Innovating Emergency MedicineHow to Add Services and Capacity in Your Current Footprint

Expanding Access to Quality Acute CareEmergency departments (EDs) play a crucial role in our healthcare system. They provide an important safety net to our communities by caring for patients across a wide variety of conditions, as well as serving as the “front doors” of hospitals by originating over half of all inpatient admissions.1 More fundamentally, they are the place many Americans visit on the worst day of their lives – unwell, in pain, or both.

Yet EDs are under severe pressure themselves.

In recent decades, ED visits have increased dramatically, with more patients presenting to EDs with serious conditions. At the same time, the overall number of EDs is declining. In the face of these challenges, hospitals must explore new ways to deliver emergency care for every individual who comes through the door.

Expensive renovations, hiring hard-to-find specialists, and adding inpatient beds are not necessary to increase ED capacity and deliver a higher level of service. Instead, hospitals should look to innovative alternatives that transform the way care is delivered.

These three solutions are what the most innovative EDs are using to positively change the way care is delivered:

1. Expand service offerings by making specialists available in the ED via telehealth platforms.

2. Integrate emergency and hospital medicine teams to increase throughput efficiency.

3. Direct patients to urgent or teleurgent care services for less severe emergencies.

This paper explains each in more detail, along with case studies that showcase them in action.

Population aging is another factor putting pressure on EDs. By 2030, almost one in four Americans will be over age 65. While there is no direct correlation between aging and increased frequency in ED visits, when older patients visit the ED they tend to have more serious conditions and require longer stays.

In addition to increasing department capacity, recruitment and retention of specialists to support top-quality programs, such as stroke accreditation, are expensive. While the supply of neurologists is expected to increase by 10 percent between 2013 and 2025, demand is expected to increase by 16 percent.8 In addition, a large majority of new neurologists go into outpatient rather than hospital-based practice.

Psychiatry is another example of a high-demand specialty that is unavailable to many EDs. In a recent ACEP survey, fewer than 17 percent of emergency physicians reported having access to an on-call psychiatrist to assist with mental health and substance-abuse emergencies.9

Rethinking the traditional paradigm of emergency services delivery has allowed many hospitals to achieve the goal of efficient, high-quality emergency care that satisfies patients and their families – without the need for facility expansion or recruiting specialists. High-performing hospitals that are deploying modern approaches to care delivery are proving they can deliver care and control costs.

EDs Are Essential Healthcare Safety Nets In an age of high healthcare costs and limited access to services, an increasing number of patients are relying on EDs for their medical needs.

A 2017 study found that ED visits far outnumber both outpatient and inpatient visits.2

The bottom line is that EDs need to deliver fast, reliable, and comprehensive care to their communities. But increased patient volume has not been supported by an increase in ED capacity. In fact, 21 percent of all rural hospitals in the U.S. are at risk of closing unless their financial situations improve, according to new analysis from management consulting firm Navigant.3

Increased ED utilization is driven by a number of factors, including a national shortage of primary care physicians, poor access to primary care in many communities, and a limited number of primary care appointments outside work hours.4 While ED visits are up across the board, mental health and substance abuse visits have contributed significantly to higher volumes.

The number of patients presenting to EDs with psychiatric complaints increased by more than 50 percent in recent years — faster than the rate for all visits.5

A 2013 Health Affairs study predicted that U.S. EDs will need to expand their capacity by 10 percent in order to meet the needs of the 2050 elderly population.7

50%

From prescription refills to stroke intervention, today’s EDs deliver nearly

half of all healthcare services.1

Recent findings have shown that telehealth programs save hospitals and health systems an estimated $1,000 to $1,500 per patient.10

Stroke care is an excellent illustration of the challenges facing emergency providers. Despite the rising demand for stroke care services, relatively few doctors are choosing neurology as a specialty.

In addition, a large majority of new neurologists go into outpatient rather than hospital-based practice.

New stroke treatments have the potential to prevent or greatly reduce death and long-term disability. One example is tissue plasminogen activator (tPA), which helps to dissolve clots and restore blood flow to the brain. For best results, patients should receive tPA within three hours of stroke symptom onset (though this window can be extended in some cases).12

Though tPA is widely available, many eligible patients don’t receive it in time because of misdiagnosis or care delays in the ED. This problem is greatly exacerbated by a national shortage of hospital-based neurologists. Many smaller EDs rely on on-call, community-based neurologists to cover stroke cases. However, off-site neurologists may not be able to respond fast enough to take advantage of tPA and other life-saving treatments.

While the supply of neurologists is expected to increase by 10 percent between 2013 and 2025, demand is expected to increase by 16 percent.11

10%Supply Demand

16%

Stroke Care with a Teleneurology Program

To effectively care for an increasingly acute and complex patient population, emergency providers rely on specialist consults. However, due to acute provider shortages in certain specialties, consults may be delayed many hours or completely unavailable. The problem is most prevalent for EDs at rural community hospitals, which paradoxically tend to serve older patient populations that demand expert management.

An effective telehealth program can help to boost quality by connecting ED patients to the right care from the right provider at the right time.

Innovative Approach #1: Deliver Specialty Care via Telehealth

Telemedicine is the most up-and-coming piece of technology that’s going to help expand healthcare everywhere. Marrying neurohospitalist and telemedicine work is one of the best ways to provide services to underserved populations.

The Memorial Medical Center ED in Modesto, CA is one of the busiest in the region, serving over 77,000 patients annually. The hospital had achieved stroke center accreditation in 2017 and was working toward Comprehensive Stroke Center certification. But when Memorial’s community-based neurology partner stopped providing services in early 2018, the ED suddenly could no longer admit stroke patients.

With its stroke program in jeopardy, the hospital turned to its ED partner, Vituity, which offers comprehensive acute neurology solutions. Vituity moved quickly to establish teleneurology support to Memorial’s ED, neurohospitalist, and neurodiagnostic services. As a result, the hospital quickly resumed admitting and caring for stroke patients, restoring a valuable service to the Modesto community.

Over a year later, Memorial Medical Center is back on track to achieve Comprehensive Stroke Center status, largely due to its implementation of teleneurology services. Vituity continues working with the hospital to recruit in-person neurologists to supplement the teleneurology team and make the program more robust and sustainable than ever.

Expanding Community Access to Neurology Care at Memorial Medical Center

Case Study

Arbi Ohanian, MD Vice President of Acute Neurology Vituity

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On-Demand Telepsychiatry Program for Behavioral Health Emergencies

Psychiatric emergencies are among the most difficult for emergency physicians to effectively treat and disposition. Most ED providers receive relatively little training in managing mental health and substance abuse-related disorders. However, as noted earlier, these patients are increasingly relying on EDs for their care.

Patients admitted to psychiatric facilities typically wait in the ED three times longer for a bed than medical patients (an average of 12 hours overall).15

Teleneurology and telestroke programs provide EDs with 24-7 access to consults with board-certified neurologists. With help from telehealth “robots,” neurologists can use video conferencing to interview and examine patients, review diagnostic testing, and quickly determine eligibility for thrombolytic therapy (tPA) and neurointerventional procedures.

ED teleneurology programs allow community hospitals to offer a broader range of services and capture patients who would otherwise be diverted to tertiary medical centers. In fact, teleneurology support can often help hospitals to achieve Joint Commission stroke center certification.

3x

A great majority of psychiatric patients don’t need to be hospitalized, if we do the right interventions, start medications, and have the proper personnel treating them. At the same time, on-demand emergency telepsychiatry is available for more serious cases. These medical professionals can provide consultations on treatments and medications. This is being done with amazing outcomes. 17

To embrace this new paradigm of early intervention, the most innovative EDs are partnering with telepsychiatry services to access 24-7 consults. On-demand telepsychiatry has been proven to reduce psychiatric hospitalization rates and is associated with good outcomes and high patient satisfaction.16

Telepsychiatry can also be used to provide psychiatrist coverage for hospital-wide or regional crisis stabilization units (called EmPath Units at Vituity). These units provide short-term psychiatric care for medically stable patients in a therapeutic setting outside the ED. More than 70 percent of EmPath patients are safely discharged to a lower level of care within 24 hours.

Scott Zeller, MD Vice President of Acute Psychiatry Vituity

As a safety net facility, St. Rose Hospital in Hayward, CA receives many patients on involuntary psychiatric holds. An involuntary hold usually means that a police officer or mental health worker has judged the person to be potentially harmful to self or to others. The hold, which lasts 72 hours in California, should ensure that the patient gets the help they need. But in the past, it didn’t always work out that way.

A few years ago, patients on involuntary holds were waiting many hours in the St. Rose ED for transfer to inpatient psychiatric facilities. Emergency physicians had no authority to place or lift a psychiatric hold, even when they believed that doing so was in the patient’s best interest.

To address the issue, Vituity and St. Rose partnered to pilot an on-demand telepsychiatry consultation service. Now when a patient presents to the ED with psychiatric complaints, the emergency physician can request a telehealth video consultation with a board-certified Vituity psychiatrist. With this robust support in place, Alameda County’s Board of Supervisors certified the St. Rose ED as the first medical facility in county history to execute and lift involuntary psychiatric holds.

The St. Rose telepsychiatry program has created a number of benefits for the patient, hospital, and community:

• Decreased ED length of stay and much shorter evaluation times for patients

• Less strain on police resources • Earlier diagnosis and therapy • Less strain on the county psychiatric facility

Increasing Access to Behavioral Healthcare at St. Rose HospitalCase Study

Many ED providers assume that most people in psychiatric crisis need inpatient care. As a result, patients presenting to the ED with a psychiatric condition are 2.5 times more likely to be admitted than patients with purely physical complaints.14

Wait times numbering in days or even weeks are not unusual. Beyond causing patient suffering, this also contributes to overall capacity challenges for departments as a whole, as scarce beds are unavailable for patients with medical emergencies.

However, recent evidence suggests that early assessment and treatment can greatly improve outcomes for this population. In fact, with prompt intervention, the majority of psychiatric emergencies resolve within 24 hours, allowing patients to be discharged to the community or a lower level of care.

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Innovative Approach #2: Integrate Across Emergency and Hospital Medicine TeamsWhile the focus may be on increasing ED capacity, a major factor affecting throughput is the efficiency and integration with the inpatient experience. Implementing a team-oriented process demands that all clinicians and team members from both departments accelerate transitions. The increased efficiency ultimately moves more patients through the ED, which frees up beds and enables staff to see more patients.

Hospitals with crowded, inefficient EDs tend to perform worse on quality measures. Studies consistently show a negative correlation between ED wait times and patient experience. What’s more, this negative perception persists as the patient moves through the care continuum. As a result, patients admitted from a crowded ED to the hospital tend to be less satisfied with their inpatient care and overall hospital experience.18

In an era of shrinking operating margins, ED crowding can threaten a hospital’s financial viability. This revenue drain begins as early as the waiting room.

Each patient who tires of waiting and leaves the ED without care represents an

average loss of 19

$1,000

EDs need to become better integrated to ensure that training and processes are appropriate for all patients. Oftentimes, processes for treating behavioral health or neurology conditions are not clinically integrated across the department, causing widespread suffering, which undermines the economics of our EDs and leads to less optimal patient outcomes.

Denise Brown, MDChief Strategy OfficerVituity

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A team-oriented process involves all clinicians in the development of a treatment plan, creating smooth and accelerated transitions. Programs focused on ED-hospitalist integration ensure that patients are dispositioned in an efficient manner and lead to an enhanced throughput process that significantly improves the overall quality of care.

Lowering average length of stay (ALOS) to 2.9 days

Care integration created efficiencies that enhanced throughput and capacity by:

Decreasing turnaround time to discharge (TAT-D) by 22 percent

Reducing transfers out of the health system

Consisting of three rural hospitals in California spanning about 60 miles, the Adventist Medical Centers in Selma, Reedley, and Hanford, CA operated in relative isolation for many years. That gradually changed as the area's population began to tick upward.

The network reached the point where their ten-bed standby ED at Reedley was seeing nearly 30,000 visits a year. To provide great care, they needed the resources of the entire system, and a cultural and operational shift was required.

At that time, admissions were handled by a patchwork of hospitalists and community physicians, with little consistency or accountability. It was sometimes easier to transfer patients out of the system than to get them admitted to one of the other network sites.

To address the issue, administrators turned to Vituity to lead the integration. By staffing all of the departments with highly motivated providers invested in Vituity’s Partnership model, the team was empowered to collaborate and elevate their performance and thus raise the quality of all the facilities.

To begin this integration, Medical Directors from all sites began meeting monthly to discuss ways to improve communication, boost consistency, and ease care transitions. The focus of these discussions was integration between care teams, follow-up care protocols, and determining how to best move patients to the appropriate facilities for optimal treatment. Additionally, the hospital administration participated on a quarterly basis to identify ongoing issues and opportunities and collaborate with their Vituity Partners on potential solutions.

Within a few months, all sites noted significant improvements across many areas: The turnaround time to discharge in the ED dropped 22 percent, effectively increasing the capacity of the department. The average length of stay for an inpatient admission decreased as well, also increasing the hospital’s capacity to care for admitted patients. The net result of this progress was a reduction of patient transfers out of the health system, ensuring patients could continue to receive care close to home – and saving the hospital millions in lost revenue.

Creating a Culture of Integration at Adventist Health Central Valley Network

Case Study

Managing ED Volume Through Patient Education at Kaweah Delta Urgent Care Clinic

Case Study

Kaweah Delta Health Care District in Visalia, CA has experienced a surge of patients to its ED in recent years. Vituity’s providers noticed that many patients were using the ED for sub-acute care because the hospital is located in a medically underserved region of California’s Central Valley. Recognizing the burden this places on the ED, Kaweah Delta’s administration turned to Vituity to manage the Kaweah Delta Urgent Care Center (UCC) in California’s Central Valley. Vituity providers at both the ED and UCC focus on encouraging patients with less severe injuries or illnesses to seek treatment in the UCC rather than the ED, which relieves the hospital of a major financial burden. The combined efforts have proven incredibly successful. After Vituity assumed the UCC contract, ED volume grew by 10 percent, to 85,000 in two years, while the UCC also saw its volume increase by 43 percent, to 48,000 in just one year.

Since then, Kaweah Delta and Vituity have partnered to create a network of urgent and “Prompt Care” centers that have both slowed the ED volume growth and also increased the overall number of patients cared for by Kaweah Delta.

Innovative Approach #3: Direct Patients to Urgent or Teleurgent Care ServicesAn estimated 13 to 27 percent of ED visits could be safely managed by primary or urgent care.20 Patients report lack of access to care as a major reason for these types of visits to the ED. Another cause is patients’ inability to self-triage.

Urgent care centers provide a lower acuity alternative to the ED. Convenient locations with flexible, walk-in hours make them attractive to patients, and shorter wait times and online check-in options improve the patient experience. In fact, shorter patient lengths of stay directly correlate to higher net promoter scores. In addition to improving access and patient satisfaction ratings, urgent care centers benefit health systems by extending a hospital’s outreach and branding into the community and by referring the right patients to hospital facilities.

Similarly, teleurgent care programs provide fast, expert care for acute illnesses and injuries via video visit. In about 80 percent of cases, virtual visits with an emergency physician can resolve the patient’s complaint, preventing a more costly ED visit.21 In addition, telehealth can serve as a low-cost option for triaging patients, helping them to understand when care is needed and where to go.

Leading health systems have invested in outreach to drive patients to urgent care or teleurgent care options and effectively freed up their EDs for true emergencies, while also providing a highly valued service to their patients and the communities they serve. These customer-centric programs help hold down costs for all stakeholders (including patients) and are a significant patient satisfier because they deliver faster, convenient access to quality care.

Together these solutions extend a health system’s ability to care for patients in need, while enabling the ED to continue to focus care on higher acuity cases.

In SummaryToday's EDs are struggling to care for an increasing number of patients. An aging population, physician shortages, and the opioid crisis are just a few of the drivers for increased ED utilization. At the same time, many ED providers have limited access to key specialists like psychiatrists and neurologists.

Traditional solutions to these challenges would require significant capital investments and the ability to lure expensive specialists to community hospitals. Instead, hospital administrators should look to innovative approaches that meet the unique needs of their community – without breaking the bank.

An integrated approach to care collaboration between emergency and hospital medicine teams can bridge the gap. Adding in services such as telehealth, urgent care, and teleurgent care also allow patients everywhere to access expert, timely, and high-quality emergency care.

These approaches result in increased market share for hospitals, greater provider satisfaction, and provide patients with a better experience while simultaneously relieving overcrowding in our EDs.

Integrated Immediate Care Centers Increase Advocate Sherman Hospital’s Market Share Case Study

The Advocate Sherman Immediate Care Centers, located around the area of Elgin, Ill. provide care for nonserious illnesses and injuries and extend the reach of Advocate Sherman Hospital into the community.

Vituity providers maximized the efficiency of these centers so that the patients receive both urgent care and seamless access to the Advocate Sherman system for more complex treatments. By extending the hospital’s patient catchment area, Vituity has both fostered an environment that makes it easier for patients to receive care and also increased the hospital’s market share by 38 percent over three years.

1 Gonzalez, Morganti, Kristy, Sebastian, et al. The Evolving Role of Emergency Departments in the United States. Santa Monica, Calif: RAND Corporation. 2013. https://www.rand.org/pubs/research_reports/RR280.html.

2 Carr, Brendan, Liferidge, Alisha, Baehr, Nicole, Browne, Brian. Trends in the Contribution of Emergency Departments to the Provision of Health Care in the USA. International Journal of Health Services. 2017. 002073141773449 DOI: 10.1177/0020731417734498.

3 Lineaweaver, Nicky. US Rural Hospitals Are Facing a Financial Crisis. February 20, 2019.

4 Pratt, E. Why Do So Many People Still Go to the Emergency Room? Healthline. Published Nov. 7, 2017. https://www.healthline.com/health-news/medical-care-in-emergency-rooms#1.

5 Emergency Department Length-Of-Stay For Psychiatric Visits Was Significantly Longer Than For Nonpsychiatric Visits, 2002–11. Health Affairs. Published Sept. 2016. https://doi.org/10.1377/hlthaff.2016.0344.

6 Weiss, A.J., M.L. Barrett, K.C. Heslin, and C. Stocks. Trends in Emergency Department Visits Involving Mental and Substance Use Disorders, 2006–2013. Agency for Healthcare Research and Quality. Published December 2016. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb216-Mental-Substance-Use-Disorder-ED-Visit-Trends.pdf.

7 Pallin, DJ., Allen, MB., Espinola, JA., Camargo, CA., and Bohan, JS. Population Aging And Emergency Departments: Visits Will Not Increase, Lengths-Of-Stay And Hospitalizations Will. Health Affairs. 32(7). July 2013. https://doi.org/10.1377/hlthaff.2012.0951.

8 Health Workforce Projections: Neurology Physicians and Physician Assistants. National Center for Health Workforce Analysis. Published March 2017. https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/research/projections/BHW_FACTSHEET_Neurology.pdf.

9 American College of Emergency Physicians Physician Poll on Psychiatric Emergencies. ACEP. October 2016. http://newsroom.acep.org/download/PsychEmergencyPollOct2016.pdf.

10 Broderick, A and Lindeman, D. Scaling Telehealth Programs: Lessons From Early Adopters. The Commonwealth Fund. Published January 2013. https://www.commonwealthfund.org/publications/case-study/2013/jan/scaling-telehealth-programs-lessons-early-adopters.

11 Health Workforce Projections: Neurology Physicians and Physician Assistants. National Center for Health Workforce Analysis. Published March 2017. https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/research/projections/BHW_FACTSHEET_Neurology.pdf.

12 Why Getting Quick Stroke Treatment Is Important. American Stroke Association. Last reviewed Dec. 19, 2018. https://www.strokeassociation.org/en/about-stroke/treatment/why-getting-quick-stroke-treatment-is-important.

13 Ohanian, Arbi MD. Addressing Stroke Treatment’s State of Emergency. May 2018.

14 Owens, Pamela L. Ph.D., Mutter, Ryan Ph.D., and Stocks, Carol R.N. Mental Health and Substance Abuse-Related Emergency Department Visits among Adults, 2007. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb92.pdf.

15 Analysis of Emergency Department Length of Stay for Mental Health Patients at Ten Massachusetts Emergency Departments. Annals of Emergency Medicine: An International Journal. Published August 2017. http://dx.doi.org/10.1016/j.annemergmed.2016.10.005.

16 Deslich, S., Stec, B., Tomblin, S., et al. Telepsychiatry in the 21st century: Transforming Healthcare with Technology. Perspect Health Inf Manag. 2013.10 (Summer):1f.

17 Zeller, Scott MD. HealthLeaders, Transforming Behavioral Healthcare in the Emergency Department. July 25, 2018.

18 Pines, J. M., Iyer, S., Disbot, M., Hollander, J. E., Shofer, F. S. and Datner, E. M. (2008). The Effect of Emergency Department Crowding on Patient Satisfaction for Admitted Patients. Academic Emergency Medicine, 15: 825-831. doi:10.1111/j.1553-2712.2008.00200.x.

19 McConnell, KJ, et al. Ambulance Diversion and Lost Hospital Revenues. Annals of Emergency Medicine. Volume 48 , Issue 6 , 702 – 710.

20 Weinick, RM., Burns, RM., Mehrotra, A. Many Emergency Department Visits Could Be Managed at Urgent Care Centers and Retail Clinics. Health Aff (Millwood). 2010.29(9):1630–1636. doi:10.1377/hlthaff.2009.0748.

21 Jefferson Health Goes “All-In” on Telehealth. American Hospital Association Health Forum. Published May 11, 2018. http://www.healthforum.com/connect/resources/pdf-files/teladoc-2018-0511-cs-jefferson.pdf.

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Meeting the emergency care needs of local communities is challenging. Maximizing quality of patient care, outcomes, and hospital profitability is no short order, and requires a collaborative approach that brings together the right ideas, providers, and systems.

Vituity has a distinguished record of designing and implementing solutions to these challenges, integrating care throughout a patient’s journey and empowering providers to treat patients in the best way possible. It’s through this integration of care that Vituity has been able to deliver outstanding outcomes at hospitals across the country.

As a physician-led and -owned, multispecialty partnership, Vituity has proactively driven positive change in the business and practice of healthcare for nearly 50 years. Our more than 3,500 doctors and clinicians provide a wide range of integrated acute care expertise. Serving over 6.4 million patients annually at 300 practice locations, our footprint continues to rapidly expand across the country as we partner with and support hospitals, health systems, clinics, payers, and employers. Vituity’s acute focus and compassionate care are the driving forces that have placed us at the heart of better care.

At the Heart of Better Care