We are at a critical juncture where the collaboration between emergency physicians and hospitalists is imperative for a hospital to achieve financial success in the future. These two hospital based specialties touch almost every one of the hospital’s entire patient population of hospital admissions each year. Yet there has in the past been an inherent conflict of interests in their clinical practices based on the drastically different priorities they each must manage.

This is no longer the way we can do things; there is a new paradigm of practice for both of these physician specialties. The integration of the clinical practices of emergency physicians and hospitalists is accelerating rapidly as hospitals increasingly seek shared financial and operational responsibility for patients and performance metrics across the Acute Care Continuum. As the healthcare crunch to reduce costs and increase revenue builds, perhaps Ben Franklin summed it up best when he said, “We must all hang together, or assuredly we shall all hang separately.”

The tensions and mistrust that can arise between the ED and hospitalist practices stem from their different responsibilities. In fact, this tension speaks to the very heart of a key challenge in healthcare: the need to treat each individual patient vs. the need to be efficient and plan for the long term. The ED must evaluate every patient who walks in the door and the goal becomes disposition with all due speed to empty beds for the next patient presenting to the ED, for the most trivial to the most major of medical or traumatic emergencies. Hospitalists must make decisions about admissions based on specific criteria (e.g. InterQual) which have financial consequences to the health plan or the hospital. To an ED doctor these requirements can appear like an unreasonable work-up, while a hospitalist faces the task of identifying the appropriate admissions and achieving the optimal length of stay with prudent lab, imaging, and medical inpatient treatment.

By Gail Silver, MD 

We are beginning to see changes in healthcare delivery in the United States as the Healthcare Reform Bill is implemented. As anticipated, there is tremendous interest nationally in understanding and strategizing how to provide access to care for all Americans, and to deliver that care in an efficient and cost effective manner. While one of the stated goals of the Healthcare Reform Bill is that every patient should have a ‘Medical Home’, the projected shortage of primary care physicians will make the attainment of that goal a distant hope, rather than an imminent reality. Urgent Care Centers (UCCs) are starting to proliferate as health care delivery systems begin to respond to that need.

UCCs can help fill the access gap for patients whose conditions do not require the level of care provided by Emergency Departments. UCCs provide expanded hours, walk-in care that often includes many primary care services in addition to treatment for minor emergencies and acute illnesses. Many UCCs have on-site x-ray capability and point-of-care lab testing. Many also offer immunizations, sports physicals, pre-employment physicals, immigration physicals, as well as care for injured workers.

UCCs can serve as a resource to ensure that patients who have been hospitalized or discharged from the ED can get necessary follow-up and further outpatient evaluation in a timely manner. This role as the outpatient interface with the ED and the hospital is a critical piece of the Acute Care Continuum. Having a place that can provide guaranteed follow-up whenever it is needed can reduce hospitalizations for ED patients, length of stay for hospitalized patients and decrease the costs of care while maintaining patient safety and satisfaction.

By Sam Jones RN, BSN, Director of Emergency Services at Mercy Hospital, Roseburg, OR

Walking into Mercy’s ED as the Director of Nursing more than a year and a half ago, I was tasked to meet three specific outcomes; improve patient satisfaction, increase overall productivity, and decrease staff overtime. After spending the first several months collecting and reviewing data, as well as collaborating with the medical director, I began building a process known as “team care” in our department. While we did experience great success in the three aforementioned areas, we also managed to reduce our turn-around time to discharge (TAT-D) by 20%.

The first step in this process was to rebuild our shift times. We discovered that we had a number of staff on at various times of the day when our census was low. We eliminated and re-created shift times so that we could have more staff available when we were busy, and less when we were not. A simple enough plan, but this concept really paved the way for our team care model by putting our staff in a position to succeed as a team.

In our old system, one nurse was assigned to three or four patients, while techs served 12-14 patients apiece. We developed a system in which every 8 patients have two nurses and one tech caring for them. This allowed more people to interact with each patient, improving the patient’s perception of teamwork in our department. Additionally, we began having a team member, preferably an RN, available and at the bedside with the provider during the initial evaluation and during the disposition of the patient. While this was originally developed so that patients would experience us working together as a team, we unexpectedly found it has also reduced our TAT-D time by 20%.

As the nexus between the outpatient and inpatient care delivery systems, the Emergency Department is increasingly the gatekeeper of inpatient admissions.

Although the complexity of ambulatory care patients is increasing, the result of economic pressures on primary care physicians is a schedule that causes the older and sicker patients to receive only  the same amount of physician time as the younger, healthier patients. As ambulatory care providers have less time to thoroughly assess the patient and arrange for direct admission, patients are increasingly sent to the ED.  The result: now greater than half of all inpatient hospitalizations are originating in the ED.

Given this dynamic, it is not surprising that the number of ED visits has been increasing significantly.  Over a recent twelve year period, visits have increased by 35%-- from 94.8 million in 1998 to 127.2 million in 2010.

But is this a bad trend? While the entirety of emergency care accounts for less than 3% of healthcare spending, inpatient hospitalization accounts for approximately a third of healthcare dollars.

I try to make it a point to find medical blogs that stay up to date on the latest emergency medicine developments. You may be especially interested in two articles. One discusses strategy and technology architecture issues associated with the future development of EMR. The other is a study about how to curtail the overuse of the ED by frequent users.

What is happening with the $19 billion stimulus aimed at modernizing EMR?

In this Forbes article by contributor Dave Chase, Health Systems Spending Billions to Prepare for the “Last Battle”, Chase talks about how designers of the next generation EMR will have to create a system that is more nimble, affordable and person centric. He explores how health systems are currently working to meet this future amidst the many challenges. Consideration is given to how a constantly changing technology architecture that creates a new software playing field every 5-10 years could impact this development.

Should the title of this blog strike fear in the hearts of emergency physician specialists? There is an erroneous urban legend which says the Chinese character for “crisis” is composed of elements that mean danger and opportunity. While the legend may be incorrect, the notion sometimes has truth behind it. Is that the case with PAs and NPs working in EDs?

The fact is that producing emergency medicine residents at the current rate, we will not be able to fill the number of open emergency department positions in the United States -- ever. That certainly seems like job security for those of us who are Board certified. I am certainly glad I have kept my Boards current, but how will that solve the man/womanpower shortage in EDs that we face now and in the future?

When I started working as a hospitalist in 1998, there were only a handful of such jobs available in the country. Hospitals were either thinking about starting a hospitalist medicine program or trying to decide if they even needed one. I started working as a hospitalist right out of my residency at Cook County Hospital outside of Chicago (which was an experience in itself). I was full of energy and knowledge, as I had just taken my ABIM boards, and thought I could handle anything. Well, my first few years were very humbling. I found out I had a lot to learn about medicine and life. It was a challenge to try to navigate patients’ end of life issues while figuring out if I really even wanted to be a hospitalist for the next 20+ years.  

I used to get comments from the PCPs that the hospitalist was just a highly paid resident, because if you were a real physician, you would take care of the patients in the clinic as well as when they were in the hospital. Or that a hospitalist was just a temporary phenomenon that would not last. And there was always the comment that hospitalists could not know a patient they were seeing for the first time as well as a PCP who had taken care of the same patient for years.