High performance emergency medicine

1. Improved clinical care

• Increased success rates with specific interventions and procedures in the ED (intubations, conscious sedation for fracture reduction, central lines, etc.)

• Improved time-to-treatment for specific time-sensitive interventions (thrombolytic therapy and percutaneous coronary interventions for ST segment elevation myocardial infarction, thrombolytic therapy for stroke, early goal-directed therapy for sepsis, etc.)

• Decreased morbidity for certain conditions (as measured by shorter length of inpatient hospitalization, or perhaps shorter stays in ICU setting)

2. Improved patient satisfaction

3. Downstream cost savings for the healthcare system through:

• shorter hospital lengths of stay

• decreased utilization of healthcare and rehabilitation resources

4. Reduced resource utilization at the hospital level

• reduced use of specialists

• decreased overcrowding

• shorter lengths of stay

• improved diagnostic study turnaround times

• reduced readmissions

5. Reduction in unnecessary admissions to hospital for specific conditions (low risk chest pain, congestive heart failure, COPD, etc.)

6. Reduction in utilization of specialist consultants from other departments (big cost savings) as the ED physician and nursing staff becomes able to provide more care without need for supervision or involvement from other specialties (airway management, fracture reduction, etc.)

7. Decompression of workload for acute patients creates more space for other activities – such as elective patients, non-clinical activities such as research, education, administrative, professional development, etc.

The high performing ED’s scope of care

• Perform initial patient management

  • Stabilize

  • Initiate targeted diagnostic and treatment plans

• Determine appropriate inpatient destination for patients needing admission

• For patients being admitted:

  • Ensure that those patients arrive in stable condition

  • Ensure patients arrive with a working diagnosis and the relevant initial diagnostics and therapeutics initiated.

• For patients who do not require admission:

  • Initiate relevant treatments that can be started in the ED

  • Discharge patients with appropriate follow-up plans in place.

How can your system or hospital implement high-performance emergency medicine?

• System-wide changes that redirect patients with undifferentiated medical problems to the Emergency Department (ED)

• Hospital and ED management and policies that clearly define the scope of ED care

• Improved access to and improved processes surrounding diagnostic and therapeutic resources

• Improved medical decision-making ability, and clear role definition, of the senior emergency physician

• Standardization of patient management through use of evidence-based pathways

• Optimization of ED processes through continuous lean process improvement initiatives

• Creation of a staffing model to optimize operations and patient management needs

• Development of education and training programs to support the new staffing model, including team-training for interdisciplinary care

Earlier diagnosis and treatment in the ED improves downstream outcomes.

Early Goal Directed Therapy in the Emergency Department for Sepsis Patients

• 20.3% reduction in mortality from Early Goal Directed Therapy

• 32.6% reduction in hospital Length Of Stay (4 days per hospital admission)

• 23.4% reduction in hospital costs related to sepsis

  (Otero et. al. CHEST 2006)

Impact of Emergency Medicine Training Programs on Trauma Center Performance

• Fewer complications (5.1% vs. 11.0%) p < 0.0001

• Lower mortality (4.7% vs. 5.4%) p = 0.0013

• Shorter hospital Length of Stay (4.9 days vs. 6.3 days) p < 0.0001

  (Taylor et.al. J Emerg Med 2005)