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Emergency Department Leadership and Performance Measures

Emergency Department Leadership and Performance Measures. James Augustine, MD, FACEP. James J Augustine, MD. Conflict of Interest Disclosure. James J Augustine, MD. I have no financial relationships with a commercial entity producing healthcare-related products and/or services.

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Emergency Department Leadership and Performance Measures

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  1. Emergency Department Leadership and Performance Measures James Augustine, MD, FACEP James J Augustine, MD

  2. Conflict of Interest Disclosure James J Augustine, MD I have no financial relationships with a commercial entity producing healthcare-related products and/or services. Course Name

  3. The ED Volume Issue for ED Leaders. Even if You Don’t Build it They Will Come!!!

  4. The CDC Data: Americans Vote With Their Feet 140 Million ED Visits

  5. The CDC: NHAMCS 2007 Last Published

  6. The Regulatory Issue. They Want Measures of Quality. If they don’t exist… • CMS on ED Quality: Pneumonia Measures, … • CMS on Admission Times • Current Definition • Admit Decision to Departure Time • Time Interval beginning when “Admit Decision” is made until the actual departure time of the patient from the ED This is a CMS Hospital Inpatient Quality Measure for public reporting in 2013

  7. New Directions/Data Elements • Shall we collect and share some CMS metrics? • The “Decision to Admit” debate • CMS definition= admit order from the chart • More helpful might be “I know I want to admit the patient”, documented on the chart • A new metric we can develop within EDBA? • How about a new or at least consistent RN staffing metric? • RN work varies not by arrivals but by severity and how many patients are in the department (LOS and admit percent proxy)

  8. ED Performance Measures • Early Problem: There are no consistent definitions in industry • EDBA hosted Summit 2006 • Second summit in 2010 in SLC Published 2011 in Annals and AEM • AHRQ funded program on improved ED intake systems

  9. NHAMCSUpdate • Just Published for 2010 • Volume down from 2009 (H1N1 year) • Acuity Up • Demographic trends continue: more elderly, more medical

  10. EDBASolutions • Utilize and assist the CDC NHAMCS survey • Produce good data source for ED leaders • Don’t put ACEP and ENA in untenable positions • Find places to disseminate and publish • Call together groups and produce Definitions (ED Performance Measures Summit in 2006) • Counteract “Street Legends” • Identify Best Practices

  11. Financing the ED: MEPS Data • Medical Expenditure Panel Survey (MEPS), a publicly available dataset available through the Agency for Healthcare Research and Quality (AHRQ). MEPS is an ongoing nationally representative survey which provides data on health care use and expenditures. MEPS is a large-scale survey of the U.S. non-institutionalized civilian population which uses a stratified, multistage probability sampling design • http://meps.ahrq.gov/mepsweb/ • For Years 2005 to 2010 • Medicaid Total Charges $2122.9 Total Payments $553.2 • UninsuredTotal Charges $2040 Total Payments $550 • Private Total Charges $2178.2 Total Payments $991.1 • Medicare Total Charges $2500Total Payments $1000

  12. Florida Data • Published by FL Agency for Health Care Administration • Average charges per hospital ER visit (2008 prices) • $2996 for adult • $1324 for child • Non-emergent ER visits • $2907 adult • $1278 pediatric • Based on common symptoms • $5135 for abdominal pain visit • $2655 average cost for hypertension • $1878 for asthma • $2000 - $3000 for headache including migraine

  13. Florida Data • About half of all Florida ER visits were deemed avoidable • An interactive model is available • Count 7.1 m visits to June 2012 • $3562 average charge for facility, physician, and ancillary services • Results in $25.6 B in charges • If that is same across country: • 140m visits results in $498,689,000,000 charges • A 30% collection rate equals $149.604 Billion

  14. An Early Observation: ED Process Depends on ED Volume The 2010 Challenge The 1990 Challenge

  15. The EDBA Annual Data Survey

  16. Percentage admitted

  17. % Leaving Before Treatment is Complete (LBTC)

  18. General Population Patient Flow is Predictable EMS Emergency Department Walk-ins to ED 371 / 1000 Population 80/1000 Population Total use 451 / 1000 Population 82% Walk-Ins 18% Arrival by EMS LBTC 2% Admit 17% Treat & Release 81% Transfer 2%

  19. Trending and Planning: NHAMCS Helps Predict Future Patient Flows • 3% more patients per year for about the last 18 years • Injury is 34% of ED Patient Load • Highest injury rates are over age 75 • Extended Care Facility Patients are the Most Frequent ED User • 3 m visits in 2010 • 45% admission rate

  20. Predicting Volume Ahead

  21. Not Only More ED Visits in the Senior Age Brackets More Population Enters those Age Groups Each Year

  22. The Patient Mix. Very Important and Unrecognized Issue • The Burn, Trauma, Injury and Cardiac Arrest Issue • What should we have known? • Prevention Works • When prevention works, more people are alive to get ill • Trauma population ages

  23. Changing ED Patient Mix

  24. The ED Payer Mix not Changing Much, except Medicare Payor Class% of Visits Self Pay 15% Medicare 18% Medicaid 31% Worker’s Comp. 1.2% Commercial 37%

  25. ED Utilization Use Per 1000 Persons • Nursing Home Residents (over 1000) • Homeless (around 1000) • Infants under age 1 (931) • Medicaid • Medicare • Insured • Self Pay

  26. Adult & Pediatric EDs Serve Different Needs

  27. ED Visits 1992 to 2010Diagnostics

  28. ED Visits 1992 to 2010Therapeutics

  29. ED Visits 1992 to 2010Critical Care

  30. ED Visits 1992 to 2010Mental Health

  31. The EDBA Data Survey

  32. EDBA Survey 2012 • 1000+ EDs serving over 33 million patients • Volume was up 4-6% versus 2011 • Patient acuity higher, and more patients admitted • Continued increase in EKG utilization • Xray use is down, plateau in use of CT • MRI now running about 1%

  33. EDBA Survey 2012 • EDs are improving throughput, walkaway rates have decreased • About 18% arriving by ambulance and are admitted at an increasing rate • Payor mix stable, except more MCR • Bed Utilization around 1600 visits per patient care space • CPOE about 75% • New Team Triage systems over 25%

  34. The EDBA Annual Data Survey Super Centers

  35. Location and Type

  36. Functional Areas in the ED

  37. Documentation

  38. Greeting Process

  39. Scheduled Hours NOT worked hours

  40. High Acuity ED Visits

  41. Length of Stay and Walkaway

  42. Length of Stay and LBTC

  43. Admit Times (CMS Measure)

  44. EMS Impact: 26M Transports • 42% admitted • Most Common Presentations: • Chest pain and heart disease • Short of breath • Contusions/blunt injury • Sprains of neck and back (MVA) • Syncope and seizures

  45. Correlation of EMS Arrival and Admission

  46. Important Trends even over only 8 years of Data

  47. EKG Utilization Increases from 2004 to 2011

  48. Admissions Through ED

  49. ED Geography: Space and Bed Utilization

  50. Making the Data Valuable: A Day in our ED

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