The ed as gatekeeper in transitions of care james hoekstra md 1
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The ed as gatekeeper in transitions of care james hoekstra md 1

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    The ed as gatekeeper in transitions of care james hoekstra md 1 The ed as gatekeeper in transitions of care james hoekstra md 1 Presentation Transcript

    • 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
    • Initial Risk Stratification Scheme Chest Pain History, Physical EKG, TnI UA/NSTEMI/ DefiniteSTEMI Inter Risk Low Risk Non-Cardiac High Risk
    • 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  DVT Asthma  Hyperemesis CHF  Sickle Cell Dehydration  TIA Hyperglycemia  Allergic Reaction Hypoglycemia  Renal Colic Cellulitis  Pain Syndromes Pyelonephritis
    • 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 LevelICU 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 forReadmissions Drivers Percent of ResponsesCommunication 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?