James Augustine, MD, FACEP
James J Augustine, MD
ED Leadership EDPMA 2013
James J Augustine, MD
I have no financial relationships
with a commercial entity
producing healthcare-related
products and/or services.
Course Name
ED Leadership EDPMA 2013
The ED Volume Issue for ED Leaders.
Even if You Don’t Build it They Will Come!!!
ED Leadership EDPMA 2013
The CDC Data:
Americans Vote With Their Feet
ED Visits
160,000,000
140
Million ED
Visits
140,000,000
120,000,000
100,000,000
80,000,000
ED Visits
60,000,000
40,000,000
20,000,000
1992
1995
1997
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
0
ED Leadership EDPMA 2013
The CDC: NHAMCS 2007
Last Published
ED Leadership EDPMA 2013
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
ED Leadership EDPMA 2013
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)
ED Leadership EDPMA 2013
7
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
ED Leadership EDPMA 2013
NHAMCS Update
 Just Published for 2010
 Volume down from 2009 (H1N1 year)
 Acuity Up
 Demographic trends continue:
more elderly, more medical
ED Leadership EDPMA 2013
EDBA Solutions
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





ED Leadership EDPMA 2013
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
Uninsured
Private
Medicare
Total Charges $2122.9
Total Payments $553.2
Total Charges $2040 Total Payments $550
Total Charges $2178.2
Total Payments $991.1
Total Charges $2500 Total Payments $1000
ED Leadership EDPMA 2013
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
ED Leadership EDPMA 2013
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
ED Leadership EDPMA 2013
An Early Observation:
ED Process Depends on ED Volume
The 2010
Challenge
The 1990
Challenge
ED Leadership EDPMA 2013
The EDBA Annual Data Survey
2011 Results for 830 EDs
seeing 29.6m pts
Over 100K EDs
2011 results
80 to 100K EDs
2011 results
60 to 80K EDs
2011 results
40 to 60K EDs
2011 results
20 to 40K EDs
2011 results
Under 20K EDs
2011 results
Hi CPT
Acuity
Under
age 18
Admit %
Transfer
%
EMS
Arrival
EMS
Arrival
Admit
Median
LOS
66%
20.2%
21.8%
0.9%
23%
42%
214
182
71%
18.4%
20.9%
1.1%
21%
44%
218
66%
18.2%
20.8%
1.2%
19%
44%
65%
19.5%
19.1%
1.4%
18%
63%
20.2%
17.1%
1.8%
55%
23.7%
12.7%
99.0%
2.7%
Pediatric EDs
48%
2011 Results
Adult, Specialty EDs
71%
2011 Results
Urgent Care, Freestanding EDs
41%
23.6%
2011 Results
LBTC
Door
to Doc
EKG
per
100
356
2.3%
31
30
187
362
3.4%
38
25
205
174
337
2.8%
35
31
43%
186
156
303
2.3%
33
28
16%
41%
160
134
261
1.7%
28
26
2.7%
12%
39%
139
115
227
1.4%
23
20
11.4%
0.6%
8%
33%
147
132
270
1.4%
31
4
25.5%
1.1%
23%
48%
240
204
346
3.2%
40
34
4.2%
3.4%
7%
31%
100
97
240
1.0%
22
12
ED Leadership EDPMA 2013
MLOS Treat MLOS
& Release
Admit
Percentage admitted
40%
95% CI Notched Outlier Boxplot
35%
Outliers > 1.5 and < 3 IQR
30%
Outliers > 3 IQR
25%
20%
15%
10%
5%
0%
Admit %
ALL EDs
4/8/2015
Admit %
>100K
Admit %
80-100K
Admit %
60-80K
Admit %
40-60K
Admit % Admit % 1- Admit %
20-40K
20K
AdultEDs
Admit %
PedEDs
16 ED Leadership EDPMA 2013
% Leaving Before Treatment is Complete
(LBTC)
8%
95% CI Notched Outlier Boxplot
7%
Outliers > 1.5 and < 3 IQR
6%
Outliers > 3 IQR
5%
4%
3%
2%
1%
0%
LBTC ALL
EDs
4/8/2015
LBTC
>100K
LBTC 80100K
LBTC 6080K
LBTC 4060K
LBTC 2040K
LBTC 120K
LBTC
AdultEDs
LBTC
PedEDs
17 ED Leadership EDPMA 2013
Patient Flow is Predictable
General Population
EMS
Emergency Department
Walk-ins to ED
371 / 1000
Population
80/1000
Total use 451 / 1000
Population
Population
82% Walk-Ins
18% Arrival by EMS
Transfer
Admit
2%
17%
Treat &
Release
81%
ED Leadership EDPMA 2013
LBTC
2%
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
ED Leadership EDPMA 2013
Predicting Volume Ahead
Graying of the ED
800
700
600
500
1992
400
2008
300
200
100
0
All ED Visits
Ages 45 - 64
ED Leadership EDPMA 2013
Age over 65
Age over 75
Not Only More ED Visits in the Senior Age Brackets
 More Population Enters those Age
Groups Each Year
800
Graying of the ED
700
600
500
1992
400
2008
300
200
100
0
All ED Visits
Ages 45 - 64
ED
Leadership
EDPMA 2013
Age over
65
Age over 75
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
ED Leadership EDPMA 2013
Changing ED Patient Mix
ED Leadership EDPMA 2013
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%
ED Leadership EDPMA 2013
ED Utilization
Use Per 1000 Persons
•
•
•
•
•
•
•
Nursing Home Residents (over 1000)
Homeless (around 1000)
Infants under age 1 (931)
Medicaid
Medicare
Insured
Self Pay
ED Leadership EDPMA 2013
Adult & Pediatric EDs
Serve Different Needs
ED Leadership EDPMA 2013
ED Visits 1992 to 2010
Diagnostics
ED Leadership EDPMA 2013
ED Visits 1992 to 2010
Therapeutics
ED Leadership EDPMA 2013
ED Visits 1992 to 2010
Critical Care
ED Leadership EDPMA 2013
ED Visits 1992 to 2010
Mental Health
ED Leadership EDPMA 2013
The EDBA Data Survey
Super Centers
Over 100K
Over 275 PPD
Very Large
Over 80,000
Over 220 PPD
Large
60 – 80K
165 – 220
Medium
40 – 60K
110 – 165
Small
20 – 40K
55- 110
Micro
Under 20K
Under 55
Pediatric and
Freestanding EDs
Any Volume
Any PPD
ED Leadership EDPMA 2013
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%
ED Leadership EDPMA 2013
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%
ED Leadership EDPMA 2013
The EDBA Annual Data Survey
LBTC
Door
to Doc
EKG
per
100
356
2.3%
31
30
187
362
3.4%
38
25
205
174
337
2.8%
35
31
43%
186
156
303
2.3%
33
28
16%
41%
160
134
261
1.7%
28
26
2.7%
12%
39%
139
115
227
1.4%
23
20
11.4%
0.6%
8%
33%
147
132
270
1.4%
31
4
2.7%
25.5%
1.1%
23%
48%
240
204
346
3.2%
40
34
Urgent Care, Freestanding EDs
41%
23.6%
2011 Results
4.2%
3.4%
7%
31%
100
97
240
1.0%
22
12
2011 Results for 830 EDs
seeing 29.6m pts
Over 100K EDs
Super Centers
2011 results
80 to 100K EDs
2011 results
60 to 80K EDs
2011 results
40 to 60K EDs
2011 results
20 to 40K EDs
2011 results
Under 20K EDs
2011 results
Hi CPT
Acuity
Under
age 18
Admit %
Transfer
%
EMS
Arrival
EMS
Arrival
Admit
Median
LOS
66%
20.2%
21.8%
0.9%
23%
42%
214
182
71%
18.4%
20.9%
1.1%
21%
44%
218
66%
18.2%
20.8%
1.2%
19%
44%
65%
19.5%
19.1%
1.4%
18%
63%
20.2%
17.1%
1.8%
55%
23.7%
12.7%
99.0%
Pediatric EDs
48%
2011 Results
Adult, Specialty EDs
71%
2011 Results
ED Leadership EDPMA 2013
MLOS Treat MLOS
& Release Admit
Location and Type
Urban
Suburban
Rural
Academic
Trauma
Over 100K
56%
44%
0
78%
94%
80 to 100K
72%
24%
4%
68%
85%
60 to 80K
48%
49%
3%
42%
66%
40 to 60K
50%
39%
11%
30%
42%
20 to 40K
42%
29%
29%
19%
25%
Under 20K
24%
27%
49%
5%
3%
Adult ED
95%
5%
0
67%
61%
Peds ED
83%
17%
0
67%
63%
ED Leadership EDPMA 2013
Functional Areas in the ED
Fast Track
Trauma Area
CDU/Obs
CPOE
Over 100K
88%
88%
50%
87%
80 to 100K
90%
80%
24%
80%
60 to 80K
60%
59%
35%
83%
40 to 60K
61%
24%
19%
65%
20 to 40K
48%
18%
7%
70%
Under 20K
2%
0
2%
75%
Adult ED
75%
69%
8%
80%
Peds ED
70%
50%
8%
90%
33%
18%
ED Leadership EDPMA 2013
75%
All EDs
58%
Documentation
Computerized
Dictated
Templates
Hand
Written
Scribes
Over 100K
50%
21%
28%
21%
21%
80 to 100K
75%
10%
15%
10%
25%
60 to 80K
60%
45%
24%
17%
19%
40 to 60K
61%
27%
21%
17%
17%
20 to 40K
67%
24%
14%
11%
15%
Under 20K
70%
17%
22%
10%
10%
Adult ED
63%
23%
25%
12%
25%
Peds ED
54%
8%
4%
8%
4%
67%
23%
20%
12%
16%
All EDs
ED Leadership EDPMA 2013
Greeting Process
Nursing
Physician
MLP
Over 100K
100%
17%
6%
80 to 100K
100%
40%
5%
60 to 80K
100%
19%
17%
40 to 60K
100%
31%
10%
20 to 40K
100%
6%
5%
Under 20K
92%
0
2%
Adult ED
100%
21%
12%
Peds ED
100%
3%
0%
98%
18%
8%
All EDs
ED Leadership EDPMA 2013
Scheduled Hours NOT worked hours
RN
Techs and
Clerks
Physician
Physician
and MLP
Over 100K
0.7
1.1
2.65
2.2
80 to 100K
0.7
1.3
2.87
2.3
60 to 80K
0.7
1.5
2.65
2.3
40 to 60K
0.6
1.4
2.89
2.7
20 to 40K
0.7
1.9
2.63
2.1
Under 20K
0.6
1.5
1.7
1.5
Adult ED
0.6
1.4
2.52
2.0
Peds ED
0.6
1.5
2.12
1.9
0.7
1.5
2.5
2.2
All EDs
ED Leadership EDPMA 2013
High Acuity ED Visits
ED Leadership EDPMA 2013
Length of Stay and Walkaway
ED Leadership EDPMA 2013
Length of Stay and LBTC
ED Leadership EDPMA 2013
Admit Times (CMS Measure)
ED Leadership EDPMA 2013
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
ED Leadership EDPMA 2013
Correlation of EMS Arrival and Admission
25%
20%
15%
Admits
EMS
10%
5%
0%
Very Large
Large
Medium
Small
ED Leadership EDPMA 2013
Micro
PEDs &Freestanding
Eds
Important Trends even over only 8 years
of Data
Year
2011
EKG
Hospital Admits
26
67%
2010
24
67%
2009
23
65%
2008
22
64%
2007
20
62%
2006
19
61%
2005
18
61%
2004
17
58%
ED Leadership EDPMA 2013
EKG Utilization Increases from 2004 to 2011
35
30
25
20
15
10
5
0
Macro
Very Large
Large
Medium
Small
Micro
ED Leadership EDPMA 2013
PED EDs
Adult EDs
Admissions Through ED
Percentage
70%
60%
50%
40%
30%
20%
10%
0%
1980
ED Leadership EDPMA 2013
1990
2010
ED Geography: Space and Bed Utilization
Size of Facility
Square Footage
Per Bed
Super Center
3.9
1422
Very Large
3.2
1606
Large
2.8
1561
Medium
3.3
1621
Small
3.2
1641
Micro
2.6
1391
Pediatric EDs
3.7
1792
Adult EDs
3.3
1389
ED Leadership EDPMA 2013
Making the Data Valuable: A Day in our ED
130
Patients to be seen, although 3 want to leave
40
Will be in Fast Track
56
Will need Monitors
23
Will be Admitted 26% Of Patients in Main ED
6
Will have Dental Problem
991
25
Orders will be Entered in CPOE, or 7.6 per patient, and 21% of all
orders Entered in the Hospital Today
Will Arrive by EMS
ED Leadership EDPMA 2013
ED Metrics and ED Future
 Plan Forward with Hard Numbers
 Know, Understand, and Share your
Numbers, Compare to Cohorts
 Make Sure all Staff Know Numbers
 Use Data to Drive Future
 Tell Your Story Effectively in Developing
Designs, Process, Staff
ED Leadership EDPMA 2013