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?