The Evolution of Emergency Care: Beyond Fast Track

By: Linda Harder

Photography by: Tracey Brown

Maryland Physicians interviewed four emergency physician leaders to learn how various area emergency departments (EDs) have found better ways to evaluate patients, coordinate between shifts, provide humane psychiatric care, and even detach ED care from the hospital.

These advances take place against a backdrop of dramatic growth in emergency services; nationally, ED visits doubled in less than a decade, with wait times increasing 25% from 2003 through 2009. Population growth and aging, physician shortages and healthcare reform all make it likely that this trend will continue. Innovative approaches such as the ones described here enhance patient safety and convenience in these fast-paced environments.

Rapid Medical Evaluation: Keeping Patients Vertical

For decades, the traditional model of treating a patient in the emergency department (ED) involved ‘serial processing’ – having a triage nurse assess the patient and then having them wait until the physician or mid-level provider could treat them. Even the advent of Fast Track systems did not significantly change this serial approach. A program at Washington Adventist Hospital has altered that model by having a team consisting of a nurse, physician and patient care technician see each patient as they arrive.

Drew White, M.D., emergency physician and chairman of Emergency Medicine at Washington Adventist Hospital, initiated a pilot Rapid Medical Evaluation (RME) program in 2009. He says, “Nationally, the door-to-doctor times have been increasing in the past 15 years, and a long wait time is a predictor of bad patient outcomes. Our model addresses that gap by having a care team triage the patient, perform an initial exam, provide initial treatment and assign the patient to the appropriate level of care. If a treatment room is available, we start that process right in the room.”

Dr. White notes that, while Washington Adventist did not invent the model, they were one of the first to launch it in this region. “What makes it successful is the way we implemented it and that we have been able to sustain our gains,” he explains. “We performed intensive staff training, conducted focus groups, solicited input from people on the front line, and provided lots of data and feedback. For the first few weeks, we had frequent huddles to discuss how to address issues that arose and altered the plan as needed.”

The hospital found that the model was most useful during peak times, typically 11 am to 9 pm. The model employs an additional full-time physician or physician assistant during these hours and dedicates two rooms to the RME. However, the costs of more staff and significant coordination are more than offset by other savings and benefits. “Our LWBS (left without being seen) patients went from about 4% to about 0.5%, versus a national average of 1% to 2%,” Dr. White comments.

Other RME advantages relate to reductions in unnecessary testing, faster treatment, and improved patient satisfaction. “Studies have shown that up to one third of patients don’t need to be subjected to lots of testing,” notes Dr. White. “We can address their medical issues right from the start and give them what they need to get better. Lots of EDs have triage nurses that can issue standing orders, but by using physicians and mid-level providers, we can customize the orders and decrease unnecessary testing. We order the correct tests for the patient and start the optimal medical treatment earlier, including giving IV fluids and medication. When we finish the initial triage and exam, everyone, including the nurse, tech, and patient, know the plan of care and what to expect.”

He concludes, “Other advantages of this approach are decreased testing denials and the ability to stay off diversion far more often, so more people can come here for care. Our patient satisfaction is now among the highest in the country and our ED has had a higher growth rate than the regional average.”

Safer Sign Out: Bedside Rounding

Dr. White and the team also sought to address the highly variable and high-risk sign out process among ED physicians during change of shift. “An estimated 80% of serious medical errors involve miscommunication between caregivers when patients are transferred or handed off,” he explains, “with 24% of ED malpractice claims involving these faulty handoffs. The Joint Commission has identified this as a National Patient Safety Goal. In place of the typical process, which involves giving a quick verbal report to the incoming physician, we now have a standardized communication tool and process for bedside rounding on all patients at shift change. The incoming doctor meets the patient instead of merely reviewing a chart.”

Dr. White continues, “We will be presenting this concept at the Maryland Patient Safety Conference in April. It seems like a common sense idea, but it is a revolutionary change in practice. The more times you round on a patient, the more likely you are to pick up something. With this approach, the incoming doctor knows what tests the patient is waiting for and, during the rounding, the physician may pick up on changes in the patient’s condition since they last checked him or her. We piloted this program at Calvert Memorial Hospital, Washington Adventist Hospital, and some of the other hospitals where Emergency Medicine Associates practices, and then we expanded it to all of our hospitals.”

Dedicated Psychiatric Emergency Services

In contrast to many EDs, where mental health care typically consists of psychiatric consultants and a small section of the main ED, the psychiatric emergency services (PES) department at the University of Maryland Medical Center (UMMC) focuses solely on psychiatric/addiction evaluation and care for those in crisis. Medical Director Eric Weintraub, M.D., was recruited in 2010 to head up this new service, which sees patients from as far away as Frederick and the Eastern Shore. During his tenure, volumes have grown from about 2500 to 3500 patients/year.

PES patients enter through a central triage area shared with the main ED. Those deemed to require psychiatric intervention and who do not have an acute medical problem go directly to the PES department, located within the same building. “We have parameters for blood glucose, blood pressure and other clinical syndromes such as chest pain,” notes Dr. Weintraub. “Patients needing medical stabilization must be cleared medically in the main ED before they come to us.”

A team of attending psychiatrists, psychiatric nurses, psychiatric residents and social workers staffs the PES. An attending psychiatrist is available from 8 am to 9 pm on weekdays and 8 am to 4 pm on weekends. The space includes both an unlocked and locked area and patients are triaged to either side according to the acuity of their symptoms. The locked side can accommodate about 15 patients on reclining chairs and that accounts for nearly 80% of the total patient volume. The unit also includes a shower, a small room for interviews, and two seclusion rooms that can be left open or closed.

“The advantages of this model,” Dr. Wieintraub enthuses, “are that we can identify the patient’s major mental health issue(s) and then better manage the crisis, including starting patients on medications, performing crisis interventions with a variety of therapies and when appropriate referring patients to other appropriate mental health resources. We can forge a therapeutic alliance with the patient, and prevent a lot of hospitalizations. It’s not uncommon for patients to spend the night here so that we can watch and evaluate them overnight. Many people come in intoxicated from alcohol, cocaine, or other drugs including synthetic marijuana; after a few hours, their behavior often changes and you can get a much better assessment than you could have upon arrival.”

“To the best of my knowledge, our PES is unique in Maryland,” continues Dr. Weintraub. “We refer patients to other great mental health services such as Baltimore Mental Health Systems, Baltimore Crisis Response Inc. and Healthcare for the Homeless. Where we can refer them is dependent in large part on their insurance and where they live.”

Dr. Weintraub encourages referring physicians to call the PES before they refer a patient. He advises, “We depend on family, friends and physicians for collateral information. We like to know what medications the patient is on, what their issue is, and what might have caused a crisis. Patients often tell us, ‘My doctor just told me to come in.’ We’re happy to speak with doctors by phone to get the information we need to better care for their patients.”

Freestanding EDs Come of Age

By the early 2000s, explosive population growth and traffic congestion in upper Montgomery County had conspired to make it challenging at best for ambulances and those needing emergency care to get to an ED. The closest EDs were at Shady Grove Adventist in Rockville, which was handling some 90,000 visits a year and Frederick Memorial Hospital.  Ambulance service was hampered by long out-of-service times required to travel to and from the available EDs.

The solution?  After years of addressing legislative and regulatory concerns about a freestanding center, in 2006 Shady Grove Adventist was able to open the first freestanding ED in Maryland in Germantown. Brett Gamma, M.D., chief of emergency services at Shady Grove Adventist Emergency Center at Germantown, describes the results.

“The goal was to increase emergency access for upper Montgomery County residents and we’ve accomplished that,” he notes. “We have 19 private beds in a 17,000 square foot facility that sees about 37,000 patients a year. We diagnose, treat and stabilize patients, then transfer them to the hospital if needed. Most patients are discharged back home. Today, some 8 to 10% of our patients are transferred, up from 2006 when people were less educated about our ability to handle true emergencies.”

Dr. Gamma explains that the freestanding ED can treat all emergencies. Patients who require surgery, cardiac catheterization, or a labor and delivery suite are stabilized and transferred to the hospital. He comments, “We can stabilize heart patients and get them to the cath lab at the hospital, which is a Cycle III Chest Pain Center, in a comparable amount of time as patients who present to the hospital directly. For stroke patients, we can give tPA before transferring them for definitive care.”

In fact, the transfer times for ST-Elevation Myocardial Infarct (STEMI) patients from the Emergency Center at Germantown to the catheterization lab in the main hospital is in the top 15% of the nation. The Center prides itself on being part of a hospital system that received a Gold Achievement Award for cardiac care and is an accredited Chest Pain Center and Primary Stroke Center, with one of the best door-to-TPA times in the state. The freestanding center also scores well on other clinical outcome measures, such as providing appropriate use of blood cultures and antibiotics to patients with community acquired pneumonia. “Our goal is to provide these to 100% of all community-acquired pneumonia patients within specified time frames,” comments Dr. Gamma.

The center has comparable technology to that at a hospital-based ED. “We have all the technology we need, including ultrasound, high resolution CT and a dedicated lab that has incredibly fast turnaround because we’re not sharing it with inpatients,” Dr. Gamma continues.  A Picture Archiving Communication System (PACS) provides digital imaging to radiologists at the hospital.

The hospital recognized that it would be critical for the freestanding ED providers to have the same training and experience as those at the hospital – in fact, the same board certified emergency physicians rotate between the two EDs.

The majority of patients who are discharged to home are discharged in less than 150 minutes.

“Patient satisfaction is high, but perhaps no one is happier than those involved with EMS. They can now return to service for the next patient much faster,” he adds.

Starting 2010, legislation requires the state to set reimbursement rates for freestanding emergency facilities in Maryland, bringing them under the authority of the Health Services Cost Review Commission and making them available for Medicare and Medicaid fee-for-services reimbursement.

The Germantown ED is no longer the only one in the state; in 2010, a similar freestanding ED, the Queen Anne’s Emergency Center, opened on the Eastern Shore. The growth in freestanding facilities in Maryland mirrors a national trend; as of 2009, there were more than 240 freestanding EDs in the country.

Point of Care Testing Expands

Point of Care testing (POCT) has been available to some extent for more than a decade, but several newer tests that deliver results in minutes rather than hours or days are now in use.  Since 2007, the market for cardiac, stroke and infectious disease (especially HIV) POCT has roughly doubled.

POCT includes the measurement of blood glucose, blood gas and electrolytes, rapid coagulation, rapid cardiac markers, drugs of abuse, urine strips, pregnancy testing, fecal occult blood, food pathogens, hemoglobin, infectious disease and cholesterol.

While POCT may not decrease overall ED time significantly, “It gives the best care in the most efficient time,” according to Dov Frankel, M.D., assistant director of the Emergency Department at Sinai Hospital of Baltimore. “We can get results in less than two minutes using two drops of blood.”

Dr. Frankel states, “POCT involving cardiac enzymes has made a huge difference in getting patients to the cath lab on time, and is especially valuable in anyone with an equivocal story that may or may not be cathed depending on the troponin results. Since time is muscle, these tests are important for speeding treatment.”

The most commonly tested cardiac markers (enzymes or proteins that tend to be concentrated when a cardiac event is likely to or has occurred) are Total CPK (creatine phosphokinase), CK-MB (creatine kinase) and troponin I/T. Myoglobin levels may also be tested. Testing for these markers can reliably indicate when intervention is or isn’t necessary. Lab-based tests can take up to 1.5 hours, which has driven demand for the point-of-care products that can deliver “stat” results.

For patients with suspected MI who are first seen by their own physician, Dr. Frankel advises referring physicians to run basic chemistries or check INR instead of sending people to lab or ED to check.

The Sinai ED also has found that POCT has improved the ability to determine which patients can benefit from TPA. “Using POCT to test the International Normalized Ratio (INR) for patients with suspected strokes has allowed ED physicians to decrease the time to administer TPA so that more patients can receive it within the three-hour window,” Dr. Frankel notes.

POCT is also useful for patients suspected of having internal bleeding with signs of pallor, shortness of breath, etc. “They can get a hematocrit in minutes, compared to an average of one hour for a ‘stat’ lab test. That allows us to give that patient a blood transfusion far faster,” says Dr. Frankel.

However, Dr. Frankel believes there are certain conditions that should be diagnosed and treated even before the labs come back, such as heart failure and sepsis, which are based on the clinical presentation. He comments, “These labs are still useful but patients should be treated before the lab results are back.”

Those using POCT need rigorous systems to ensure ongoing quality. At Sinai, providers scan their badge, the patient’s badge and then the cartridge used in the POCT. Quality Control staff checks the machines weekly and recalibrates them as necessary. Dr. Frankel says, “I tell residents to ensure that the test result matches up with the patient’s clinical presentation, or redo it.”

While the Sinai ED doesn’t yet offer a POCT CBC test for white counts, platelets and infections, Dr. Frankel acknowledges that this test would be useful.  Perhaps surprisingly, however, he finds another valuable POCT test is the blood quantitative pregnancy test. “One in eight patients in our waiting room is pregnant. They came in due to a problem such as vaginal bleeding, but they often don’t know they’re pregnant.”

______________________________________________________

Drew White, MD, MBA, FACEP, chairman of Emergency Medicine and president of the Medical Staff, Washington Adventist Hospital.

Eric Weintraub, M.D, associate professor and division head, Psychiatry, University of Maryland Medical Center

Dov Frankel, M.D., assistant director, Emergency Department, Sinai Hospital of Baltimore

Brett Gamma, M.D., chief of Emergency Medicine, Shady Grove Adventist Hospital.


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