“Change is hard”
- Insurance companies intensified denials of admissions that were solely for diagnostic chest pain workup. They Reasoned that these could be accomplished in different settings (including in the ED, during observation, or as an outpatient).
- Increased demand for our hospital’s telemetry beds as local hospitals closed their inpatient units.
- The decision to defer establishment of a non-ED based observation program at our facility.
- Better evidence based risk stratification coming from published trials.
- High sensitivity troponins that help better risk stratify low risk patients.
- CT Hearts (Calcium scoring) that significantly reduce post test probability of ischemic cause of chest pain.
- Most importantly improved care coordination with cardiology including immediate outpatient followup and stress testing.
So now our choices for lower risk chest pain are numerous and require additional skill sets. The simple stay or go has been replaced by:
- Send home after risk stratification using high sensitivity troponin.
- Stay longer and get additional testing (CT heart).
- Discharge after a normal prolonged ED work up for close cardiology follow up.
- ED Observation including serial troponins and cardiac stress testing.
- Admission if EKG, troponins, or risk stratification (high TIMI score) warrant a more extended evaluation.
We developed LOW RISK CHEST PAIN GUIDELINES to optimize flow and reduce admissions for diagnostic evaluation only. For the docs this requires a deeper knowledge of the extended evaluation of chest pain along with how to interpret diagnostic tests previously little used by them (calcium scoring, exercise and cardiolyte stress tests).
Also as some patients stay longer (for ED Observation lasting 16+ hours) the nurses will have to adapt to different set of patient needs and care coordination (including daily meds).
The percent of patients admitted to the hospital from our ED was already on the decline (See below). This is a reasonable step forward in that trend. Will this have the desired effect of safely reducing admissions?
Will this lead to additional guidelines targeting other types of previously admitted conditions?
Will my head explode just thinking about this? Stay tuned. 🙂
David
Anatomy of a Super ER 
I think my head will explode! Great article. I think this trend will crossover to other medical issues.
I agree. My hope is that we will incorporate more care managers and others to help with these issues. I think physicians do best in deciding What a patient needs…we can’t also be experts on how that What gets done.
I miss those good-old days, I was literally trained on the “sick” vs. “not sick” model. As pointed out, the never-ending ED holds (lack of observation/tele beds) was and is a HUGE problem clogging up every ED I’ve encountered . New C/P admission criteria definitely help with the dreaded emergency hold.
**Personal Perspective Disclaimer ** I’ve worked as a registry RN in emergency departments around the valley and across the demographic spectrum of Phoenix metro area.
Over the past seven years, there’s been an unmistakable pattern : from a booming to the crashing economy –> tens of thousands dropped from AZ Medicaid (AHCCCS ) –> pts forgo basic preventative care/disease management and ignoring signs/symptoms of health problems.
Some claim fear of hospital admission and/or financial concerns caused them to “hold out as long as” possible before calling 911. A few pt’s have virtually begged to be sent home an hour or two after checking into the ED with crushing C/P attempting to avoid med bills.
This population of un-insured/under-insured can GREATLY benefit from the widening array of diagnostic tools that are becoming the available standards in ED care. When finances are an ever-present/ deciding factor for patients in their medical care, providing alternatives to a hospital admission could literally prove life -saving.
Many Emergency Residents and Attending alike express the “haven’t we got enough on our plates already?” complaints re: the increase of pre-admit diagnostics.
From the Emergency RN’s perspective, anything that keeps patients moving (whether to inpatient or D/C’d ) is a good thing.
* Now if we a better algorithm to improve flow/placement /treatment in our psychiatric patients, the ED world would definitely be hugely grateful!
How is the “ED Observation” patient managed to gain optimal revenue?
We are capturing the facility portion but not the physician portion fully. This is related to the limitation of billing either the E&M or obs code
Our ED observation unit is staffed by internal medicine MDs hired into the faculty practice. This allows us to capture full professional as well as facility E&M revenue. There’s a learning curve when the IM docs first come on board, but as they acclimate, they learn to manage obs in terms of hours, not days.
Thought provoking article. We’re all being asked to do more with less. I like the idea of having IM providers helping to manage these patients, however I would advocate for an Observation / Short Stay Unit outside of the ED, especially with the new Core Measures for ED Length of Stay.
Donald
Totally agree with your feelings about OBs\Short stay. Unfortunately our hospital has not chosen to go that route so this is our response. I do think even with OBs we can directly discharge more low risk CP patients. We will be putting out some data soon!
Good article, David. Thank you for sharing. Keep writing. 🙂