improvements began as an initiative of the Chief Nursing Officer in collaboration with ED medical director Dr. Matthew Stilson. The CNO instituted a multidisciplinary process that consists of huddles, one to two times each day. Departments identify current surgical patients who will need inpatient beds and estimate the number of likely unplanned patients to be admitted from places like the ED and direct admits. Each unit then designates first, second and third admit beds and maintains these beds ready with an assigned nurse throughout the day. Assignment of a bed occurs within five minutes of an admission request by the case managers.
The hospital also staffs a direct admit unit. Patients coming from providers' offices are taken directly to that unit for initiation of orders. When the ED gets full, admitted patients can also be transferred to this unit while waiting for a bed.
Since the beginning of the hospital's contract with CEP America, the team at Northwest Community has decreased TAT-A from 314 to 233 minutes:
Memorial Hospital (Belleville, Ill.)
Memorial, which is located just outside of St. Louis, had a history of many holds and long waits in the ED. To address this problem, ED medical director Dr. Savoy Brummer and his team focused on increasing collaboration between the emergency and hospital medicine departments (which were initially managed by separate physician groups).
To expedite admissions from the ED, the teams added a new goal to the hospital scorecard: discharges for inpatient units were to be written by 11 am. The hospitalists have achieved a 90 percent success rate in meeting this goal.
The hospital also adjusted the workflow around admissions. Hospitalist physician assistants are stationed in the ED during peak admit hours with the sole responsibility of assessing the patient, writing orders and expediting the admission. During non-peak hours, the ED physicians write basic transition orders to expedite transfer out of the ED.
Collegiality between the emergency and hospital medicine departments was enhanced significantly when the hospitalists joined CEP America in April 2014. This made them partners under a single entity and aligned their performance incentives when it came to expediting patients through the system. In particular, the group found monthly joint meetings to be key to building relationships and arriving at joint decisions.
More than ever before, the new ED core measures targeting TAT-A require ED personnel to work closely with inpatient colleagues and stakeholders across the hospital. While this is a difficult goal, it's also certainly a worthwhile one that can relieve crowding and enhance patient satisfaction and outcomes.
Each of the above hospitals found its own way to expedite admission times by leveraging its unique strengths and building on existing processes and relationships. Executive leadership can foster success by championing a multidisciplinary approach that fosters collaboration across departments.