Thinking about this dynamic time around us in The Acute Care Continuum has made me reflect on my years as an attending emergency physician at a hospital in Southern California. It does not seem so long ago (though it has been 30 years) that I started my career and we had only 27,000 patients coming through our doors each year. This year that number will reach more than 90,000 with only a modest increase in the available ED space, which was designed 30 years ago for at most 50,000 visits per year.
About a decade ago the ED where I work implemented Rapid Medical Evaluation® (RME). This has significantly improved our time to provider (TTP) in the ED as well as our patient satisfaction. Our TTP went down from well over an hour to about 21 minutes, while patient satisfaction scores went up for both our high- and low-acuity patients. I remember skeptical nurses and some very pleasantly surprised patients, but ultimately the RME process became routine. We developed the concept of “vertical” and “horizontal” patients, streamlined throughput and created ED virtual space to see more patients.
And more patients came year over year over year. With every new surge in patients we redesigned the RME process, learning what worked and what didn't from other practice locations in our organization. Now we are poised to hit 100,000 patients per year in the near future.
Improving the ED operations often requires the improvement of processes throughout the hospital. We recently implemented a Capacity Alert Response system to address hospital-wide patient throughput. When the ED is packed and we are boarding admitted patients who are waiting for an inpatient bed, a multi-tiered alert goes out to all hospital departments. Working together, the department leaders move patients out of the ED, reducing overcrowding and ensuring patients are cared for in a timely manner.
I believe this is the year when we, as physicians, can no longer treat our patients in “specialty silos.” We cannot simply hand our patients off to the next specialist with little thought to collaborating with the other physicians responsible for the patient’s medical care and experience throughout their hospital stay. In my prior blog posting, I mentioned the collaboration of emergency physicians and hospitalists as crucial to the survival of the hospital in the future. In this coming era of bundled payments, healthcare providers will no longer be reimbursed on a fee for service basis, but rather on providing value as part of the healthcare team.
Recently I have seen a movement by hospitals to integrate the ED and Hospitalist physician practices. These two specialties now need to speak a common language and understand each other’s clinical practice, performance metrics, and operational issues. Hospitals are now asking physician groups to respond to requests to staff both the ED and the Hospitalist programs with revenue and hospital financial support shared between the two physician specialties. This strategy is a game changer and will no doubt lead to additional consolidation of hospital-based physician practices as bundled payments from payers begin.