Gatekeepers of the ED
Hospitals can alleviate the difficulty of rework by having experts at all entry points into the hospital, and by deploying a front-end revenue cycle team, which also can function as a strong gatekeeper.
The decision to admit a patient from the emergency department (ED) to a hospital bed is one of the most expensive healthcare decisions. As payers continue to decrease payments for hospitalizations and as more diagnoses move to the outpatient setting, hospital systems need to have more efficient processes in place to decrease unnecessary admissions.
During times of COVID, when hospitals are at capacity, we have seen patient admissions decrease. Although not a new concept, in 2014, Reducing Variation in Hospital Admissions, by Sabbatini, Nallamothu, and Kocher, reported the same trend: that emergency visits resulting in hospitalizations decreased when hospital capacity was up, regardless of diagnosis or geographic location. The largest variation was found in admissions for chest pain, soft tissue infection, asthma, chronic obstructive pulmonary disease (COPD), and urinary tract infections. Despite the spectrum of severity for these diagnoses, a true gatekeeping process for ED admissions does not always exist. Admissions can vary by who is doing the admitting, not necessarily the clinical pathway. To meet appropriate criteria for hospitalization, patients in the ED must have both emergent and necessary treatment that cannot be completed in an outpatient setting. They must then be evaluated for inpatient status by the hospitalist or attending physician to determine appropriate severity of illness, and level of care – and whether that care requires a stay of greater than two midnights for treatment.
In evaluating hospitals across the country, we have seen some common trends that lead to this problem, and it all comes down to the push and pull of the ED physician, the admitting, and the hospitalist. The ED continues to manage by door-to-doc time, and ED-to-admission (or out the door). The ED physician is often pressured to make decisions quickly, and sometimes, when all the evidence is not present or the discharge from the ED is too difficult or untimely, the patient is admitted under observation for the next team to figure out what to do. The patient then goes to the floor, the hospitalist team and care management team evaluate, and then they essentially create a lengthy process of determining what to do next (or ask why this patient was even admitted). Hospitals can alleviate this by having experts at all entry points into the hospital, and by deploying a front-end revenue cycle team, which also can function as a strong gatekeeper.
Your gatekeeper teams should include the following:
Hospitalists for all admissions;
A utilization review specialist with some basic knowledge in clinical documentation integrity as frontline support;
A physician advisor for back-up support; and
A social worker for complex ED cases and social needs.
A utilization review specialist (URS) is trained and has use of programs that identify patients who are appropriate for admissions. The URS can also assist the physicians in the ED to identify the patients appropriate to discharge from the ED. Locating the URS in the ED near the hospitalist will increase communication during the evaluation and allow the physician to ask questions regarding admission status and appropriate documentation. Cross-training this URS with clinical documentation integrity (CDI) can have added benefits, to assist with understanding the clinical truth of the case and what can be documented to ensure an accurate description of why the patient needs to be admitted.
For patients who are medically or socially complex and require additional assistance, a social worker being available during peak hours of the ED (at a minimum) is a true advantage to ED throughput. The social worker can relieve the nurse and physician from the complex work of addressing potential child abuse, adult abuse, or the social determinants of health (SDoH), which can create barriers in the ED. Social workers can refer patients to community support systems and outside resources, so the ED does not become the “safety net” for patient care related to societal issues. Good catches can occur to admit patients to skilled nursing directly from the ED, arrange home health, or coordinate care back to a primary care physician or outpatient specialist, such as urgent ortho. Utilizing the electronic medical record (EMR), social workers can track and alert patients who are potential readmissions to the hospital, and alert the medical team to evaluate if readmission is necessary.
Data-Driven Decisions
A good use of your utilization review (UR) committee is to evaluate data associated with over-utilized resources. Patients who are unnecessarily admitted to the hospital are key factors that can be reported, discussed, and triaged for a new process. Data can highlight variation in admission practices by ED physicians and hospitalists for similar chief complaints. By getting both groups talking and involving the UR committee/case management department, alternative approaches can be tackled to address this scenario: we have this diagnosis, we know they do not belong in the hospital, but we don’t know where else they should go. A great example of this is low-acuity chest pain: patients who require a quick cardiology consult, and potentially a rapid stress test. If the hospital coordinates a fast track for these patients from the ED to the outpatient cardiology office for evaluation of stress tests, the hospitalization can be avoided altogether, saving time for the hospitalist, staff, and on-call cardiologist.
Consider a Clinical Decision Unit
If the patient must enter the hospital, but does not meet inpatient criteria, successful observation management will be key, and is best managed under a true clinical decision unit (observation unit). This tells the patient they are not truly inpatient, but staff can run the unit like an emergency department by tracking patients by the hour, not the day. UR and case management (CM) continue to serve as gatekeepers, and assist the team in evaluating appropriate documentation, severity, level of care, and potential barriers in the progression and transition of care.
During times of COVID, hospitals were forced to really evaluate the necessity of care in the emergency room for hospital admission. However, as history shows us, the healthcare system is not the best at sustaining lessons learned. As beds become more available, those diligent practices are likely to relax. Keeping this time fresh in our minds, to really reflect and implement the good things that came out of medical care, will be valuable as we continue to move to a value-based framework for healthcare.
Maintaining a strong gatekeeping team for your hospital admissions, particularly in the emergency room, will produce a strong front-end revenue cycle management.