HomeMy WebLinkAboutMINUTES - 10282008 - D.3 sE-L
TO: BOARD OF SUPERVISORS
Contra
" 3, ` Costa
FROM: William Walker, M.D., Director o! "s
Contra Costa Health Services ' 40
�osT
DATE: October 28, 2008 a cbu`K'� County
SUBJECT: Emergency Department Utilization in Contra Costa County
SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION
RECOMMENDATION:
ACCEPT report from the Health Services Director on the challenges facing Contra Costa
Regional Medical Center Emergency Department and the strategies being used to streamline
operations and improve patient care.
FISCAL IMPACT:
No impact from this report.
BACKGROUND:
Emergency departments across the country are struggling to keep pace with exploding
demands. Today we're going to discuss the challenges being faced by emergency departments
in general and we'll focus especially today on what strategies our Contra Costa Regional
Medical Center Emergency Department is using to meet the increasing patient load and provide
quality care.
CONTINUED ON ATTACHMENT: X YES SIATURE:
_jZ' RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
_APPROVE OTHER
SIGNA RE(S):
ACTION OF BOARD ON LO/a �/� O APPROVE AS RECOMMENDED X OTHER
VOTE OF SUPERVISORS
I HEREBY CERTIFY THAT THIS IS A TRUE .
UNANIMOUS (ABSENT �N�d�/ ) AND CORRECT COPY OF AN ACTION TAKEN
AND ENTERED ON THE MINUTES OF THE BOARD
AYES: NOES: OF SUPERVISORS ON THE DATE SHOWN.
ABSENT: ABSTAIN: / p
ATTESTED O f y0.
DAVID A,CLERK OF THE BOARD OF
SUPERVISORS AND COUNTY ADMINISTRATOR
Contact Person: Julie Freestone
CC: Health Services Department
BY: DEPUTY
Health Services Emergency Department Challenges
Page 2 of 3
1. According to a study released by the Centers for Disease Control and Prevention
National Center for Health Statistics in August 2008, hospital emergency departments,
typically the medical providers of last resort, are becoming the only option for insured as
well as uninsured people who are unable to get care elsewhere.
2. The report indicates that emergency room visits jumped more than 32% from 90.3 million
in 1996 to 119 million in 2006, the most recent year statistics are available, according to
the National Center for Health Statistics, a division of the Centers for Disease Control
and Prevention. Only about 13 percent of visits to emergency departments resulted in a
hospital admission. Shortly you'll be hearing our own local statistics on increased ED
visits at CCRMC.
3. The report notes that the difficulty in getting primary care appointments could be
contributing to the rise in emergency room use, particularly by those with insurance or on
government programs such as Medicare or Medicaid. That is an issue in our system,
with some delays in getting primary care appointments and longer waits for speciality
care across the county and the state.
4. While the number of people without health insurance has risen to about 47 million, an
increase of more than 5 million since 1996, neither that increase nor the overall growth in
population accounted for the overcrowding of emergency departments, the report said.
5. A study in the August Annals of Emergency Medicine confirmed the federal government's
findings. That study found the proportion of emergency visits by the uninsured had not
changed substantially between 1992 and 2005, while the number of overall visits went up
28 percent. The survey also found that people in the highest income bracket- in excess
of 400 percent of the federal poverty level - accounted for an increasing portion of
emergency room visits, while the lowest income brackets remained virtually unchanged.
6. Locally and across the country, the problem is compounded by a dramatic decrease in
the number of emergency departments. Statewide, more than 65 emergency
departments have closed over the 15 years, 28 of them since Jan. 1, 2000, according to
the state's Department of Health Services. In Contra Costa, since 1994, those closures
have included Los Medanos Hospital, Doctors Hospital Pinole and Kaiser Martinez.
Kaiser Antioch opened this year.
7. One of the compelling reasons for the County's commitment to stabilizing Doctors
Medical Center related to the Emergency Department and the Intensive Care Unit. In a
report preapred in 2004, the Abaris consulting firm reported the following:
a. Downsizing or closure of the ED at Doctors Hospital San Pablo will have a
substantial affect on local health care providers and to the public in general in the
West County.
b. Kaiser Medical Center Richmond's ED and inpatient capacity would not be
sufficient to handle the new volume of cases from the ED. Waiting times at Kaiser
Medical Center Richmond will likely reach 10-12 hours for walk-in patients.
REGIONAL MEDICAL CENTER DISCUSSION:
Dr. David Goldstein is the Chief of Emergency Medicine at CCRMC and has been leading our
process change there. Dr. Goldstein will describe the trends over the last 10 years and some of
Health Services Emergency Department Challenges
Page 3 of 3
the work his team has undertaken to streamline patient flow and improve care. He will describe
trends such as:
- The increase in ED visits from 30,000 a year in 1998 to more than 50,000
- 100 patients a day admitted to double that now
- The increase in wait for a bed once admitted from the ED from three hours to 12 hour
Dr. Goldstein will explain a number of trials being conducted to achieve dramatic improvements
with modest staffing and physical plant changes.
ADDENDUM
October 28, 2008, Agenda Item D,$
On this day, the Board of Supervisors considered accepting an update from the Contra
Costa Health Services Director on the status of the Contra Costa Regional Medical
Center (CCRMC) Emergency Department.
Dr. William Walker, Health Services Director, introduced the status report and noted the
Board Order gives a landscape view of Emergency Room (ER) use across the country.
He said that not only is ER usage going up nationwide, but that only 13% of ER visits
result in admissions to the hospital. He said it is a myth that ER use is on the rise due to
the rising uninsured; he said uninsured use does account for some of the rise, but that
numbers of ER use are rising among both the uninsured and the insured due to other
factors, such as the difficulty people are having getting in to see their primary physician
in a timely way.
Peter Fromm, Program Manager in the Emergency Department, said patients who leave
the ER without having been seen are a problem. He noted that CCRMC's ER has
improved its numbers from 5 to 6 percent of patients leaving without being seen to a
current number of just 1 to 2 percent who walk out without being seen. He noted this
number is better than the national average.
Dr. Goldstein said CCRMC's ER has improved its performance in a number of areas,
adding that they have been some of the fastest and most dramatic changes and
improvements he's ever seen in a hospital.
Dr. Walker added that improvements in the ER show how efficient change can be when
its an up-front process with staff, and with a willingness to be open to trial and error.
Supervisor Uilkema offered her congratulations to Dr. Walker and said it would be
helpful to keep the Board informed of other changes that may be going to occur.
Supervisor Piepho asked what future plans may be in place for the ER in anticipation of
population growth and the demand for services in a tough economy.
Dr. Walker responded that he will be returning to the Board in late November or early
December with information on upcoming plans. He said expanding the lobby is
important, and added that moving psychiatric services offsite will also help create room
for services.
Dr. Fromm added that once you divert people offsite, you risk losing some people. He
said the short answer is to do what we can now and work for more space and more
capacity.
ADDENDUM
October 28, 2008, Agenda Item D.2
Dr..Walker said they are trying to open more evening and outpatient clinics to help
alleviate capacity demands at the ER. He added that even with other services available,
the ER will continue to be the site of last resort for medical services.
Supervisor Gioia suggested taking some of the good work that's been done at the
CCRMC and looking at possibly implementing those changes at Doctor's Medical Center
in San Pablo.
Supervisor Bonilla asked if increasing co-payments might be a way to discourage use of
the ER for visits that are not urgent.
Dr. Walker responded that in looking at national numbers, increasing co-payments
doesn't seem decrease the number of ER visits. He said he wants to focus on increasing
the alternatives to the ER visits.
Supervisor Bonilla asked how the County's costs of an ER visitcompare to the costs of a
clinic visit.
Dr. Walker responded that the ER actually provides very cost-effective services because
it is a"one-stop shop."
Supervisor Uilkema encouraged the Board to remember that the Emergency Room is the
County's provider of last resort, and discussing patient co-pays could lead to needy
citizens not being able to receive medical attention.
Supervisor Gioia added that today's report underlines the fact that CCRMC isn't just a
safety net hospital but is a community hospital for everyone.
By a unanimous vote with none absent, the Board of Supervisors took the following
action:
ACCEPTED an update from the Contra Costa Health Services Director on the status of
the Contra Costa Regional Medical Center Emergency Department.
M.W.+. R.—
a �
11 2
o
D DmgDD�� WUMSM qhS FED)
o Emergencies
o o Limited Access or' no 'Medical Home'
All in One Shop-Full service (lab,
o radiology, specialty care, follow up
❑
referral)
o Prefer drop, in care/co.nvenien,ce factor
o Emergency,, Medli'dall Treatment, And,
)or Act-Legal! Requa'
irernents
I
ED 'in Crisis Nationally
im Fewer inpatient hospital beds
Fewer ED beds
im Increasing population
Sicker atients in and, at homep
Increased ED ,urea with a h g h,er�
F
pere n tage� o i IN URED� patients
E
=r'S;77b"y*g W;O_d°',.m*�a
" 6M I pat�exnt ca ayycity�jflo6we issuesc results rEn
s.l
oardni,ng patine z is inthFe E,D §
It x
`"�'r
3..a
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CCRMC ED
1998 2008
ED volume roughly M ED Volume will
30,000 visits when exceed 50,000 this
hospital opened in
year
1998.
Daysin,oexcess of
Busy day was
When'llPatient: is.its�
` � we szaw� 100 pafients
Y
• `a �
Ranee toxfticeepA.an = Adma.tted` pat ents.�e
� � � �� adrnitted patientgin�� may. wa,it- as, 1png� as�
e E,Dwfo�r� more�� .x 6-� 2 ho�urrs, rarely
3« �do u rs �� �� 24-36� h o u rs ink EDk
4fie T r 'k a a i. .€s s a a w 8 ,5�. #
k� 3,�a 9 �9F'
0
� x�„ ' a..* srs”
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i
AcultyPatlents
Low the Easimes' t Portion of
the , ED Crisis to Solve
t
Beds occupied by admitted patients
and:. complicated patients' reduce the
size£ of the ED thus sortie pa lents wait;
as� long 'as 4-6 hours to bae seen; for
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CCRIVIC Emergency Department
Patient Yearly Census
50000 -
48000 -
46000 -
44000 -
--V7—
42000 0'
® Number
up
40000 - of Patients
38000
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LILL
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34000 5 1 1,M 7711§1
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6
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32000 --------
2000 2001 2002 2003 2004 2005 2006 2007
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CCRMC ED in a Nutshell
17 beds
im 6 hallwayurne s
9 Yj
3 Fast;-Track rooms (20. 05) in converted.
off i ce s pace: ,
EE ;� :- Wheel chair AltlefY
3
�E g espy i h�jatrrc Emergency (CFSU)
4,77: b :p 's a "a v- .+ n R
7 S a
tt
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91 CCRMC ED Functions
Receive ambulances from Com I munity
Receive walk-ins
1 m Receive transfers From County Clinics, other EDs
Medically clear all psychiatric patients both voluntary and 5150 holds
Medically clear all custody if any medical issues suspected or
significant intoxication 1
Clinic Overflow
`Front Door' to the County system for uninsured
AdviceNurse Referrals
® Onl dro in care:for M'ediCal/CCHP/lndi ent-BHC
® . SART (Sexual Assault Response Team) forensic exams.
_I Teaching Family Practice.Residents, nursing, & Paramedic Students
Stabilize..and`transfer specialt (care
LT j s ,:Trauma, cardiac, dialysis, neurosurgical emergency, pediatrics.
I requinng hospitalization, Kaiser
patients
Pro.�,v„ ide ir
Emergency Care to,,Veterans Facility
§ 'w®n"
8,
i
The Solution
I
Maximize current resources and system
efficiencies BEFORE expanding ED,
otherwise, you move the same problems .
into a bigger, space., Change how you do
business FIRST G
3 a
e
� � ��I.t is�� al�l�a,bo�ut, the pa rent in, ffi& I�obfby wfh
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knwv�',
All"
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�i�,me�im dtr q'�t�" � 8v 'Y`� d��ie`m�9,✓�� 1--,AE � � , Y
El
El
El
F-1
Q . Do
F]
❑
Initiated in 2005 in converted office
El
space at rear of department
is 16 , hours/day, 7 djays/week
F1
Typically sees, 251%;: ED volume
-
ij Triage Criteria, fo.:, le s; complex,, fewer
r,
0,
muntervents-1ns,,. limlited, works up
p Helps, but maibtai"nis, a, less, effildent
model of care 4y, �usJ'ng a, 1i'near process,
10
I
❑
11
MD) F&UP(B)IMiR p im(L)oz
❑ Patient Arrives & ',VAIT Patient sees VAIT
[ signs in at Triage Nurse
Greeter
El
❑ WAIT Patient to room VAI1` Registration
❑ 4— to see MD
❑
❑ j
3 Patient sees MD ! FiT XRAY/LAB {t
I
El
i
4
❑ ( Interventions/ MD gives test i
❑ ` �; ®-- treatment results
I
EI
Nurse Discharges
Il
i
El
❑
ElD
0 Dio
0 o MD at front end with nursing, orders/intervention can
be initiated, on arrival
o Registration simultaneously at bedside
0 o Most low acuity patients treated with initial evaluation
n and discharged from front end (never enter main
❑ department, never wait for anything)
13 a Moderately ill patients have work up initiated and
wait in the ED hall/s.ub waiting area while results are
pending or into ED bed Ito get, treatment/procedure
El
® Critical 01-(less, recognized, earlier with more rapid E
intervention, immediately placed in ED bed. This,
a area sh.owed.th,e. least i;mprove:me,n,t„ s,ugg,esting we
are currently doing; we l`wth the critically ilf.
12
i
❑
F1 'T[F,Dm U Rso M U ft0
0 o Low acuity patients from door to discharge on
average in one hour (improved from 3 hours)
0 o Sick patients recognized more quickly, interventions
o initiated sooner
El ❑ `Left Without Being Seen' rate from 5-6% baseline to
❑ 1 -2%0, Improved by 60%
0 o Patient Care, Quality, satisfaction and Safety
o ' Improved
0 o Overall Length of Stay [improved %20, door to MD
Lj time Improved by 25%El
'
El o No lobby full of waitin;g,{u,n,diffe,rentiatedI patients, who
1 will not see; an MD so:rneti:mes. for 6>'hours
G
(LITERALLY NO LOBBY);
131
i
i
El
r [EndEOgE
El
El
El
El
EJ ❑ Slightly more labor intensive, will most likely require
71 small ancillary staffing increases . Did not require
E any increase in nurse or MD staffing
❑ Will require build out of 'lobby but not change the
El
footprint of the ED/hos 'ital
p P
Multiple trials were required to convince staff that it
a can be done.-Now no going back
Q ❑ The model for how ultimate ED expansion should
occurwith an emphasis on front end process change
0
Does not address inpatient capacity issues, and, their
impact on the: ED
1.4
i
i
What was Learned
Dramatic improvements are possible
with modest staffing and physical plant
changes.
Timet td 1, st MDA contact
< y
LWBS/LOS
s
2r
3
Low ; dische-
arpatieTtsi', �ra ip :d � " g�
a patE
$ entsp rapids i;nte; e f ,tio { {A
y
q:3�3 i tii 1I2..
KK r xgL �
s bbylPe3ss E �"a. �n xn& ..«�' � 's7E^r gyp+
„15