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The ED as the Gatekeeper            in   Transitions of Care           James Hoekstra, MD         Professor and Chairman  ...
Dr. Hoekstra’s Disclosures   Consultant: Daichi Sankyo, Merck,    Astra Zeneca, Janssen, Verathon   Research Support: Sa...
Objectives   Participants will understand the concept of    transitions of care   Participants will understand the impor...
The ED as a Gatekeeper   Classic Emergency Medicine:    – “Who’s Sick, Who’s Not”    – Sick = Admit. Not Sick=D/C   The ...
The Role of the ED in Transitions             of Care    Observation versus Admission
Initial Risk Stratification Scheme        Chest Pain                                    History, Physical                 ...
NSTE ACS  Risk Stratification Levels       Clinical Criteria•STEMI:    ST elevation or New LBBB•Hi   Risk: Dynamic ECG, +T...
NSTE ACS           Risk Stratification Levels              Patient Disposition•Hi   Risk: Invasive Strategy: Cath < 24 hou...
Patients Eligible for Observation   Chest Pain, R/O ACS      DVT   Asthma                   Hyperemesis   CHF        ...
What Do We Have to Know?   Diagnosis (Eligible?)   Care Pathway or Protocol (Doable?)   Planned    intervention/treatme...
The Role of the ED in Transitions             of Care     Determining and Transmitting          Patient Acuity LevelICU ve...
Transmitting Acuity Level   SBA    – Situation    – Background    – Assessment    – Recommendation   Include information...
Transmitting Acuity Level   CC, Reason for Admission   Pertinent H and P/Comorbidities   First and last vital signs   ...
The Role of the ED in Transitions             of Care          Protocol Driven Care        Care Pathways started in the ED...
Protocol Driven Care:            Guideline Based   Chest Pain/AMI   PNA (HAP and CAP)   Sepsis/Fever/Fever and Neutrope...
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...
The Role of the ED in Readmissions   “Bounce Backs” can be admissions,    observation, or discharges   Coordination of c...
Focus Group Surveys: Identified Drivers forReadmissions                        Drivers           Percent of               ...
The Role of the ED in Readmissions   Discharges:    – Automated outpatient physician follow      up/discharge planning   ...
The Role of the ED in Readmissions   Admissions/Observation:    – Prefer Obs if possible    – Admit back to same service/...
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   Mort...
Hospice/Palliative Care   Palliative Care Service admissions    – 24 hours a day, 7 days a week    – On-line or immediate...
The Role of the ED as Gatekeeper     in Transitions of Care     It Ain’t That Easy Any More           QUESTIONS?
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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

  1. 1. The ED as the Gatekeeper in Transitions of Care James Hoekstra, MD Professor and Chairman Department of Emergency Medicine Wake Forest University Health Sciences
  2. 2. 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
  3. 3. 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
  4. 4. 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
  5. 5. The Role of the ED in Transitions of Care Observation versus Admission
  6. 6. Initial Risk Stratification Scheme Chest Pain History, Physical EKG, TnI UA/NSTEMI/ DefiniteSTEMI Inter Risk Low Risk Non-Cardiac High Risk
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. 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.
  11. 11. The Role of the ED in Transitions of Care Determining and Transmitting Patient Acuity LevelICU versus IMC versus Tele versus Floor
  12. 12. Transmitting Acuity Level SBA – Situation – Background – Assessment – Recommendation Include information to determine not only admission, but level of care
  13. 13. 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?
  14. 14. 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
  15. 15. 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.
  16. 16. The Role of the ED in Transitions of Care Avoiding Readmission PNA, CHF, MI
  17. 17. 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
  18. 18. 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
  19. 19. 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%
  20. 20. 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
  21. 21. 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
  22. 22. The Role of the ED in Transitions of Care Hospice and Palliative Care Reducing Inpatient Mortality
  23. 23. 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
  24. 24. 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
  25. 25. The Role of the ED as Gatekeeper in Transitions of Care It Ain’t That Easy Any More QUESTIONS?

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