5 Ways to Reduce Healthcare Spending on Emergency Departments

ED visits are growing.

ED costs are growing.

If the ED was a bakery, we could send customers away at the front door when the pastries were gone. Some still suggest this dangerous practice. Here are 5 better ideas that will work.

5 Ways to Save $$ on EDs

1. Increase access to imaging and labs. A patient can’t wait weeks to find out whether the lump in her breast is a cancer or headache is a tumour. Patients come to the ED even though they’d often rather go anywhere else.

2. Provide clinics for ‘in-between’ patients (CTAS 3). On a scale of 1 to 5, CTAS 3 patients aren’t dying but have more than a sunburn. These patients needs tones of care and investigations. A few are acutely ill, but most suffer from chronic issues. Either give them direct access to clinics, or let emergency physicians send patients directly to specialty clinics (same day appointments).

3. Get admitted patients out of the ED. Admitted patients get horrible care in the ED and cost the most, by a very wide margin. ED care costs more than ward care. Get admitted patients were they can get the care they need: up to the wards!

4. Don’t transfer dying patients to the ED who never wanted to come to the hospital in the first place (signed advanced directive).

5. Close EDs. In Canada, we close rural EDs and refuse to expand the size or number of EDs to keep pace with population. It’s a terrible option for customer service, but it does save money. 🙁

What do you think? Click Leave a Reply or # Replies below.

ED Efficiency: High Acuity vs. Volume

Myth survives as common knowledge. Healthcare sages propagate emergency department (ED) efficiency myths like:

“If the ED only saw ‘true-emergencies’, ED crowding and costs would improve.”

“Many patients don’t need to be in the ED. We would save money by sending them somewhere else.”

The myth of High-Acuity, ‘true-emergency’ EDs assumes:

1. It’s possible to educate patients to go elsewhere.

2. Patients have somewhere else to get care.

3. Staff can safely tell who is a ‘true-emergency’ and send all others elsewhere.

4. Low-acuity patients crowd the ED and shouldn’t be there.

5. We can save money by decreasing low acuity ED visits.

Myth Busting

1. Patients attend the ED for access, not because they are stupid. Most patients don’t need education.

2. Patients come to harm if sent elsewhere. (JAMA)

3. Low-acuity patients do NOT crowd the ED. They cycle through quickly. Sick, admitted patients crowd the ED.

4. Marginal costs for minor patient complaints are minuscule: pennies compared to the cost of keeping the ED open.

High Acuity

‘True-emergencies’ don’t trickle in one at a time.

‘True-emergencies’ often present in batches. In larger EDs, three critically ill patients often present at the same time, and most providers can recall a time when 4 critically ill patients showed up within minutes. Each critically ill patient requires up to 4 nurses, a physician, a respiratory technician, and more.

ED Efficiency Killer

Why do governments close low-volume EDs even if they have money to keep them open?

Small EDs often have many hours when they see very few patients. An acute care resource running at anything less than full capacity wastes money. Idleness equals waste; it kills efficiency.

ED Efficiency Solution

Consider a trauma room. Most hospitals keep one or more operating rooms open (staffed), at great cost, to manage trauma or emergency surgery. Idle trauma rooms are expensive. Hospitals can recover some cost by managing non-emergent cases, especially if the team has already been called in and a suitable admitted patient awaits surgery.

Eliminate idleness to increase ED efficiency.

Hospitals recover cost and gain efficiency by using the trauma room for less urgent, non-trauma patients!

Even IF there was a way to figure out which patients were ‘true emergencies’, EDs large enough to manage all the ‘true emergencies’ in a community would stand idle much of the time at HUGE cost.

EDs recover cost and gain efficiency by seeing less-acute patients.

Mythical ‘High Acuity’ EDs never match the efficiency of a high volume ED.

How do you approach efficiency in your ED? How would you deal with ED idleness if you could identify and safely send away all the non-true-emergencies?

Emegency Departments That Lag

Time to treatment equals quality for much of emergency medicine. It’s also the easiest way to decide whether an ED is any good. Missed diagnoses, errors of judgment, and clinical mistakes can be hard to spot by comparison.

Emergency Departments That Lag

1. Long Line up at triage –

The most at-risk patients stand in the line-up for triage. Every day, patients walk in with a deadly process inside of them. Until they have been seen, they are unsafe. A line up to be seen is indefensible.

2. Long triage process –

Triage should be sorting; not a primary nursing assessment. Patients need a diagnosis and treatment. In most cases, this means getting patients and physicians together as fast as possible. A long triage process does not add value for patients.

3. Long Line up at registration and long registration process –

Registration – getting a chart made – does not add value for patients; it only delays care. It must be short!

4. Packed waiting room –

There is no reason for patients to EVER wait in the waiting room. Please argue in the comment section below if you disagree.

5. Patients must repeat their story over and over and over.

Providers should quickly check what others have recorded, verify the facts and ask additional questions. Starting over with every provider drives patients nuts.

6. No discharge excellence

Patients should leave the ED with copies of lab and radiology reports, written discharge instructions (if necessary), and clear instructions for follow-up and return visits to the ED.

7. Dismissive attitude

Patients should be welcomed to the ED for ANY complaint. No complaint is trivial for a patient. We – healthcare providers, media, government, all of society – seem to think healthcare would be just fine if it weren’t for all the patients. Besides being unwelcoming non-verbally, there’s a big difference between “Why are you hear today?” and “How can I help you?”

Rules in case you get sick:

Don’t go to your family doc unless you’ve tried something yourself first.

Don’t go to your specialist unless you go to your family doc first.

Don’t go to the ED unless you’ve gone anywhere else first.

Don’t go to the ED unless you are nearly dying.

If you are dying, you shouldn’t go to the ED because we can’t do anything for you…

Excuses

But all our beds are full of admitted patients!

Definitely the most popular excuse, admitted patients definitely make it almost impossible to provide emergency care some of the time. But, even with admitted patients blocking beds, patients should still be brought into the ED and seen on exam tables. If they can wait on chairs in the waiting room, they can wait on chairs inside after they’ve been assessed.

Thankfully, Ontario has started to hold hospitals accountable for getting admitted patients out of the ED, and up to the wards.

Who owns morale?

Management owns operations; staff owns morale. Sure, you can crush morale in even the most engaged staff, but blaming management for staff attitudes will mire an ED in under-performance. Staff control their own morale, and it must be part of performance management.

How does your ED stack up? As a patient, have you researched your local EDs to see which ones to avoid?