The Modern Emergency Department: More Than an Emergency Room

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Daniel Marino:

Welcome to Value-Based Care Insights. I am your host, Daniel Marino. Many hospitals, struggle time and time again with managing a lot of the activities in the emergency department, and everything from overcrowding, to long wait times, to impact, related to readmissions. Certainly on the value-based care side, many hospitals and health systems are thinking about different alternatives that help to provide, additional urgent or emergent-type support to patients, certainly having patients go to urgent care, or at least being able to provide some other… some other alternatives for emerging care and so forth. But it doesn't… hasn't really done a lot to solve the problem with overcrowding. And, you know, there's a whole host of reasons for that. I think some of it, you know, potentially is the care model. I think some of it is the lack of primary care physicians, a shortage of primary care physicians. Some of it is just need. I mean, patients, you know, have a condition, they have a clinical need, and they don't know where else to go, so they go to the emergency department. Well, I'm excited today to have my colleague, Marty Lucenti, join me in the conversation. Marty is a national… nationally recognized expert in emergency department operations. He's worked with organizations all over the country on emergency medicine delivery, optimization. He not only is an emergency medicine physician, but he has a PhD in mechanical engineering as well. Marty, welcome to the program.

 

Marty Lucenti

Thanks for having me, Dan.

 

Daniel Marino:

So, Marty, let's dive into this. When, you know, working with organizations around the country, what are you seeing as the big challenge, or maybe the big drivers related to overcrowding in emergency departments?

 

Marty Lucenti

You know, I think… I think the starting point when you start to look at overcrowding in the emergency room, it's really important to start with, you know, what do you see emerge as the patterns of utilization in the emergency room? What does the emergency room of today provide for the health system? Quite honestly, when you take a look at what the emergency room does now. I like to refer to it as the emergency room has slowly and predominantly transformed itself into an acute diagnostic center. And because much of the original physical footprints were originally designed with the primary concept of an emergency room. This is where you go when you have a life-threatening emergency. A lot of the capacity designs were done with that in mind. But when you actually look at, you know, the populations that actually present to the emergency room. The emergency room forms a much broader, you know, set of services for the health system. When you look at the populations within an emergency room, there is that group that is, you know, has a life-threatening injury or illness, but that only represents about 25 to 30% of the ER visits. There’s another 25% that are relatively low acuity, but that low acuity often requires some uniqueness of scope of practice. You know, the misperceptions office about low-acuity emergency room visits is they could have gone to an urgent care, they could have gone to a primary care, when oftentimes even the low acuity visits in the emergency room. We’re actually referred over, by urgent cares, or family practice or, you know, primary care providers, just because of scope of practice. You know, don't do incision and drains, not comfortable. Doing some light sedation on a child to do suture repairs, and so forth. So that represents another 20-25% of the emergency room. But the area that has become the dominant center of mass of patient care in the emergency room is actually this complex patient population. Patients who have either medical complexity, have a lot of comorbidity issues, or have a complicated problem. They're not acutely decompensating, they're not in the process of dying, but they're getting sicker, and they've got… and in order to really fully evaluate them. There’s a lot of diagnostics and potentially a series of different scopes of practice, specialty perspectives that need to be interjected. And that actually represents almost 50% of emergency visits. So it's an interesting constellation of, you know, of presentations that come to the emergency room. Very few emergency rooms were fully designed with that full responsibility.

 

Daniel Marino:

Sure.

 

Marty Lucenti

The other… the other part to look at, Dan, is the single greatest predictor of an overcrowded emergency room is a full hospital.

 

Daniel Marino:

Yeah. Well, you see that all the time. I mean, a lot of times. You know, when the census in the hospital is, you know, above 90%, you know, then all of a sudden the hospital's scrambling, and maybe, you know, they're discharging and getting the… transitioning the patient out, only to come to find out that maybe the post-follow-up, post-discharge transitions care, really, those protocols aren't in place, or the processes aren't in place as strong as they should be, so what happens? The patient shows up at the emergency department.

 

Marty Lucenti

Yeah, and you used a number 90%, which is… which shows me, you know, a little bit about cueing theory, because you start to get balking when you get above 85-90%, so there's… your number told me that you've got a little bit of a background, but you're exactly right, Dan. And so, when you think about an emergency room, if you planned your resource model for everybody to come in, get 3 or 4 hours of care, and leave. And then you have people waiting 2-3 days for an inpatient bed, and you're… more and more of your resources are transferred over to providing additional inpatient care because your inpatient services is over full, it really creates a strain. Once again, I'll remind everybody, the single greatest predictor of an overcrowded emergency room is a full hospital. But it's that constellation. Yeah.

 

Daniel Marino:

Yeah, absolutely. So let me ask the question. In your experience, though, when you look at that… again, I'm gonna use kind of a physician analogy here. When you're looking at diagnosing the problem of overcrowding, right, is it, you know, what I'm hearing you say is it may not necessarily be that there's patients who are going there that shouldn't go there. Some of it could be as a result of just the poor processes that we have in place, the poor throughput that we have in place. Is that true? Is that what you're saying? And if so, you know, how do we manage one or the other?

 

Marty Lucenti

Yeah, you know, here's what I would say is… is it's one… so, Dan, you're… you're dead… you're dead on, although you will see most people who try to fix this problem just believe that they can efficiency themselves into solving this, you know, this acute care capacity crisis. What I would tell you is the flaw generally starts before the process engineering, it actually starts with the resource planning and understanding stochastic or variable demand. We do so much planning based on averages, but… but these are queuing systems that have arrival patterns with distributions that have variability. And so. You know, you've got to be able to use some of those statistical constructs from, you know, high-reliable system design to make sure that you've got enough resources to adequately meet the demand.

 

 

Daniel Marino:

So let me dive into that a little bit, because I want to put this into kind of a, you know, a practical approach here. So are you saying that as you start to think historically about the patients who are presented to the emergency department. We should be looking at what the, you know, the emitting ER diagnosis is, and, you know, begin to maybe risk stratify the patients, so we can better almost create the care model based on, historically, profiles of patients who have come there. Is that what you're sort of referring to?

 

Marty Lucenti

So, what I'm saying is, you know, take a look at your arrival pattern. So, like, when I fix an emergency room. So know, whether it's an inpatient hospital or it's an emergency room, this is a traditional queuing system challenge. It's a capacity demand matching algorithm, right? So when I look at an emergency room, I have to have enough docs, nurses, and care spaces to take care of all the patients that arrive. So I study the demand by hour of day, day of week, week of month of year, and I understand that distribution, not just the average, but the 75th or 90th percentile. If I want to be safe and reliable, I’ve got to be able to deal with my 90th percentile demand. Within that construct, Dan, you've got to understand the district, you know, the various types of presentations, the levels of acuity that come, and then exactly what you want to do is have designed care pathways for different levels. People want… different types of patients want very, very different things, right? If you're a high acu… if you're a high acuity patient, right? If you're a high-acuity patient, there's only one thing you care about. Please, save my life, right? You're not… you're not worried about comfort, you're not worried whether you've got a TV, you're not worried about communication, just save my life. Likewise you know, if you've got a minor problem. Really what you care about is getting discharged as quickly and move on with the rest of your life. So, the care space design and so forth are very different for those subpopulations. And then that middle group, which I talked about, the 50th percentile, who have a lot of coexist, you know, pre-existing medical issues that may or may not be deteriorating that need a very big workup. Those people really do care about comfort, because they're going to be there for a while. They were already uncomfortable with the chronic illnesses they're dealing with, and their, you know, the challenges of trying to navigate the outpatient space that haven't given them the answers they're looking for. And so. You’re exactly right, and you need to know all of those things with a probability distribution.

 

Daniel Marino:

If you're just tuning in, I'm Daniel Marino, and you are listening to Value-Based Care Insights. I am here talking today with Dr. Marty Lucenti, and we're talking about addressing the overcrowding issue in the emergency department. So, Marty, I'm a big proponent of risk stratifying populations, and risk stratifying the patients, and I've felt like through the work that I've done with hospitals all over the country, the more that you know about the patient, the more you know about the risk factors that are driving the needs of the patient, the more proactive you can be in delivering the exact care that they need. When you think about, let's say, the high trauma patients, or the patients that are the rising risk patients, or the patients, you know, that are coming in, as you've kind of mentioned, those high acuity patients. How does the data figure into that? Because again, you know, you're not necessarily planning for the emergency medicine visits, they just… patients just show up, right? So how do you integrate that level of data, that level of informed knowledge into the care model so you're actually able to deliver that care and create the efficiencies that hopefully you're able to gain out of, you know, addressing the overcrowding issues?

 

Marty Lucenti:

Yeah, no, you know, that's a really good question, and you know, healthcare has spent a lot of money, really, trying to get to some of those solutions. If you look at it, centralization of electronic medical records so that the second I actually identify you, I am immediately fed all that information. Think about, you know, a lot of trauma is, you know, trauma is generally a young person's game. Most of the people we see in trauma are young, but there's a decent population that are geriatric trauma. And when I'm… when I'm dealing with geriatric trauma, trauma is a… is a, you know, traumatic, shock is usually a hypovolemic, they're losing blood. But there are other kinds of shock, cardiogenic, and so forth. And so there's some special considerations when you're dealing with trauma patients, if they've got, you know, pre-existing congestive heart failure, and some of the traditional approaches would not work. So, you know, having a robust, you know, EMR with shared access so that the second you scan somebody in, that information is being fed to you is incredibly valuable.

 

Daniel Marino:

Oh, yeah.

 

Marty Lucenti

You’ve seen health systems across the country have spent a lot of money, you know, actually… they know in… they know in the, you know, in their, you know, in their soul that having all that information in one place easily, easily, easily accessible is going to lead to better outcomes. And I think it's on this front, right, in those… in time-critical moments, the quicker you can assimilate all that information and calculate it into your diagnostic and therapeutic interventions, incredibly helpful.

 

Daniel Marino:

It absolutely is. I mean, that's where, really, the efficiency and the care comes in, and we make sure we're providing the right level of care for the patient that needs it. Talk a little bit in terms of what you've seen around the country with some of these innovative models. You know, in some cases, when I've had the opportunity to go in and to assess workflow in the emergency department, you know, I've… we've assessed kind of the overcrowding issue and kind of the throughput of it. You know, you can't… you know, oftentimes, and again, I'm not a physician, but oftentimes I think that a lot of the workup and a lot of the activities that are being done isn't necessarily focused on patient need. It could be focused on a protocol, it could be liability factors that come into play, too, making sure that we're doing all these tests to rule out certain, you know, this, that, or the other that comes in. But I don't really see that as innovative models, right? I think it's more of just standard operating procedures. What do you see are some of these innovative models that are combining the knowledge, the data, the innovative, you know, throughput and care models that are really helping to take these emergency departments to more of a high-performing standard.

 

Marty Lucenti:

Yeah. You know, so the first problem you always have to solve is that capacity demand problem, right? And if you have enough resources to just serve that first function, which is, you know, keep people alive who have emergencies, you're going to be problematic on all the other patient populations that are, you know, that you have to provide care to. So solve that problem. But that's when, after that, Dan, it starts to get to be really interesting, which is, how do you design your emergency room, and what should your emergency room do? You know, there are folks… and you have to decide whether you're going to be sort of operate as a traditional emergency room, which is basically make sure they're not having an emergency. If they're not having an emergency room, discharge them with lots of follow-up visits, you know, and try to get plugged into the outpatient care. Or you can take the other approach, which is, this is an outpatient facility, and I'm going to… I'm going to give you the answer now. I'm going to put together that which would take 3 weeks, you know, for you to get, you know, to, you know, efficiencies. And when you look at value-based care, there's a lot of emphasis, you know, on efficiencies and quality. You know, what I find, you know, when I talk with specialists is the errors that I see in medicine are errors of omission, or… which is… means… are predominantly, I didn't… things that didn't get done, or should have been done quicker, right? Right. You know, so the answer is, most people, you know, if you try to do a complicated workup in the primary care or outpatient facility, it's 5 different places with 6 different appointments, and it's hard to get, you know, to get all of those somewhat coordinated. Whereas in the emergency room, you can get all of those things very quickly. If you lean into the concept of an acute diagnostic center and set as a priority that this is where you come for an answer, which is much different than the emergency room that says you're not having an emergency, go away, go try to work this up in the outpatient. You can really create a lot of value to your patient population, reduce suffering, eliminate errors, improve efficiencies, all of those things. And so, when you start to think about those sort of innovations. It’s a philosophical difference in the way you go about approaching a patient who presents to the emergency room.

 

Daniel Marino:

I really like your… if I could build off of a point, I really like what you mentioned about the transition from an emergency department to an acute diagnostic center. Because that sort of changes, then, the mindset, that paradigm shift on how we're treating patients, and what the emergency department really should be doing. But, you know, as you're talking through this, you know, putting my finance hat on, there's an economic impact here, right? And in some cases, the emergency department is an economic engine. Or a hospital. In other cases, maybe not so much, depending upon the payer mix, but nonetheless, it does have some financial implications. How does the finance piece of this fit into it?

 

Marty Lucenti

Well, you know, I think this is a really great question, and we can kind of walk through this, and I'll talk to you to kind of give you… that the answer can be a little bit different depending on the circumstance. So if you look at the operating margin of a hospital, right, an operating margin of a hospital, you know, generally 1%, 2%, 3%. It is an incredibly low margin business, right? So, you honed in, you honed in one of those very first principles when you mentioned 90%. So, I was running an operation that has an incredibly low margin, I want it to be completely full. I can't have any excess capacity so that I'm reliable, because it makes my… it cuts my margin, gets tighter and tighter. And so, being full with a waiting room, right, being full with a waiting room makes some financial sense, to the hospital, doesn't it? Right?

 

Daniel Marino:

Absolutely.

 

Marty Lucenti

The patient is right down in the emergency room. Not only that, Dan, but when you actually, depending on the circumstance, right, full with a waiting room, alright, so once you're full with a waiting room, start to think about this. You have 3 different sources of patience. You have patients that come from the ER, patients that get admitted to the hospital from the OR, and patients that are transferred in for specialty care. What do you make… what do hospitals make the most money on? Which… which patient populations?

 

Daniel Marino:

Well, I would imagine patients that, you know, come from the emergency department and getting admitted into the hospital.

 

Marty Lucenti:

No, that's the lowest margin patient. That patient… that is the poorest insured, and the lowest, lowest problem mix, of those. So you make the most money off your OR patients, the second most off your transfer patients, and the final is the ER patients. So start to think about it as if, once I get full, I back up into the ER, it does actually, in some sense, create a little bit of a negative feedback to your lowest margin point of entry to your facility, doesn't it?

 

Daniel Marino:

Yeah, you're absolutely right, right, because that's where the contribution margin's gonna come in. So, maybe it's then designing, as you mentioned, the acute… the ED is an acute diagnostic center that helps to manage some of those trauma patients, and almost thinking about maybe the medical side of emergency department different than the procedural side of the emergency department, so then you are able to kind of address those trauma cases quickly and efficiently.

 

Marty Lucenti

Yeah, you know, what I generally do on that, so once you get to that, like, what you start to do is what I usually will do in those circumstances. So, right, this is a full house. This is, you know, this is most downtown academic medical centers. They're full with the ER backed up with borders. What I generally do is try to hybridize that, which is, basically, I make… I make the ER both an ER and an ops unit, and they're not physical locations, but they're… but their status is within the same physical space. So that I try to… I try to reduce the admissions… I try to reduce the emissions by 25% by keeping the patients and being really efficient at getting them the CAT scans, MRIs, the consults, and avoid a 2- or 3-day admission by being ultra-effective, ultra-quick at getting diagnostics and consults in an op status, so that I can… so that I can… I can filter off 25% of the admissions. They’re thus saving, you know, thus decreasing my tomorrow's… tomorrow's challenges.

 

Daniel Marino:

Yeah.

 

Marty Lucenti

Take the opposite approach, though, Dan. You’re a hospital that's… You know, that's 30-40%, you know, occupied, that's having financial trouble you’ll see them use their ER as a mechanism to grow desirables. So a lot of times when I work with, you know, for-profit organizations, you know, they look at the ER completely the opposite. They don't, you know, they don't start a negative feedback to their ER because they're already full and they're trying to enrich their problem mix. They look at it the other way. This is my point of entry for a lot of relatively lucrative stuff, to grow my inpatient volume and so forth. So once again, it's not… the ER isn't one piece… there isn't one answer to how you configure an emergency room. You actually have to configure that emergency room to be most effective in the broader care system that you're providing your community.

 

Daniel Marino:

Yeah, well, that's a great point, and really based on, you know, historically what the needs are of the community, needs are of the patients, and so forth. Well, Marty, this has been great, and I think we just barely scratched the surface on this. You know, as many organizations, they're continuing to work through efficiencies in the emergency department, address overcrowding, all of those issues. If any of our listeners are interested in contacting you, can you share your contact information or your LinkedIn address?

 

Marty Lucenti

Sure, sure, it's… it's… you can… it's mjlucenti@ECG.com is my email.

 

Daniel Marino:

Wonderful. Well, I appreciate it, Marty, this is great, and, you know, I'd love to, maybe down the road, talk about some specific case studies. You know, this is such an important topic, and it touches so many different areas. You know, maybe sometime down the road I'll have you back in, but I'd love to kind of dive into some specific case studies with some outcomes. I think that would be really interesting.

 

 

Marty Lucenti

Absolutely, would love to dive in deeper. Yep.

 

Daniel Marino:

Wonderful. Well, thank you for coming on. I really appreciate it. And a special thank you to all of our listeners for tuning in. If you're interested in learning about this topic, or any of the topics that we've discussed on Value-Based Care Insights, please log into LuminaHP.com/insights, or visit ecgmc.com for a lot of other information, and quite a few of the topics that we've discussed. Until our next insight, I am Daniel Marino, bringing you 30 minutes of value to your day. Take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners