Emergency and hospital medicine have traditionally operated in separate silos, with each group setting its own processes and priorities. But bringing these services under the same management can have a wealth of benefits, as our Midwestern hospital has discovered.
Building on Success
Memorial Hospital in Belleville, Ill., is a 316-bed acute care hospital serving St. Louis' eastern suburbs. Its busy emergency department (ED) handles 70,000 visits per year. The hospital is an accredited chest pain center, an American Nurses Credentialing Center MAGNET and is renowned for its pediatric care. Memorial is currently in the process of building a second hospital in nearby Shiloh, Ill.
In 2011 wait times at Memorial's ED were running above the national average, and about 8 percent of patients were leaving before seeing a provider. Recruiting issues were a major factor behind the bottleneck, as the team was relying on locums for about 60 percent of its staff. This instability inhibited providers' collaboration with nursing and ancillary services, which in turn had a negative effect on patient satisfaction.
To improve care quality and attract the best and brightest, the organization partnered with the acute care management group CEP America
. The group's reputation and democratic ownership model proved popular with residents at local training programs, and within a few months, the department was fully staffed with board-certified emergency physicians.
With strong physician leadership and implementation of RME, Team Care and a transformational EPIC committee, Memorial's turnaround time to discharge decreased from 200 minutes to 145 (and falling), and its time to provider dropped from 86 minutes to 11. Less than 1 percent of patients are now leaving without being seen.
A New Challenge
A few years later, the hospital's administration hoped to achieve similar gains with their hospital medicine program. At the time, Memorial directly employed its hospitalists. However, administrators believed that outsourcing the group's management would improve recruiting, decrease administrative burden and make the program's costs more predictable.
Administrators considered several physician management companies, but ultimately chose CEP America once again. They believed bringing both departments under the same leadership would promote integration and position the hospital to succeed under value-based reimbursement programs. (This integration of physician services was key to their strategic goals for the hospital.) They also believed CEP America's in-house billing services and experience with EMR implementation would improve operational efficiency across the hospital.
The transition from employees to physician owners was a major cultural change for the hospitalist providers. Fortunately, they already shared a good rapport with the ED team. Ultimately, all of the hospitalists chose to join CEP America. This 100 percent retention rate greatly smoothed the transition for everyone involved and created the momentum for innovation and change.
To meld the two teams, we medical directors attended one another's team meetings and scheduled quarterly joint meetings between our departments. Our two teams also began to share quality data and to learn more about the other's performance goals (e.g., turnaround for the ED, readmissions rates and morning discharges for the hospitalists).
In addition, we sought to bring our teams together through informal gatherings and social events. We regularly attend each other’s recruiting events in the city to help demonstrate to new physicians the commitment that we have to each other — and that we would expect from them as new partners.
The two departments soon began to align their goals and function more as one.
To help out their ED colleagues, the hospitalists agreed to take over the writing of admissions orders, which freed up an estimated 15 percent of the emergency physicians' work time. The hospitalists also allowed the emergency department to initiate their own bed requests (even if the patient hadn't yet been seen by a hospitalist). To help improve communication, the two groups began communicating directly by email and text message rather than waiting for the department secretaries to relay information. Finally, CEP America hospitalist nurse practitioners were assigned exclusively to the ED to facilitate the transitions of admitted patients. All of these improvements helped decrease turnaround time to admission.
The integration also provided the infrastructure the hospital needed to achieve Stage 2 of EMR Meaningful Use. Working together, the teams were able to generate and transmit almost 100 percent of their medication orders electronically. With the local primary care doctors still using paper records, the hospitalists and ED physicians were instrumental in helping the hospital achieve the necessary threshold.
Ultimately, the entire hospital benefited from having hospital and emergency medicine on the same team. Working side-by-side on hospital-wide committees, we providers combined our efforts and championed one another's causes. This led to innovations such as:
- Integrated code response team. When a code happens anywhere in the hospital, the emergency physician and hospitalist respond together. The emergency physician handles intubation and procedures while the hospitalist runs the code and manages all ancillary medical conditions.
- Palliative care program. This CEP America initiative provides an integrated care pathway for ED patients who might benefit from non-curative care and support.
- Telemetry bed report. The departments are currently working together to redesign the bed assignment system to keep telemetry beds free for patients in need of round-the-clock monitoring.
- Documentation enhancement. Both teams worked with case management to define appropriate admissions criteria and standards for its documentation.
- Critical care services. A designated hospitalist with critical care training was assigned to round on critical care patients not only in the ICU but also in the ED upon admission.
As administrators hoped, Memorial's ED-hospitalist integration has resulted in measurable improvements in inpatient care quality. Nearly 70 percent of inpatients are now discharged before 11 a.m. and 30-day readmissions have decreased by 18 percent. What's more, Memorial's case mix index (CMI) has grown by 37 percent, thanks to improvements in documentation and admissions criteria.
Perhaps the most telling indicator of our integrated performance is the trust shown by our colleagues in the medical staff. The local primary care providers have been so impressed with our integrated performance model that the hospitalists have gone from managing approximately 50 percent of the inpatient census to 90 percent.
Things have also improved from the patients' point of view. We providers make a point of reassuring patients that we trust our colleagues and communicate across departments. Patients and families see care coordination in action — and feel reassured that a team is working together on their behalf.
The integration has been such a success, that Memorial recently chose CEP America to staff the ED, hospitalist and intensivist programs at Memorial and its new facility. Administrators hope that this arrangement will benefit patients not only within the new building but across the entire system.