PROJECT NAME: Transforming the Emergency Department Treatment of Nonemergent
Patients Utilizing the Concept of “Triaging To” Appropriate Patient Centered Care
Institution: University of Texas Health Science Center at Tyler
Primary Author: Brenda Lee, MSN, RN
Secondary Author: Dr. Jonathan MacClements
Project Category: Effectiveness
Overview:
An impetus to redesign the non-emergent care of patients occurred in 2011 when the Family
Medicine Residency program began to explore opportunities to increase access to care in the
Family Medicine Clinic. The program was looking for ways to increase the acuity, diversity and
volume of training opportunities. One consideration was implementing a fast track clinic
adjacent to the emergency department, staffed by residents.
Family Medicine physicians, staff and representatives from administration formed a team and
began to explore the redesign. Unfortunately, the proposed redesign would not meet ACGME
requirements for a Family Medicine Residency program. The expectations of ACGME are; “that
the unit must be contained within walls and clearly identified as the Family Medicine Clinic on
the door of entry……there is no non-residency related activities taking place within the walls of
the FMC”. Therefore, patients would have to be seen in the Family Medicine Clinic.
The team discussions led to meeting the EMTALA Act as a requirement of the new design. The
Emergency Medical Treatment and Active Labor Act, requires a medical screening exam and
stabilizing treatment for all patients presenting to an emergency department in the United
States. However, there is a cultural perception among some that the ED is where one goes for
all care, not just emergency, and it is a right and therefore should be “free”.
Ethical considerations of the EMTALA Act promote lively discussion with regards to treatment of
non-emergent patients. Emergency medicine physicians may have an ethical obligation to
promote treating all patients presenting to the ED however, the hospital has a legitimate right to
limit non-emergency care as it affects the solvency of the hospital. With this legitimate right the
hospital has an ethical obligation to direct non-emergent patients to the appropriate setting for
care. In general, the main goal should be to provide patient centered care that focuses on
medical indications and patient preferences should retain priority.
In 2006, Congress passed technical amendments in the Tax Relief and Health Care ACT, which
further clarified the 2005 Federal Deficit Reduction Act, provisions on cost sharing as
prerequisite for receiving nonemergency services in an ED under certain specific
circumstances. The Federal requirements for co-payment in the Emergency Room would
provide the steps required in order to analyze cost effectiveness of the non-emergent patient.
Studies vary widely on what percentage of overall ER visits are unnecessary, for Medicaid
patients and others. The research firm Rand found in 2010 that about 17 percent of visits to
ERs were unnecessary and added $4.4 billion in annual health-care costs. A 2010 study in
Health Affairs found that up to 27 percent of all emergency room visits could take place at
urgent-care centers or retail health clinics.
National Studies have found Medicaid recipients use the ER at almost three times the rate of
privately insured and uninsured individuals. Efforts to reduce unnecessary ER visits by Medicaid
patients are proliferating as states search for ways to control the soaring cost of the program.
Texas is no exception to the Medicaid reduction efforts as evidenced by reducing
reimbursement by 40% for non-emergent patients effective. One contributing factor to the high
rate of Medicaid use is the lack of primary care providers accepting Medicaid patients. This
would be eliminated as a patient barrier in the hospital’s redesign. The hospital’s data suggest
an average 24% Medicaid recipient.
TOTAL EMERGENCY DEPARTMENT VISITS BY PAYOR
Payor
2012
2011
2010
Commercial
18.5
18.5
18.9
Correctional Managed
.3
.8
.8
Care
Medicaid
25.4
23.5
23
Medicare
26.0
27
27
Indigent
.3
.4
.7
Self-Pay
29.5
29.8
31
The mandated reimbursement changes became the catalyst for the redesign of care for nonemergent patients presenting to the emergency department. This project aligns with the
hospital’s strategic plan for both the financial and growth pillars.
Aim Statement:
Emergency Department non-emergent patients “Triaged To” the Family Medicine Clinic will
result in a 5 % increase in patient visits by July 2012.
Measures of Success:
Total number of Hospital nonemergent visits where an alternative is available
Value stream analysis of process
Patient Satisfaction
Rate of increase in visits for the ED and FMC
Payer analysis of nonemergent patients
“Triaged To” Patient demographics
Use of Quality Tools:
The fishbone diagram identified registration and reimbursement barriers to be addressed in the
written procedural document. The literature search did not provide an example of how other
hospitals have addressed these issues.
Physicians
Registration
Criteria for Level 4 & 5
Medicaid Regulations
Acute care volume
Identify flow
Non-emergent patients
in Emergency Department
Lack of PCP use
Transportation
Volume shift to after 6 pm
Perceptions of non-urgent patients
Nurses
Where / how to bill patient
Avoid duplication of service?
Have to register in clinic?
Triage
Lack of access
Residency
No pay at front / No co-pay
Admit then discharge (double work)
Documentation in EMR LSS/
Meditech (template -vs- dictate)
Legal
No billing from ED
ER – Meditech
Clinic – LSS (IT)
Overwhelmed during day ( )
EMTALA (who/
where)
Reimbursement
Where?
Productivity decrease
Patient
Patient may adjust behavior to
after hours
Self select ER
Triage = Direct to clinic
The ESI 5 level triage represents patient flow through the system for all patients as well
as nonemergent.
Enter
Emergency Department
Waiting room
Triage Nurse Station
Triage Nurse
·
·
Takes patient information
Sorts patient into one of 5 ESI levels
based on her/his condition
ESI-1 Patient
ESI- 2 Patient
ESI-3 Patient
ESI-4 Patient
ESI-5 Patient
Most severe
injuries
Severe injuries
Require
multiple testing
Require one
testing
Require no
testing
Young
Patient
Elderly
Patient
Med/Surg
24 hours a day, 7 days a week
ICU
24 hours a day, 7 days a week
ICU Patient
·
Med/Surg Patient
Has severe clinical condition that
require urgent action
Has highest priority of all
patients
·
Medical Screening
by Physician
Non-urgent
·
·
Has severe clinical
condition
Has lower priority than
ICU patient
Patient escorted to
PCMH
Patient seen by
First available
provider
MD Assessment
Diagnostic Testing Station
Yes
Technician
Provide X-ray, Imaging (CT/MRI),
Ultrasound, or Lab Testing (ex.
Blood, urine, etc.)
Diagnostic
Testing
required?
No
Follow-up Treatment
·
·
Doctor/Physician Extender/
Resident
Reviews the documents and
results from initial
assessment and diagnostic
testing
Decides what additional
treatment procedures are
required
Patient leaves the ED
The patient is
either discharged
from the ED or
admitted to the
hospital depending
upon the doctor’s
orders
Yes
Discharge?
No – ICU
No – Med/Surg
Interventions:
The overall improvement plan would incorporate the following elements:
1. Patients who present to the ED should be given an examination informed by the best
clinical judgment, and taking into account the patient’s personal preferences.
2. To determine whether the patient has a medical emergency and can be safely triaged to
another health care setting.
3. Patient would be informed of state-specified cost-sharing provisions.
4. Arrangements would be made, during regular family practice clinic hours, for a physician
to examine and treat the patient. An Intermediate Care Physician (resident) would be
assigned to the patients triaged to the Family Medicine Clinic
5. Patient would be physically escorted to the Family medicine clinic.
The ED team members outlined the procedure for patients from arrival at the ED to transport to
the FMC. The ESI 5 Level triage system was fully implemented with completion of competency
training for nursing and physicians. The addition of a transporter was the only FTE required for
the change.
The FMC team members completed the procedure from time of arrival and check in to check
out. The initial design of the procedure would have eliminated the requirement to register at the
FMC and repeat patient triage assessment components of vital signs, chief complaint, etc.
Unfortunately the ED is not utilizing an EMR while the FMC is currently utilizing an EMR. The
solution was to copy the Triage documents and send with the patient during transport.
The registration and financial team members outlined the process for both ED and FMC. The
patient would be registered as usual. Once the patient is triaged a level 4 or 5, the physician
performs the medical screening exam in the triage room. The patient is provided with the option
of being seen in the FMC or seeks medical care from the provider of their choice. The patient is
not charged an emergency room visit. They are then transported upstairs. An appropriate
charge is determined based on whether the patient is new or established.
The physicians and residents created a plan for scheduling the Intermediate Care Resident on a
rotational basis. The resident would have open slots for patients as well as scheduled patients.
In the event the Intermediate Care resident is not available any other Family Medicine physician
would see the patient. A specific template was created in the EMR for this type of patient.
The timeline required the new patient flow be implemented by March 1, 2012.
Results:
Overall patient satisfaction results did not demonstrate a statistically significant variation
during implementation of the process change. This illustrated the process design was
not perceived negative by patients.
Date and time results for nonemergent patients are consistent with national findings for all
patients seeking care in the ED. We will need to expand the study to capture the peak rise seen
from 8pm to 11pm in the next phase of the study.
The initial administrative concern regarding financial risk for decreasing ED revenue was not
supported. The ED was able to maintain volumes while “triaging to” the FMC an average of 5%
-10% patients per month.
UTHSCT Non-emergent Patient Flow
ED Check In
Triage to FMC
Transport Time
from ED to FMC
FMC Check In to
Registration
Registration To
Room
Room to Nurse
March = 33
April = 34
May = 29
June = 30
July = 36
March = 9
April = 7
May = 6
June = 5
July = 6
March = 8
April = 9
May = 9
June = 10
July = 8
March = 3
April = 4
May = 5
June = 6
July = 8
March = 5
April = 6
May = 6
June = 5
4
July = 4
Minutes
Mean = 32
Minutes
Mean = 7
Minutes
Mean = 9
Minutes
Mean = 5
Minutes
Mean = 5
Nurse to Ready
Ready to Physician
Physician to
Depart
Overall Time in
FMC
March = 3
April = 3
May = 5
June = 4
July = 2
March = 6
April = 13
May = 16
June = 16
July = 12
March = 37
April = 37
May = 28
June = 34
July = 27
March = 57
April = 76
May = 68
June = 71
July = 68
Minutes
Mean = 3
Minutes
Mean = 13
Minutes
Mean = 33
Minutes
Mean = 68
The patient flow means will be analyzed to determine if non-value added steps can be
eliminated in the process. At current, the process variation may be tied to level of patient
encounter and will be assessed in the next phase of study.
Revenue Enhancement /Cost Avoidance / Generalizability:
ED Non-emergent Patients by Payer and Total Visit Charges
Comm.
Ins
Month
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Total
Month
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Total
Less Transport FTE x 5
months:
Medicaid
15
11
8
3
4
41
Medicare
10
11
16
10
11
58
Self-pay
25
40
49
13
16
143
Monthly Total
Comm.
Ins
5471.00
8933.00
10433.00
3114.00
3520.00
31471.00
Medicaid
3611.00
2497.00
1739.00
755.00
928.00
9530.00
Medicare
2049.00
2235.00
3786.00
1916.00
2332.00
12318.00
Self-pay
5000.00
6050.00
7900.00
3500.00
2990.00
25440.00
41
47
59
27
23
197
91
109
132
53
54
439
Monthly Total
$16,131.00
$19,715.00
$23,858.00
$9,285.00
$9,770.00
$78,759.00
-$10,400.00
$68,359.00
*July financials estimated based upon average charges per patient:
Commercial Ins: 220.00
Medicaid: 232.00
Medicare: 212.00
Self-pay: 130.00
Annualized ROI For FMC
Projected ER 2012
Visits
Commercial - 18.5%
Medicaid - 25.4%
Medicare - 26.0%
Indigent - 3%
Self-pay - 29.5%
Correctional - 3%
13,538 x 10%
= 1,353
250
344
352
4
399
4
220
232
212
$55,000.00
$79,808.00
$74,624.00
130
$51,870.00
$261,302.00
-$24,960.00
Less Transport FTE

*ROI $236,342.00
Conclusions and Next Steps:
The project was successful in alignment with strategic goals. FMC was able to increase
volumes; the ER was able to better manage the day shift hours without adding an additional
mid-level provider to assist with nonemergent patients. Both physicians and nursing voiced
increased satisfaction with triage to the FMC.
The tracking report will include patient chief complaint in the future to compare to the Medicaid
Top 10 diagnosis: common cold, sore throat, stomach problems, pregnancy-related symptoms,
vomiting, bronchitis, bruising, headache, urinary tract infection, viral infection. The advantage to
tracking specific patients versus pulling based on coding is the accuracy will not skew the data
for Medicaid cost savings. We will also need to have an accurate report for all patients by ESI 5
level system to estimate the availability of primary care providers required to increase access to
care after hours and weekends.
Variation from 5% - 10% of “triaged to” will need to be reduced by determining if all
nonemergent patients are actually being sent to the FMC. Standardization of the new process
will ensure this occurs.
This project has significant generalizability to UT System hospitals as well as any Emergency
Department. The next phase of the study will also determine the cost savings to Medicaid at the
Federal and State level once a larger sample size is available.