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Studer Spotlight: Improving Patient Experience for Emergent Admissions

Posted on Wed, Aug 31, 2016
Studer Spotlight: Improving Patient Experience for Emergent Admissions

Since 2010, EmCare has maintained a strong partnership with Studer Group to improve clinical and operational results for our client hospitals. As a result of this partnership, Studer Group has provided access to exclusive content only available on StuderGroup.com. Each month, one of Studer Group's insightful articles will be made available to Emcare.com blog readers. For more information about EmCare's partnership with Studer Group, click here. For more exclusive content, including webinars, learning labs, networking opportunities and more, visit StuderGroup.com.

By Stephanie Baker, RN, MBA, CEN

With as high as three quarters of all unscheduled hospital admissions coming through the emergency department (ED), the overall patient experience hinges on how patients perceive the care they receive in the ED. 1

For those with hospital admissions greater than 90 percent from the ED, the patient satisfaction stakes are even higher. Recently a hospital senior leader asked our team what more they could be doing for patient experience given their high percentage of emergent admissions and correspondingly low percentage of elective admissions which tend to report an overall better patient experience.

Below are three strategies we recommend for driving a positive patient experience:
 

  1. Fast track all direct admission patients or elective patients to protect their arrival experience. The goal is for patients to be admitted and in their bed within 60 minutes of arrival. It is imperative that patients receive effective communication using AIDET® so they understand the plan for their care and feel comfortable. Nurse leaders should round on all new admissions within the first 12-24 hours to welcome them to the unit, provide relevant information, and let patients know that they will round on them daily during their stay. Although this may only apply to a small percentage of your admitted patients, it helps streamline and hardwire an effective admission process and creates a positive first impression. Be sure to validate patient turnaround times daily to see how close you are to the 60-minute arrival-to-bed goal. This lets you know if the process is working and holds admitting and patient placement staff members accountable for results.

  2. Expedite ED admissions based on acuity and length of stay. This is an inherent goal of every ED, but when a large percentage of all hospital admissions come through the ED, the approach must be relentless. Here are a few best practices that can help get the job done:

    • Patient placement coordinators or related roles should round together with the ED manager and charge nurse every four hours to talk to patients to keep them informed and ensure the patient’s clinical status is appropriate for the unit selected for admission. This keeps everyone updated on the status of patients and informs decisions about prioritizing admissions.

    • Inpatient nurse managers should round on ED holding patients at least once a shift to introduce themselves to patients, assess clinical status, ensure admission orders are in progress, and show care and compassion to the patient. This is a big win for both ED holding patients and ED staff as it demonstrates partnership and ownership. The CNO plays a big role in the quality of the experience for ED patients.

    • The CNO should round with the ED Manager on all patients with hold times greater than four to six hours and then round again with those same patients within 24 hours of arrival on the inpatient unit. This sends a strong message to staff and patients that expediting care and admissions from the ED is a priority and helps the CNO assess how well the admission process is working and what specifically needs improvement. To drive accountability and transparency, the CNO will want to review admission process metrics daily at patient flow meetings. Lastly, the CNO provides coaching for leaders who are underperforming and leads sub-groups for areas that need process improvement.

  3. Focus on your care transitions. Effective and safe handovers from the ED to inpatient units are critical to patient safety and clinical outcomes. Of all the patient experience measures included on the HCAHPS survey, care transitions has the highest correlation to overall patient satisfaction. Yet based on national averages, most organizations are not getting it right. There are some best practices for ED to inpatient care transitions you can implement and you should also consider the impact of handovers happening across the continuum of care.

1 American College of Emergency Physicians. http://newsroom.acep.org/2015-05-04-ER-Visits-Continue-to-Rise-Since-Implementation-of-Affordable-Care-Act. (May 2015)

Stephanie Baker

Stephanie Baker has over 25 years of clinical nursing and administrative experience in the areas of Emergency, Trauma, Flight and Critical Care medicine and proven results with her partners around the country. She is a graduate of San Diego State University, has a Bachelor of Science in Nursing and a dual Masters degree in Business Administration and Health Care Management, and is a Certified Emergency Nurse. She is a past recipient of the prestigious “Tribute to Women in Industry” (TWIN) award, a nine-time Studer Group Pillar award winner, and the recipient of the prestigious Studer Group “Flame” award.

Baker is the Emergency Services Division Leader for Studer Group and is an international speaker, coach, and account leader. In addition, she has published multiple articles in peer-reviewed nursing journals, author of the book Excellence in the Emergency Department: How to Get Results and co-author of the book Advance Your Emergency Department: Leading in a New Era.

 

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Tactics for Reducing AMA Discharges

Posted on Wed, Jul 27, 2016
Tactics for Reducing AMA Discharges

By Adam Corley, MD, FACEP, FAAEM
 
A few weeks ago, I cared for a very nice woman who was suffering from a mild cerebral vascular accident (CVA). Her symptoms of weakness in her arm and leg and mildly slurred speech had been going on for more than a few hours, so I didn’t consider her a TPA candidate.
 
I ordered all of the usual treatment and tests for CVA, including a CT of the brain, which confirmed the diagnosis. I went back in to re-examine her, discuss my findings and recommendations, and to let her know that she would need to be admitted to the hospital for additional testing and to see a neurologist.
 
Her exam was unchanged and she listened patiently as I discussed her test results and my recommendations. She asked several questions to better understand her diagnosis and prognosis and she asked me what would happen if she wasn’t admitted to the hospital. I went over the details of my proposed hospitalization, the tests that we would run and the importance of seeing a neurologist.
 
My patient then told me that she would not be able to stay in the hospital. She was the only caregiver for her sick husband and felt that she could get all of the necessary testing as an outpatient. We discussed the risks, benefits and alternatives to hospitalization and discharge, which she seemed to understand. I made a few phone calls to make sure that she could have easy access to the necessary outpatient testing, treatments and specialists, wrote her prescriptions, and encouraged her to return if her condition worsened or if she changed her mind. She completed the necessary paperwork and then I discharged her home from the ER with a diagnosis of acute ischemic CVA.
 
Patients like this who are discharged against medical advice (AMA) make up 1 to 2 percent of all medical admissions and represent unique ethical, legal, financial and operational challenges in healthcare.
 
A 2007 study published in the Journal of Allergy and Clinical Immunology showed that patients with asthma who leave AMA are four times more likely to return to the ER within 30 days and nearly three times more likely to require readmission to the hospital. A study in the International Journal of Clinical Practice concluded that the average length of stay for a readmission following AMA discharge was 2.4 days longer and cost 56 percent more.
 
Several studies have examined the demographic correlations for patients deciding to leave AMA. Substance abuse, lack of insurance, Medicaid and lower socioeconomic status tend to correlate with higher AMA rates.
 
Recently, I have noticed certain groups and hospital systems considering focusing on reducing AMA discharges as a quality measure. The thinking is that if we can reduce patients leaving AMA, they will receive the care necessary to properly treat their illness and probably save the patient, hospital, insurance company or government payer money at the same time. However, it is critically important to approach this issue in a careful and deliberate manner to preserve patient liberty.
 
Patients who are competent to manage their own healthcare and understand the treatment recommendations presented to them should have the autonomy to make decisions that they feel are in their own best interest. Even the sagest medical advice may not be right for some patients or in certain situations.
 
As we work to improve the quality of healthcare in American and continue to focus on population health, it is critically important to maintain patient autonomy and the sanctity of the doctor-patient relationship. Patients should be free to choose the right treatment course for them or to forgo treatment all together if that is their choice. We must avoid the temptation to apply a one-size-fits-all mentality to the delivery of healthcare.
 
Excellent physician communication, systems that reduce barriers to healthcare delivery, individualized solutions to improve patient experience and a flexible approach to meeting patient needs are all excellent tactics to reduce AMA discharges. However, a heavy-handed approach to pressure patients to comply with recommended treatment would be wrong. We should respect patient autonomy and encourage people to make their own healthcare decisions — even if we disagree with them. 


 
Dr. Adam Corley is a practicing emergency physician with more than 10 years of clinical and leadership experience. Dr. Corley serves as Executive Vice President for EmCare’s West Division. He also serves as the medical director for several EMS services and the Anderson County Texas Sheriff’s Department. Dr. Corley lectures and writes on a variety of topics, including decision science and behavioral economics, management of disruptive behavior in healthcare, conflict resolution and healthcare leadership.
 
 

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