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