The ED as the Gatekeeper in

Transitions of Care

James Hoekstra, MD Professor and Chairman

Department of Emergency Medicine Wake Forest University Health Sciences

Dr. Hoekstra’s Disclosures

Consultant: Daichi Sankyo, Merck, Astra Zeneca, Janssen, Verathon

Research Support: Sanofi-Aventis

None of this has anything to do with this presentation

Objectives Participants will understand the concept of

transitions of care Participants will understand the importance of

the ED in communication with primary/specialty providers in transitions of care

Participants will understand the role of the ED in determining observation versus admissions

Participants will understand the role of the ED in reducing admissions for HF, MI, and PNA

The ED as a Gatekeeper

Classic Emergency Medicine: – “Who’s Sick, Who’s Not”

– Sick = Admit. Not Sick=D/C

The “New World” of Emergency Medicine: – ICU versus Tele versus Med/Surg versus

Obs versus D/C

– And don’t forget Hospice

The Role of the ED in Transitions of Care

Observation versus Admission

History, Physical EKG, TnI

Chest Pain

STEMI UA/NSTEMI/ High Risk

Inter Risk Low Risk Definite

Non-Cardiac

Initial Risk Stratification Scheme

NSTE ACS Risk Stratification Levels

Clinical Criteria

•STEMI: ST elevation or New LBBB •Hi Risk: Dynamic ECG, +Tn, or TIMI >3

•Intermediate Risk: -ECG, -Tn, TIMI 2-3

•Low Risk: -ECG, -Tn, TIMI 0-1

NSTE ACS Risk Stratification Levels

Patient Disposition •Hi Risk: Invasive Strategy: Cath < 24 hours

• CCU Admit

• ASA, Clop, UFH/Enox, ?GPI, Cath

•Intermediate Risk: -ECG, -Tn, TIMI 2-3 • Tele Admit, ? Obs Unit

• ASA, ? Clop, ?LMWH, serial ECG and Tn, Stress or Cath

•Low Risk: -ECG, -Tn, TIMI 0-1 • Obs Unit

• ASA, serial ECG and Tn, CTA or Stress

Patients Eligible for Observation

Chest Pain, R/O ACS Asthma CHF Dehydration Hyperglycemia Hypoglycemia Cellulitis Pyelonephritis

DVT Hyperemesis Sickle Cell TIA Allergic Reaction Renal Colic Pain Syndromes

What Do We Have to Know?

Diagnosis (Eligible?) Care Pathway or Protocol (Doable?) Planned

intervention/treatment/diagnostics Stability (Too Sick?/Interqual Criteria) Start Time/Finish Time >8 hours, <24

hours Documentation at start and finish of

care.

The Role of the ED in Transitions of Care

Determining and Transmitting Patient Acuity Level

ICU versus IMC versus Tele versus Floor

Transmitting Acuity Level

SBA – Situation

– Background

– Assessment

– Recommendation

Include information to determine not only admission, but level of care

Transmitting Acuity Level CC, Reason for Admission Pertinent H and P/Comorbidities First and last vital signs Interventions/Drips/Drugs Risk Scores (TIMI, PORT, EWS) Discussion of

Obs/MedSurg/Tele/IMC/ICU Send them up or see them in the ER?

The Role of the ED in Transitions of Care

Protocol Driven Care

Care Pathways started in the ED continue on the floors.

Guideline adherence leads to better outcomes

Protocol Driven Care: Guideline Based

Chest Pain/AMI PNA (HAP and CAP) Sepsis/Fever/Fever and Neutropenia Asthma CHF DKA Discuss with admitting MD, track

adherence, start in the ED.

The Role of the ED in Transitions of Care

Avoiding Readmission

PNA, CHF, MI

The Role of the ED in Readmissions

CMS tracked for MI, PNA, CHF Highest in academic centers Medicare and Medicaid populations Poor outpatient follow up Poor home care Poor SNF, NH care

The Role of the ED in Readmissions

“Bounce Backs” can be admissions, observation, or discharges

Coordination of care at the ED site can lead to reduced admission

Med reconciliation, appropriate ED follow up, and judicious use of observation can reduce readmission rates

Focus Group Surveys: Identified Drivers for Readmissions

Drivers Percent of Responses

Communication Across Providers/Settings 35%

Medication/Medication Reconciliation 35%

Patient Education/Health Literacy 32% Financial Issues 25%

Social/Family Issues 21%

Physician Follow-up 21%

Lack of Community Resources 15%

The Role of the ED in Readmissions

Discharges: – Automated outpatient physician follow

up/discharge planning

– SBAR referrals/contact

– Med reconciliation

– Home health arrangements

– Social services/medication supplies

The Role of the ED in Readmissions

Admissions/Observation: – Prefer Obs if possible

– Admit back to same service/MD if admit

– Care coordination

– Social services

– Start discharge planning asap

– Reduce LOS, reduce admission versus observation

The Role of the ED in Transitions of Care

Hospice and Palliative Care

Reducing Inpatient Mortality

Hospice/Palliative Care

Patients admitted but dying within 24 hours count on the hospital mortality rates

Mortality rates are public knowledge for AMI, HF, PNA

Physicians can identify these patients Mechanisms to “grease the skids” for

hospice/palliative care can reduce unnecessary admissions/mortality

Hospice/Palliative Care

Palliative Care Service admissions – 24 hours a day, 7 days a week

– On-line or immediate ED consultation ability for “the discussions” with family

– Physicians/Social Workers, readily available to the bedside.

– Outpatient hospice sites for placement

The Role of the ED as Gatekeeper in Transitions of Care

It Ain’t That Easy Any More

QUESTIONS?