With Joanne Barnett, RN, MSN, and Curt Cabral, RN, JD
Nurses are a key part of the acute care team who play a crucial role in redesigning healthcare delivery. This week, Reform Realtime is pleased to welcome Joanne Barnett, Director of Adult Inpatient and Emergency Services at Pomerado Hospital in Poway, Calif., and Curt Cabral, Clinical Director of Emergency Services at Natividad Medical Center in Salinas, Calif., to talk about the changes taking places at their hospitals and the role nurses play in improvement efforts.
Reform Realtime: Joanne, Curt, welcome. To start us off, can you tell us what changes you've seen at your hospital since January?
Curt Cabral: The first thing that comes to mind is volume. We used to see about 130 patients a day on average, and now we’re consistently up to 140. I'm not sure that’s a direct effect of healthcare reform, because our volumes have been increasing steadily in the past few years. But based on my conversations with patients, I do think expanded access to insurance coverage is a factor.
It’s also my understanding that we’ve seen a favorable shift in our payer mix. Our hospital’s revenue is up about $1 million in the first six months of 2014, and they’re attributing that to the increase in covered patients.
Joanne Barnett: One thing we've experienced is a marked increase in the boarding of psychiatric patients. San Diego County has seen roughly a 40 percent increase in psychiatric ED visits over the past few years. Now I don’t believe that’s directly related to healthcare reform, but combined with all the other changes upon us, it’s impacted our department greatly.
On the upside, we just had a very successful Joint Commission survey and passed their new, more rigorous standards for ensuring the safety of the ED psychiatric patient and the boarding of those patients. And I think that really ties into the overall goals of reform — of holding ourselves accountable for our patients' safety and outcomes. And I think we will continue to see an increase in this patient population using the ED for services, which is a major cause of ED overcrowding.
Reform Realtime: What are patients saying about healthcare reform?
Joanne Barnett: I haven't heard a whole lot, but it does seem that a lot of newly insured patients are continuing to rely on the ED for their care. Some still have trouble getting an appointment with a primary care physician, and there are only a few clinics to whom we can refer our patients for follow-up. When the newly ensured are not getting timely follow-up, the ED still remains the default option for care. We have also seen an increase in patients with Medi-Cal coming to the ED for an admission.
In addition, we have seen an increase in the acuity of our patients, which isn’t accounted for in our census-driven budget, and we do expect the acuities to remain higher than in past years. This puts pressure on the ED to meet throughput metrics and also on ED staff, who now have to care for the higher-acuity patient.
Curt Cabral: I have met some newly insured patients coming in with chronic conditions who say they put off care until they could get insurance.
And though it's not department-related, I do know a young person who switched from her parent’s insurance to an exchange policy who now can’t find a primary care doctor who’ll accept her as a patient. Two of the doctors she contacted told her, "We'll have this insurance in place within three or four months." So it'll be interesting to see what happens.
Reform Realtime: What changes do you expect to see in your department over the next few years?
Joanne Barnett: I do expect a continued increase in ED census for a number of reasons. First, as our population ages with chronic medical conditions, we will continue to see an increase in ED visits for those requiring emergent medical care.
Second, not all EDs and hospitals can meet the demands of healthcare reform and declining reimbursements, and realistically some will close, which puts pressure on those left standing.
Now volume is still generally a good thing from a revenue point of view. But I think we’re starting to ask ourselves, Is it the right volume? Are patients coming to the most appropriate place? Our ED staffing isn’t increasing, and government reimbursements are shrinking, which is going to make it more and more challenging to deliver excellent care without increasing expenses.
Curt Cabral: We’re also expecting higher volumes at our site — both because of recent trends and changes in coverage. We’re also scheduled to become a designated trauma center in 2015, which should bring more and more acute patients our way.
I hear a lot of talk about care shifting to outpatient settings. On the surface, that makes sense. The Affordable Care Act is geared toward preventative care and cost savings, and hospitals are a pretty inefficient way to deliver that. But I also wonder if as more people gain coverage, they’ll present to the ED with chronic problems that should’ve been taken care of long ago. So I don’t think our inpatient census is going to drop for several more years. I think it’ll stay the same or go higher, actually.
Reform Realtime: What steps is your hospital taking to prepare for these changes?
Joanne Barnett: One thing we’re very focused on is throughput — not just as an ED, but across the entire hospital and system. One of our fiscal year initiatives is throughput with a goal to decrease staffed hours and patient LOS. We implemented a centralized bed placement system for the district to increase our efficiency to place patients in the right bed the first time. Our overall goal is to decrease late-day discharges so we don’t have to staff the units for those patients being discharged after 7 p.m. We also are working on turnaround times for transport to decrease patient wait times for admission or transport to ancillary departments. .
On the ED side, we’ve significantly cut our door-to-discharge time by improving our turnaround times with our ancillary partners in lab and radiology. We have changed our workflow on the discharge process for both the nurses and the providers as well as how we collect urine specimens to improve our metrics.
It is also imperative we minimize our "left without being seen" patients in order to capture every source of revenue. Currently we are at 1 percent for our "left without treatment" patients and hope to continue to capture those patients before they walk out the door.
Going forward, we’ll focus on new core measures that track turnaround time to admission. One of our first goals will be to decrease ICU length of stay in the ED, We know that the longer a critical patient stays there, the greater their morbidity and mortality. Waiting also creates additional stress on the patient and family. To speed up the process, we're working with the inpatient side to move patients out of the ICU as soon as it's appropriate. We’ve also done a lot of work around standardizing admissions orders to help physicians quickly get patients to the right bed in the right unit.
Curt Cabral: A big priority for us, which goes hand-in-hand with throughput, is to use our physical space wisely. We currently see about 50,000 patients annually in our 19-bed ED, so departmental "real estate" is extremely valuable. The hospital is planning a multi-million dollar renovation that will increase our beds to 30, but it won’t happen overnight. So we’ve also worked hard on our throughput process.
I co-chair the patient flow committee, and we’ve done a lot of internal fact gathering. We actually found that we were turning around our transfer patients — those who were transported to other facilities — faster than our admissions. Part of that is due to space limitations on the inpatient side. We really are quite a small hospital, so we don't always have beds available. Staffing was another issue: sometimes we didn’t have the nursing ratio in place to admit a patient. But some things we did have control over, like our admissions process and our collaboration with the accepting department. So those are the areas we're focusing on.
Reform Realtime: How does reform impact the nursing profession? Do you expect your job to change down the road?
Joanne Barnett: I think we’ll need to continue finding ways to work more efficiently. It’s going to be a difficult balance, because we expect new mandates and core measures — EDCAHPS, for example. I also think we’re going to need to be increasingly rigorous in using the EMR to document outcomes and metrics. So we need to balance all of this with bedside care and customer service, which is challenging.
Curt Cabral: Case management is another piece I expect to see nurses taking on. Our hospital has nurse case managers, but as the need for care coordination increases, I think some of that work will flow to the bedside. I wouldn’t be surprised to see floor nurses coordinating care and making follow-up appointments for patients.
Reform Realtime: Thanks so much to both of you for answering my questions. Any parting thoughts?
Curt Cabral: In the midst of all this change, it's good to step back and look at what we're doing well. For example, we've been working really hard on throughput. And at this point, our 19-bed ED at Natividad actually boards far fewer patients than my previous ED, which had 34 beds — even though we see more patients here. So I think that's something we can be proud of.
Joanne Barnett: For better or worse, I think change is the new norm. We can’t just be satisfied with the status quo anymore. We need to be innovative, creative and to some degree, able to forecast where policy is headed. As leaders, we need to be resilient and be the change agent in order to motivate and engage our staff on the journey. We can all be proud that we have embraced our current challenges while we deliver safe, quality, customer focused and timely care to our patients, It's exhausting at times, but it's also exciting to be a part of the change.
Joanne Barnett, RN, MSN, is currently the Director of Adult Inpatient and Emergency Service for Pomerado Hospital an acute care facility with Palomar Health. Her administrative responsibilities include strategic and operational performance for the emergency department, critical care unit, intermediate care unit, and medical-surgical and telemetry units. She has also served as the interim Chief Nursing Officer.
Curt Cabral, RN, JD, has served as ED Director at Natividad Medical Center for three years. He graduated Bakersfield College with an associate’s degree in nursing and completed his law degree at the Central California College of Law. He has worked in the ICU, OR, and ED settings over the last thirty years.