What is the Role of the Emergency Department in Transforming Healthcare?

Most healthcare leaders are in agreement that a critical transformational strategy is to increase the number of and access to primary care providers for patients and their families. However, the shortage of primary care providers has plagued the US healthcare delivery system for decades, causing Emergency Departments to often accept the role of de facto primary care provider, resulting in a rapid increase in ED volumes, year after year.

It is clear that the first experience with any hospital is often in an Emergency Department, whether being seen for emergent or non-emergent care. Emergency room patients typically generate between 20% and 40% of the hospital’s inpatient admissions. Recognizing these practices, I wrote, over 30 years ago, a medical paper entitled, “The Emergency Department is the Front Door of the Hospital”. It appears the observations and conclusions made over three decades ago are still valid today.

Because EDs have had to fill the primary care void present in many communities, numerous negatives have resulted. These include:

1. Overcrowding of the Emergency Department’s footprint,
2. Long waits by non-emergent patients,
3. High costs of the primary care delivered in this setting,
4. Lack of coordination of care between primary care patients and their other treatment points,
5. Minimal focus on prevention and wellness, and
6. Lack of “best practice” protocols for chronically ill patients who utilize the EDs frequently.

All of the these negatives were highlighted in the October, 2013 Health Leaders Magazine. In an insert, Truven Health Analytics provided data that showed that the inappropriate use of emergency department services is growing and continuing the trend of providing primary care that is more costly and lacks continuity. In addition, the data supported the tenet that most ED visits are avoidable, with only 29% of patients presenting with an emergent condition that required the expertise of the well trained emergency department staff. In contrast, 24% presented with no emergent medical need at all, and 42% could have been treated in a primary care setting, while 65% could have avoided the ED trip with timely outpatient care.

So what should be done? It seems that to address these challenges and reverse the negatives outlined above, Emergency Department leadership needs to consider a more active role in developing transformational strategies which will drive higher quality and safe care at a more affordable cost and in a more timely manner. Such strategies might include:

1. Expanding the non-emergent track which many EDs have all ready implemented. This includes needs for space, staffing (often with midlevel providers), and additional hours of operation;
2. Managing costs in the non-emergent track so that charges are significantly less than in the other service lines in the ED;
3. Have physicians, or other clinicians, perform the initial clinical screening in the triage area, treating the non-emergent patient immediately and, thus, eliminating the long waits typically experienced by this patient population;
4. After the non-emergent patient is seen, the ER provider should commit to doing everything possible to connect the patient with a primary care physician, nurse practitioner, or a medical home;
5. Consider referring patients to clinics to that see “self-pay/non-paying patients” - a cost-avoidance strategy;
6. 6. Provide education to non-emergent patients as to other more suitable venues for their longitudinal care;
7. Institute 24 hour Nurse Call programs to address non-emergent issues and therefore avoid a ED patient visit entirely.

Although these transitional strategies take time and energy, and are often resisted by the “status quo” oriented staff, emergency medicine leaders, working in collaboration with hospital leadership teams, must become a leader and contributor to the “value versus volume” strategic plans which will be critical for a successful and sustainable future.