emergency department leadership and performance measures

ED Leadership EDPMA 2013

James Augustine, MD, FACEP

James J Augustine, MD

ED Leadership EDPMA 2013Course Name

I have no financial relationships with a

commercial entity producing healthcare-related products

and/or services.

James J Augustine, MDJames J Augustine, MD


The ED Volume Issue for ED Leaders. Even if You Don’t Build it They Will

Come!!!


The CDC Data: Americans Vote With Their Feet

140 Million ED

Visits


The CDC: NHAMCS 2007 Last Published


The Regulatory Issue. They Want Measures of Quality. If they don’t exist…

• CMS on ED Quality: Pneumonia Measures, …

• CMS on Admission Times• Current Definition

–Admit Decision to Departure Time–Time Interval beginning when “Admit Decision” is made until the actual departure time of the patient from the ED

This is a CMS Hospital Inpatient Quality Measure for public reporting in 2013


New Directions/Data Elements

• Shall we collect and share some CMS metrics?• The “Decision to Admit” debate

– CMS definition= admit order from the chart– More helpful might be “I know I want to admit

the patient”, documented on the chart• A new metric we can develop within EDBA?

• How about a new or at least consistent RN staffing metric?– RN work varies not by arrivals but by severity

and how many patients are in the department (LOS and admit percent proxy)

7


ED Performance Measures

–Early Problem: There are no consistent definitions in industry

–EDBA hosted Summit 2006

–Second summit in 2010 in SLC Published 2011 in Annals and AEM

–AHRQ funded program on improved ED intake systems


NHAMCS Update

Just Published for 2010Volume down from 2009 (H1N1 year)Acuity UpDemographic trends continue:

more elderly, more medical


EDBA Solutions

Utilize and assist the CDC NHAMCS survey Produce good data source for ED leaders Don’t put ACEP and ENA in untenable

positions Find places to disseminate and publish Call together groups and produce Definitions

(ED Performance Measures Summit in 2006) Counteract “Street Legends” Identify Best Practices


Financing the ED: MEPS Data• Medical Expenditure Panel Survey (MEPS), a publicly available

dataset available through the Agency for Healthcare Research and Quality (AHRQ). MEPS is an ongoing nationally representative survey which provides data on health care use and expenditures. MEPS is a large-scale survey of the U.S. non-institutionalized civilian population which uses a stratified, multistage probability sampling design

• http://meps.ahrq.gov/mepsweb/ • For Years 2005 to 2010• Medicaid Total Charges $2122.9 Total Payments $553.2• Uninsured Total Charges $2040 Total Payments $550• Private Total Charges $2178.2 Total Payments $991.1• Medicare Total Charges $2500 Total Payments $1000

http://meps.ahrq.gov/mepsweb/

http://meps.ahrq.gov/mepsweb/


Florida Data

• Published by FL Agency for Health Care Administration• Average charges per hospital ER visit (2008 prices)

– $2996 for adult– $1324 for child

• Non-emergent ER visits• $2907 adult • $1278 pediatric

• Based on common symptoms – $5135 for abdominal pain visit– $2655 average cost for hypertension– $1878 for asthma– $2000 - $3000 for headache including migraine


• About half of all Florida ER visits were deemed avoidable• An interactive model is available• Count 7.1 m visits to June 2012• $3562 average charge for facility, physician, and ancillary

services• Results in $25.6 B in charges• If that is same across country:• 140m visits results in $498,689,000,000 charges• A 30% collection rate equals $149.604 Billion

Florida Data


An Early Observation: ED Process Depends on ED Volume

The 1990Challeng

e

The 2010Challeng

e


The EDBA Annual Data Survey2011 Results for 830 EDs

seeing 29.6m ptsHi CPT Acuity

Under age 18 Admit % Transfer

%EMS

Arrival

EMS Arrival Admit

Median LOS

MLOS Treat & Release

MLOS Admit LBTC Door

to Doc

EKG per 100

Over 100K EDs2011 results 66% 20.2% 21.8% 0.9% 23% 42% 214 182 356 2.3% 31 30

80 to 100K EDs2011 results 71% 18.4% 20.9% 1.1% 21% 44% 218 187 362 3.4% 38 25

60 to 80K EDs2011 results 66% 18.2% 20.8% 1.2% 19% 44% 205 174 337 2.8% 35 31

40 to 60K EDs2011 results 65% 19.5% 19.1% 1.4% 18% 43% 186 156 303 2.3% 33 28

20 to 40K EDs2011 results 63% 20.2% 17.1% 1.8% 16% 41% 160 134 261 1.7% 28 26

Under 20K EDs2011 results 55% 23.7% 12.7% 2.7% 12% 39% 139 115 227 1.4% 23 20

Pediatric EDs2011 Results 48% 99.0% 11.4% 0.6% 8% 33% 147 132 270 1.4% 31 4

Adult, Specialty EDs2011 Results 71% 2.7% 25.5% 1.1% 23% 48% 240 204 346 3.2% 40 34

Urgent Care, Freestanding EDs2011 Results 41% 23.6% 4.2% 3.4% 7% 31% 100 97 240 1.0% 22 12

ED Leadership EDPMA 201304/22/23 16

Percentage admitted

ED Leadership EDPMA 201304/22/23 17

% Leaving Before Treatment is Complete (LBTC)


Walk-ins to ED

371 / 1000 Population

80/1000

Population

Transfer

2%

Admit

17%

Treat & Release

81%

Emergency Department

Total use 451 / 1000 Population

82% Walk-Ins

18% Arrival by EMS

General Population

EMS

Patient Flow is Predictable

LBTC

2%


Trending and Planning: NHAMCS Helps Predict Future Patient Flows

3% more patients per year for about the last 18 years

Injury is 34% of ED Patient LoadHighest injury rates are over age 75

Extended Care Facility Patients are the Most Frequent ED User3 m visits in 201045% admission rate


Predicting Volume Ahead


Not Only More ED Visits in the Senior Age Brackets

More Population Enters those Age Groups Each Year


The Patient Mix. Very Important and Unrecognized Issue

The Burn, Trauma, Injury and Cardiac Arrest Issue

What should we have known?

Prevention WorksWhen prevention

works, more people are alive to get ill

Trauma population ages


Changing ED Patient Mix


The ED Payer Mix not Changing Much, except Medicare

Payor Class % of Visits

Self Pay 15%

Medicare 18%

Medicaid 31%

Worker’s Comp. 1.2%

Commercial 37%


ED UtilizationUse Per 1000 Persons

•Nursing Home Residents (over 1000)•Homeless (around 1000)•Infants under age 1 (931)•Medicaid•Medicare •Insured•Self Pay


Adult & Pediatric EDs Serve Different Needs


ED Visits 1992 to 2010Diagnostics


ED Visits 1992 to 2010Therapeutics


ED Visits 1992 to 2010Critical Care


ED Visits 1992 to 2010Mental Health


The EDBA Data SurveySuper Centers Over 100K Over 275 PPD

Very Large Over 80,000 Over 220 PPD

Large 60 – 80K 165 – 220

Medium 40 – 60K 110 – 165

Small 20 – 40K 55- 110

Micro Under 20K Under 55

Pediatric and Freestanding EDs

Any Volume Any PPD


EDBA Survey 20121000+ EDs serving over 33 million

patientsVolume was up 4-6% versus 2011Patient acuity higher, and more

patients admittedContinued increase in EKG utilizationXray use is down, plateau in use of CTMRI now running about 1%


EDBA Survey 2012EDs are improving throughput,

walkaway rates have decreasedAbout 18% arriving by ambulance and

are admitted at an increasing ratePayor mix stable, except more MCRBed Utilization around 1600 visits per

patient care spaceCPOE about 75%New Team Triage systems over 25%


The EDBA Annual Data Survey2011 Results for 830 EDs

seeing 29.6m ptsHi CPT Acuity

Under age 18 Admit % Transfer

%EMS

Arrival

EMS Arrival Admit

Median LOS

MLOS Treat & Release

MLOS Admit LBTC Door

to Doc

EKG per 100

Over 100K EDs2011 results 66% 20.2% 21.8% 0.9% 23% 42% 214 182 356 2.3% 31 30

80 to 100K EDs2011 results 71% 18.4% 20.9% 1.1% 21% 44% 218 187 362 3.4% 38 25

60 to 80K EDs2011 results 66% 18.2% 20.8% 1.2% 19% 44% 205 174 337 2.8% 35 31

40 to 60K EDs2011 results 65% 19.5% 19.1% 1.4% 18% 43% 186 156 303 2.3% 33 28

20 to 40K EDs2011 results 63% 20.2% 17.1% 1.8% 16% 41% 160 134 261 1.7% 28 26

Under 20K EDs2011 results 55% 23.7% 12.7% 2.7% 12% 39% 139 115 227 1.4% 23 20

Pediatric EDs2011 Results 48% 99.0% 11.4% 0.6% 8% 33% 147 132 270 1.4% 31 4

Adult, Specialty EDs2011 Results 71% 2.7% 25.5% 1.1% 23% 48% 240 204 346 3.2% 40 34

Urgent Care, Freestanding EDs2011 Results 41% 23.6% 4.2% 3.4% 7% 31% 100 97 240 1.0% 22 12

Super Centers


Location and Type

Urban Suburban Rural Academic TraumaOver 100K 56% 44% 0 78% 94%80 to 100K 72% 24% 4% 68% 85%60 to 80K 48% 49% 3% 42% 66%40 to 60K 50% 39% 11% 30% 42%20 to 40K 42% 29% 29% 19% 25%Under 20K 24% 27% 49% 5% 3%Adult ED 95% 5% 0 67% 61%Peds ED 83% 17% 0 67% 63%


Functional Areas in the ED

Fast Track Trauma Area

CDU/Obs CPOE

Over 100K 88% 88% 50% 87%80 to 100K 90% 80% 24% 80%60 to 80K 60% 59% 35% 83%40 to 60K 61% 24% 19% 65%20 to 40K 48% 18% 7% 70%Under 20K 2% 0 2% 75%Adult ED 75% 69% 8% 80%Peds ED 70% 50% 8% 90%

All EDs 58% 33% 18% 75%


Documentation

Computerized

Dictated

Templates

HandWritten

Scribes

Over 100K 50% 21% 28% 21% 21%80 to 100K 75% 10% 15% 10% 25%60 to 80K 60% 45% 24% 17% 19%40 to 60K 61% 27% 21% 17% 17%20 to 40K 67% 24% 14% 11% 15%Under 20K 70% 17% 22% 10% 10%Adult ED 63% 23% 25% 12% 25%Peds ED 54% 8% 4% 8% 4%

All EDs 67% 23% 20% 12% 16%


Greeting Process

Nursing Physician MLPOver 100K 100% 17% 6%80 to 100K 100% 40% 5%60 to 80K 100% 19% 17%40 to 60K 100% 31% 10%20 to 40K 100% 6% 5%Under 20K 92% 0 2%Adult ED 100% 21% 12%Peds ED 100% 3% 0%

All EDs 98% 18% 8%


Scheduled Hours NOT worked hours

RN Techs and

Clerks

Physician Physician and MLP

Over 100K 0.7 1.1 2.65 2.280 to 100K 0.7 1.3 2.87 2.360 to 80K 0.7 1.5 2.65 2.340 to 60K 0.6 1.4 2.89 2.720 to 40K 0.7 1.9 2.63 2.1Under 20K 0.6 1.5 1.7 1.5Adult ED 0.6 1.4 2.52 2.0Peds ED 0.6 1.5 2.12 1.9All EDs 0.7 1.5 2.5 2.2


High Acuity ED Visits


Length of Stay and Walkaway


Length of Stay and LBTC


Admit Times (CMS Measure)


EMS Impact: 26M Transports

42% admittedMost Common Presentations:

Chest pain and heart disease

Short of breath

Contusions/blunt injury

Sprains of neck and back (MVA)

Syncope and seizures


Correlation of EMS Arrival and Admission


Important Trends even over only 8 years of Data


EKG Utilization Increases from 2004 to 2011


Admissions Through ED


ED Geography: Space and Bed Utilization

Size of Facility Square Footage Per Bed

Super Center 3.9 1422

Very Large 3.2 1606

Large 2.8 1561

Medium 3.3 1621

Small 3.2 1641

Micro 2.6 1391

Pediatric EDs 3.7 1792

Adult EDs 3.3 1389


Making the Data Valuable: A Day in our ED

130 Patients to be seen, although 3 want to leave

40 Will be in Fast Track

56 Will need Monitors

23 Will be Admitted 26% Of Patients in Main ED

6 Will have Dental Problem

991 Orders will be Entered in CPOE, or 7.6 per patient, and 21% of all orders Entered in the Hospital Today

25 Will Arrive by EMS


ED Metrics and ED FuturePlan Forward with Hard NumbersKnow, Understand, and Share your

Numbers, Compare to CohortsMake Sure all Staff Know NumbersUse Data to Drive FutureTell Your Story Effectively in

Developing Designs, Process, Staff

emergency department leadership and performance measures

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