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NON-EMERGENT USE OF
EMERGENCY DEPARTMENT
Principal Investigator:Tina Bacorn, RN
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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
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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
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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 non-
emergent population of the ED
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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
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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 non-emergent, could be treated else where, non-emergently, with equal care
Exclusion criteria: Non-english speaking patients, pregnant
patients, and prisoners.
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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
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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
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68 %
18%
10%
4%
Medical Insurance Status
Medicaid/Medicare 68%
Self-Pay 18%
Private Insurance through employer 10%
Commercial (insured through a specific health care provider) 4%
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29%
25%12%
7%
6%
6%
6%
4%3% 2%
Type of Non-Emergent Medical Complaint
Upper Respiratory Infection (cold/flu) 29%
Acute Minor Musculoskeletal Injuries 25%
Chronic Pain Management (Narcotic Rx refills) 12%
Skin Irritation (rash,insect bites) 7%
Laceration 6%
Eye Irritation 6%
Migraine 6%
Non-Pain Rx medication refill 4%
Dental Pain 3%
Non-Injury producing foreign body swallowed 2%
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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.
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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
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Analysis
23% of patients reported not having a PCP Given Genesis “No Doc” phone number:
(563-421-DOCS) 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
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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 “weren’t 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
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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
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“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
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Systematic Reviews of Literature
The most tested intervention to reduce the non-emergent use of ED’s 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)
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Fiscal ResponsibilityHigh Risk Population
68% had government funded insurance 18% were self-pay 4% had commercial insurance
68 %
18%
10%
4%
Medical Insurance Status
Medicaid/Medicare 68%Self-Pay 18%Private Insurance through employer 10%Commercial (insured through a specific health care provider) 4%
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Fiscal ResponsibilityServices and Supplies Eligible Populations by Family Income
<100% FPL 101-150% FPL >150% FPL
Institutional Care (inpatient hospital care, rehab
care, etc.)
50% of cost for 1st day
of care
50% of cost for 1st day
of care or 10% of cost
50% of cost for 1st
day of care or 20% of
cost
Non-Institutional Care (physician visits, physical
therapy, etc.)
$3.90
10% of costs 20% of costs
Non-emergency use of the ER $3.90 $7.80 No limit
Drugs
Preferred drugs
Non-preferred drugs
$3.90
$3.90
$3.90
$3.90
$3.90
20% of cost
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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)
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Fiscal Responsibility
Alternative interventions are now being implemented in ED’s across America due to the financial loss associated with these unpaid bills:
ADVANCED TRIAGE
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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.
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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 with…the 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.)
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Research Study Extensions
Additional research for Exact amounts of money lost due to unpaid
bills of non-emergent 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
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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