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ImageIt's the perpetual conundrum facing emergency departments: how to move patients through efficiently, decrease ED length of stay, wait times, and those leaving without being seen while not increasing readmission rates, particularly because failure on the latter measure will lead to Medicare penalties when the Patient Protection and Affordable Care Act goes into effect next year. A number of hospitals have implemented the Stony Brook overcapacity protocol, pioneered by Peter Vicciello, MD, a clinical professor and the vice chair of emergency medicine at Stony Brook University Medical Center, in which ED patients are rapidly shuttled to hospital wards even if it means they wait in inpatient hallways if beds are not available. (See FastLinks for the EMN editorial by Dr. Viccellio that launched the overcapacity protocol.) Alberta Health Services in Canada implemented a province-wide overcapacity protocol based on the Stony Brook model two years ago. The protocol is triggered when ED capacity hits 110 percent, when 35 percent of stretchers are blocked by patients awaiting beds, and when no stretcher is available for patients arriving as a 2 or 3 on the Canadian Triage and Acuity Scale (CTAS). ED patients are rapidly transferred at that point to an inpatient unit or other space. Researchers from the University of Calgary and Alberta Health Services reported that mean ED length of stay for admitted patients decreased 38 percent, from 16.9 hours to 10.5 hours, despite an 8.6 percent increase in total ED volume since the protocol was implemented. The average time from the arrival of a patient with a CTAS score of 3 to his assessment by a physician decreased 20 percent, from 147 minutes to 118 minutes, and rates of CTAS 1–3 patients who left without being seen fell 45 percent, from 4.7 percent to 2.6 percent. (CMAJ 2012;14[S1]; http://bit.ly/VvMXa3.) The big unknown, however, is the protocol's impact on readmission rates, said Eddy Lang, MD, a lead author of the paper and a senior researcher in emergency medicine at the University of Calgary. “Our plan this year is to look at whether the other shoe dropped and there was undue pressure on the ward to release patients early, resulting in what might be viewed as an increase in readmission rates,” he said. Dr. Lang said he hopes to have that data to present at the Society for Academic Emergency Medicine's annual meeting in May. Ideally, EDs' efforts to reduce readmission rates should be part of a broader hospital-wide strategy, said Leslie Zun, MD, MBA, the chair and a professor of emergency medicine at Chicago Medical School and Mt. Sinai Hospital. Mt. Sinai implemented a comprehensive protocol nearly two years ago for reducing congestive heart failure readmissions to the ED and the hospital called Project RED (Re-engineering Discharge). “We went through a lengthy process to figure out how to better coordinate all the services that a patient gets in order to reduce their risk of readmission, flow-diagramming every step in the process,” he said. “Quite to my amazement, it was much more complicated than I ever had imagined. Part of the problem is that each of the phases — the ED phase, the inpatient phase, the outpatient phase — is very disjointed from each of the others.” Project RED involved several key components, including medication reconciliation, a written discharge plan and individual discharge instruction booklet, post-discharge services (such as a follow-up phone call from pharmacists), and assignment to targeted physicians in the Mt. Sinai network for patients with no primary care providers. “We assigned patients in the pilot project an admitting physician who understood congestive heart failure,” he said. “Then, we had a selected group of primary care physicians on the back end who would follow up.” But perhaps the most important piece of the puzzle was the discharge coordinator, a specially trained staff member assigned to coordinate all the patients' discharge activities, educate the patient and family about the condition, medications, and care plan, and schedule their post-discharge activities. “That's what made it an optimal process,” Dr. Zun said. Emergency physicians played a key role in the implementation of Project RED, starting automatic consults with all CHF patients who fit the pilot's protocol and encouraging discussions with primary care providers to assess patients' need for admission. The results were dramatic. “Before starting the project, from July 2010 to January 2011, we had 34 readmissions in this population. Our risk-adjusted expected rate of readmission was 8.02 percent, but we were at 18 percent, so about 10 percent higher than we should have been,” Dr. Zun said. “Between February and July of 2011, after implementing Project RED, we had five readmissions. Our overall rate for that period was 3.79 percent, compared with our risk-adjusted expected rate of 7.93 percent.” Mt. Sinai is now expanding the project to other chronic diseases, including diabetes and asthma. Such efforts are laudable, Dr. Lang said, but he said he can't help questioning the validity of the whole readmissions reduction construct as it relates to reimbursement rates. “I would venture to say that there is actually very little evidence to support readmission rates being a valid quality measure. When we get our cars fixed, we expect a warranty period, but can we extrapolate that to health care? This is more complex than servicing cars. You can't have a revisit rate of zero because that means you're keeping people too long,” he said. Dr. Lang pointed to work published last year demonstrating that urgent readmissions deemed potentially avoidable represented less than 20 percent of all urgent readmissions following hospital discharge. (CMAJ 2011;183[14]:E1057.) “It's important that there be constant pressure, whether in the ED or on the wards, to discharge patients safely but in a way that puts some stress on the system,” Dr. Lang said. “Say you have a patient upstairs in the hospital on day three of pneumonia. They're starting to feel better, and it's time to switch them from IV to oral antibiotics. Do you keep them a day or two longer to make sure they're OK, or do you send them home assuming they're probably going to be OK? In the world of everybody watching over our shoulders to make sure there are no bouncebacks, there's a tendency to keep people. But there are unintended consequences of that — increased risk of hospital-acquired infections, the risk of delirium, and so on. It calls into question for me the idea of putting too much weight on readmission rates.” But he said that does not mean he is not going to measure them because they can be useful in some ways. “If Hospital A has a four percent readmission rate and Hospital B has a two percent rate, I don't know that that means anything useful,” he said. “But if hospital B goes from two percent to six percent, something might be happening. I think there's probably more value of being aware of these numbers within institutions and following them over time, rather than comparing hospitals and dinging or penalizing some for higher readmission rates.” Click and Connect!Access the links in EMN by reading this issue on our website or in our iPad app, both available onwww.EM-News.com. FastLinks Read the EMN editorial by Dr. Peter Viccellio that launched the overcapacity protocol in emergency medicine at http://bit.ly/TKfQrT. Comments about this article? Write to EMN at [email protected].

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