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EMERGENCY DEPARTMENTS: What is a pivot team?

The patient flow through the emergency department at the University of Colorado Hospital (Aurora, Colo.) was redesigned as part of preparation to move into a new, much larger facility (increasing from 18,000 to 56,000 square feet) in spring 2013.  The centerpiece of the patient care redesign was establishment of a pivot team approach, which has proved successful in decreasing patient length of stay in the ED and in eliminating ambulance diversion and nearly eliminating the number of patients leaving without being seen.

The pivot team approach is depicted in detail in the document cited below authored by the University of Colorado hospital.  The patient entering the ED has an ID check with security and then moves to an ambassador who shows the family where to wait and takes the patient to the PIVOT team, where a very fast decision is made to send the very sick patients immediately to the ED pod area and the less-sick to Intake for more in-depth assessment.  Patients are in Pivot for only 2 or 3 minutes and vital signs and medical history are not taken at this point.


Robeznieks, A. (2015, Jan. 5). Hospital revamp cuts ED wait times. Modern Healthcare, 45(1), 29. Retrieved from http://www.modernhealthcare.com/article/20150103/MAGAZINE/301039996

Scott, R., and Koehler, A. (2013). Evolution in emergency care: The pivot team. Journal of Nursing Care, 2(3). Retrieved from http://www.omicsgroup.org/journals/2167-1168/2167-1168-S1.002-067.pdf 

University of Colorado Hospital. (2013). Emergency department care redesign using the novel rapid process optimization (RPO) methodology. Retrieved from http://smhs.gwu.edu/urgentmatters/sites/urgentmatters/files/EDCareRedesignRPOMethodology.UColoradoHospital.pdf 

Chart Book: 21st Century Rural Hospitals

Is there a typical rural hospital? A new report  from the Sheps Center for Health Services Research, a rural health research and policy center based at the University of North Carolina, provides a statistical profile, including these medians:

  • It has 25 beds
  • It has 7 inpatients every day
  • It employs 321 full-time equivalent workers
  • It serves a median population of 27,930 with 36 residents per square mile
  • Typical inpatient care includes surgical, obstetric, and swing bed services
  • Typical outpatient care includes surgical, cardiac rehab, breast cancer screening/mammography, and health fair services
  • Outpatient care represents 69.3% of total revenue

The report provides more data on hospitals, inpatient and outpatient services, the rural population, and hospital finances. In some cases, its contrasts rural hospitals with urban hospitals.

Freeman VA and others. The 21st century rural hospital: a chart book. Cecil G. Sheps Center for Health Services Research, University of North Carolina, March 2015. http://www.shepscenter.unc.edu/wp-content/uploads/2015/02/21stCenturyRuralHospitalsChartBook.pdf

Posted by AHA Resource Center (312) 422-2050, rc@aha.org

Common Mistakes in Designing Psychiatric Hospitals

The Facility Guidelines Institute [FGI] recently published a white paper on common mistakes made when designing psychiatric hospitals. While the report points out there is no one-size fits all solution, it discusses common design errors  from the perspectives of a therapeutic environment, patient and staff safety concerns, programming, general layout, and general level of precautions.

The authors of the report have also written Design Guide for the Built Environment of Behavioral Health Facilities, formerly published by the National Association of Psychiatric Health Systems, but now being published by FGI.

FGI coordinates the ongoing consensus process for updating and revising the Guidelines for the Design and Construction of Healthcare Facilities, used by “The Joint Commission, many federal agencies, and authorities in 42 states … either as a code or a reference standard when reviewing, approving, and financing plans; surveying, licensing, certifying, or accrediting newly constructed facilities; or developing their own codes.

Source: Hunt J. and Sine DM. Common mistakes in designing psychiatric hospitals: an update. Facility Guidelines Institute, May 2015. http://fgiguidelines.org/pdfs/FGI_CommonMistakesPsychiatricHospitals_1505.pdf

Posted by AHA Resource Center (312) 422-2050, rc@aha.org

Resources for Hospital Community Benefit Reporting & Community Health Needs Assessment

Not-for profit, tax-exempt hospitals have long been required by the Internal Revenue Service and some state governments as well to document their benefit to the community. The Affordable Care Act added a new requirement for these hospitals to perform a community health needs assessment (CHNA) every three years and, as part of the annual filing for IRS Form 990 and Schedule H, to report progress in meeting the needs identified.

The National Library of Medicine’s National Information  Center on Health Services Research and Health Care Technology has created a web site linking to community benefit/community health needs assessment information in each of these categories:

  • Data, tools, statistics
    • State and special population resources
  • Legislation / regulations
    • Federal resources
    • State resources
  • Selected articles and documents
    • Analyses examining pre-ACA community benefit practices
  • Sample community health needs assessments
  • Meetings / webinars
  • Organizations

Source: National Information Center on Health Services Research and Health Care Technology. Community benefit / community health needs assessment. National Library of Medicine, accessed Aug. 14, 2015 at https://www.nlm.nih.gov/hsrinfo/community_benefit.html

Posted by AHA Resource Center (312) 422-2050, rc@aha.org

Percent of Office-Based Primary Care Physicians Not Accepting New Patients

The Centers for Disease Control and Prevention reports that 8.4% of office-based primary care physicians were not accepting new patients in 2013. New patient acceptance differed by insurance type, however. Over a third of the physicians were not accepting new Medicaid patients. Here’s the CDC infographic:


PCPs not accepting new patients - CDC aug15


Source: Hing E and others. Quick stats: Percentage of office-based primary care physicians not accepting new patients by source of payment – United States, 2013. Morbidity and Mortality Weekly Report, Aug. 14, 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6431a10.htm

Posted by AHA Resource Center (312) 422-2050, rc@aha.org

New Uber-Like Start-Ups Providing Medical House Calls

An article in this week’s Wall Street Journal looks at start-up firms that are providing medical house calls through an Uber-like model. The article features these companies offering on-demand visits to the patient arranged through an online app:

  • Heal serving San Francisco, Los Angeles and Orange County
  • Pager serving New York City and San Francisco
  • MedZed serving New York City and Atlanta
  • RetraceHealth serving Minneapolis, North Dakota and Wisconsin
  • True North Health Navigation [changing its name to Dispatch Health] serving Denver

Pager [using Uber] and Heal both dispatch a doctor or nurse practitioner to the patient’s home or office. RetraceHealth provides an initial video consult with a nurse practitioner and goes to the patient’s location only if hands-on care is needed. MedZed sends a nurse for the initial exam and then connects remotely to a doctor for a treatment plan. True North is offered as a lower-cost, on-location care option for 911 callers when they have a minor, nonemergency health issue.

The health care system Centura Health is collaborating with True North to reduce its emergency room use and to lower medical costs for employees and members of its health plan.

Visit charges cited currently range up to about $200, and may or may not be covered by health insurance plans. Some worry that these services will further fragment care and damage patient-provider relationships. Upon request, however, the companies will send reports to a patient’s primary care physician. One hospital ER physician interviewed indicated she enjoyed the extra time she could spend with a patient when working on a Pager shift.

A New York Times article earlier this year also looked at Go2Nurse serving Chicago and Milwaukee and Curbside Care in the Philadelphia area, both making house calls. Telemedicine apps providing virtual visits or consultations are also covered, including Doctor on Demand, Teladoc, American Well, HealthTap, MDLive, Spruce and Maven.


Beck M. Startups vie to build an Uber for health care. Wall Street Journal, Aug. 11, 2015. http://www.wsj.com/articles/startups-vie-to-build-an-uber-for-health-care-1439265847

Jolly J. An Uber for doctor housecalls. New York Times Blog, May 5, 2015. http://well.blogs.nytimes.com/2015/05/05/an-uber-for-doctor-housecalls/

Related books:

Wachter R. Digital doctor: hope, hype, and harm at the dawn of medicine’s computer age. McGraw-Hill Education, April 1, 2015. http://www.amazon.com/The-Digital-Doctor-Medicines-Computer/dp/0071849467

Topol E. The patient will see you now: the future of medicine is in your hands. Basic Books, Jan. 6, 2015. http://www.amazon.com/The-Patient-Will-See-You/dp/0465054749/ref=pd_sim_14_1?ie=UTF8&refRID=0N4GNJHP11JZ3FHF3XJ3

Posted by AHA Resource Center (312) 422-2050, rc@aha.org

Self-Insured Health Plans: 1996-2013 Statistical Snapshot

According to a new analysis from the Employee Benefit Research Institute, 58.2% of workers with employee health coverage were in employer self-insured plans in 2013. That’s an increase from the 46% covered in 1996. The size of the business matters. Only 11.5% of employers with less than 50 employees were self-insured in 2013, while 85.6% of larger businesses with 1000 or more employees offered a self-insured health plan.

Federal law allows multi-state employers to self-insure [or directly fund worker health care expenses] in order to provide uniform benefits to all its employees across states. This contrasts with fully-insured health plans where a premium is paid to a health insurance plan that is regulated at the state level and subject to varying state mandates.

The EBRI report also offers health self-insurance data at the state and industry level, although the health care industry is not one of the industries included.

Source: Fronstein P. Self-insurance health plans: state variation and recent trends by firm size, 1996-2013. EBRI [Employee Benefit Research Institute] Notes, June 2015. http://www.ebri.org/pdf/notespdf/EBRI_Notes_06_June15_SI-AutoIRAs.pdf 


Self-insured group health plans. Self-Insurance Institute of America, accessed Aug. 12, 2015 at http://www.siia.org/i4a/pages/Index.cfm?pageID=4546

Directory of self-funded group plans. Judy Diamond Associates, Inc., accesssed Aug. 12, 2015 at http://www.judydiamond.com/products/self-funded-directory/  [This vendor also offers free registration to use its FreeERISA database at http://freeerisa.benefitspro.com/; employer self-insured health plans and pension plans file ERISA Forms 5500 with federal government]

Posted by AHA Resource Center (312) 422-2050, rc@aha.org


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