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TURNAROUNDS: How to effect change quickly at a struggling hospital using ‘buddying’ mentoring approach

How a buddying partnership was used to implement a quality improvement initiative at Medway NHS Foundation Trust, a large general hospital located near London, England, is described in this detailed case study.  Medway’s partner in the buddying agreement was Guys and St. Thomas’ Hospitals Hospital NHS Foundation, which provided “advice, operational assistance, ‘compassionate’ leadership and pastoral staff…”  This team approach was successful in quickly improving patient throughput issues.

Source: Leach, R., Banerjee, S., Beer, G., and others. (2019). Supporting a hospital in difficulty: Experience of a ‘buddying’ agreement to implement a new medical pathway. Future Healthcare Journal, 6(1), 67-75. Click here for full text:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6520082/pdf/futurehealth-6-1-67.pdf  Posted by AHA Resource Center (312) 422-2050,  rc@aha.org

ED VISITS: Comparing utilization in urban and rural areas

Changes in emergency department utilization rates from 2005 to 2016 in urban versus rural areas were studied based on data from the National Hospital Ambulatory Medical Care Survey.  The data used in the analysis are representative of the nation as a whole.  Here are the changes in visits per 100 population over the time period studied:

  • Rural areas: 36.5 visits/100 population (2005) to 64.5 visits/100 population (2016)
  • Urban areas: 40.2 visits/100 population (2005) to 42.8 visits/100 population (2016)

Reasons for the larger growth in the utilization rate per 100 population in rural areas are discussed.

Source: Greenwood-Ericksen, M.D., and Kocher, K. (2019, April 12). Trends in emergency department use by rural and urban populations in the United States. JAMA Network Open, 2(4). Full text here: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2730472  Posted by AHA Resource Center (312) 422-2050 rc@aha.org

EMERGENCY: Factors involved in multiple ED visits

Patterns of multiple ED visits are likely driven by patients’ health conditions and care needs rather than by PCP-related factors.  Multiple ED visits also appear to be complementary, rather than substitutionary, to physician office visits.  This implies that multiple ED visits are not indicative of discretionary use.  The finding also suggests PCP-focused interventions aimed at reducing ED use are unlikely to have a significant impact.”

This study tackled the question: To what extent could expanded primary care options, such as changing physician office hours, substitute for emergency department care?  The data included records on over 20,000 adult patients of the Geisinger Health Plan (a Danville, PA, HMO) who visited the emergency department more than once a year during the study period 2015 to 2016.  These more frequent emergency department users tended to be younger adults (under 40 years old), Medicaid recipients, and patients with multiple clinical issues.  The more frequent users were also found to be patients with a higher number of primary care visits and inpatient hospital admissions.

Source: Maeng, D.D., Hao, J., and Bulger, J.B. (2017). Patterns of multiple emergency department visits: Do primary care physicians matter? The Permanente Journal, 21, 16-063.  Click here: http://www.thepermanentejournal.org/files/2017/16-063.pdf   Posted by AHA Resource Center (312) 422-2050, rc@aha.org


INNOVATIONS: Emergency department design

This comprehensive article, based on an extensive literature review, covers all sorts of operational innovations that hospitals are trying in order to improve their emergency departments, and then discusses the implications for facility design.  Data from the Emergency Department Benchmarking Alliance (EBDA) indicate that emergency departments with less than 20,000 annual visits do better on performance metrics than larger EDs, suggesting the consideration that larger EDs be broken into smaller functional units.  These smaller EDs could then be differentiated by acuity or chief complaint.  The concept of the Breathing ED,which means cyclically opening and closing portions of the ED according to patient load, is discussed.  Among the other concepts discussed include:

  • Triage models (should intake be done by physicians or teams instead of triage nurses?)
  • Triage pods
  • Care initiation areas
  • Low flow-high flow process model
  • Routine ordering of EKGs for patients with chest, neck, and abdominal symptoms
  • Pull to full
  • Fast track
  • Med teams
  • Geographic zones
  • Internal waiting rooms instead of housing patients in ED treatment rooms
  • Reclining chair units
  • Express admissions units
  • Discharge kiosks
  • Clinical decision units

Why I like this article:  It covers so many concepts in a thoughtful and well-researched fashion.

Source: Welch, S.J.  Using data to drive emergency department design: a metasynthesis.  HERD. Health Environments Research & Design Journal;5(3):26-45, Spr. 2012.  Click here for the publisher’s website: http://www.herdjournal.com/ME2/Default.asp  Posted by AHA Resource Center, (312) 422-2050, rc@aha.org

“15-minute” emergency department guarantee

A number of providers are experimenting with “15 minutes or free” offers for urgent care visits.   Examples include:  Emerus Emergency Hospitals, freestanding emergency hospitals in Texas, which ran a promotion at the end of 2010 guaranteeing patients would be seen by a physician within 15 minutes of completing their paperwork — or there would be no charge for the visit.   At Northern Nevada Medical Center (Sparks, NV), the guarantee is to be seen by a nurse within 15 minutes of arrival.  Emory-Adventist Hospital (Smyrna, GA) has a twist on this idea that allows the hospital to schedule the arrival of urgent care patients by offering the guarantee to those who enter the system by first registering for an appointment on the hospital’s website.  There is a small charge for this “place holder” service, but then a guarantee of being seen quickly upon arrival at the facility. 

Source: Emergency care in ’15 minutes or it’s free.’  Houston Business Journal, Nov. 5, 2010.  Please also click on the underlined hospital names above to link to more information about their 15-minute offers.

Emergency department benchmarks database

The Emergency Department Benchmarking Alliance (EDBA) is a membership organization of high-volume EDs nationwide that contribute operational data to a common database.  Studies based on the collaborative database have been published in the medical and health care administration literature for over 10 years.  Data from EDBA show that overall ED utilization in these high-volume hospitals increased 5 to 10 percent in 2009.  Intriguing studies listed as being underway include updates of Left Without Being Seen; ED Staffing; and, Patients per Hour.

Source:  Volumes still grow, says survey of EDs.  ED Management.  22(7):77-78, July 2010; and, the EDBA website.

Higher ED wait times

According to a study published in the Nov. 9 issue of Archives of Internal Medicine, the percentage of patients in the emergency department who are seen by a physician within the triage target time is at its lowest point in at least 10 years. This trend is true for patients of all racial/ethnic backgrounds and payer types.