1. The Role of the Emergency Department in Reducing Readmissions
October 16, 2014
Leslie S Zun, MD, MBA, FAAEM
Chairman and Professor
Department of Emergency Medicine
RFUMS/Chicago Medical School
Mount Sinai Hospital
Chicago, Illinois

2. Objectives
Understand the financial importance of reducing readmissions
Evaluate different methods of reducing readmissions
Focus on psychiatric patients in the ED
How the ED can contribute to reducing readmissions
Interventions based on before the ED, in the ED and discharged from the ED

3. ED Returns with Readmissions Rising, KL, et al: Emergency department visits after hospital discharge: a missing part of the equation. Ann Emerge Med. 2013;62:
23.8% returned to ED within 30 days
Older, men, English speaking
Associated with AMA (5% AMA vs. 2% not)
Non-specified chest pain
45.7% of these were readmitted
CHF highest rate 86.6%
Followed by diabetes, complications of device, sickle cell
Conclusion - Importance of collaboration with inpatient, post acute, community based care

4. Before Patient Arrives Risk Factors for Readmission Allandeen, N, et al: Refining readmission risk factors for genera medicine patients. J Hosp Med 2011;6: Mudge. AM, et al: Recurrent readmissions in medical patient: a prospective study. J Hosp Med 2011;6:61-67
Patient types
African American
Underweight & weight loss
Cognitive function & limited English proficiency
Chronic disease
Depression, cancer, renal failure, CHF
Patients taking 6 or more medications
Prior hospitalization in past 6 months
Lifestyle issues
Poor and Medicaid
Frequent ED patients
Homeless

5. Before Patient Arrives Analysis of Readmissions
Review of frequent ED users
Review of frequent readmissions from the ED
By patient
By diagnoses
By ED MD

6. Before Patient Arrives Identification of Seniors at Risk Tools Graf, CE, et al: Identification of older patients at risk of unplanned readmission after discharge form the emergency department. Swiss Med Weekly. 2012;142:w13327.
Use two tools to determine risk for readmission
Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST)
ISAR
TRST – 6 questions
Modest prediction of unplanned readmission after ED visit in patients over 75 years old

7. Before Patient Arrives Reduce Use of EDs
Expand the walk-in and urgent care facilities
Determine which patients have used EDs 3 or more times in the past month
Call these patients to let them know about other resources and link them with health care, practitioners, case management, and disease management
Important role of social workers in ED

8. Psychiatric Patients Mobile Crisis Units and Telepsychiatry
Jugo, M, Smout, M, Bannister, J: A comparison in hospitalization rates between a community based mobile emergency service and a hospital-based emergency service. Aust N Z Psychiatry 2001;36:
Comparison of mobile unit to ED admission rate
ED admitted 3x more than mobile units
Telepsychiatry Shre, JH, Hilty, DM, Yellowlees, P: Emergency management guidelines for telepsychiatry. Gen Hosp Psych 2007:29:
High provider and patient satisfaction
Wide variety of diagnosis, age and complaints
Consultations, diagnostic assessment, medication management, family and patient psychotherapy

9. Psychiatric Patients Law Enforcement Outreach Alakeson, V, Pande, N, Ludwig, M: A plan to reduce emergency room boarding of psychiatry. Health Affairs. 2009;9:
Harris County
Comprehensive ED service
6 core features-help line, mobile outreach, ED psych services, crisis counseling, residential unit
Of 2,352 pts. seen, 4% admitted
Bexar County
Collective responsibility in keeping patient out of ED
Public and private hospitals, public officials, law enforcement, community mental health, court system

10. Inappropriate Admissions
Legal and liability of sending patients home
Secondary utilizes such as police, group homes, nursing homes and families
Send to ED to resolve issues
Lack of appropriate assessment
Difficulty in contacting PCP
Need for collateral information
Problem with obtaining old medical records
Lack of outpatient resources
Housing
Medication
Care givers

11. One Day Readmissions Pines, JM, et al: Post discharge adverse events for 1-day hospital admissions in older adults admitted from the emergency department. Ann Emerge Med. 2010;56:
Examined ED readmissions with 1 day stays
12.1% of all patients
CHF, COPD, prior hx of CHF
841 patients of 1207 admitted
12 died within 30 days
3 had definitive F/U, 4 missed F/U appointment
Questions
Is it due to premature hospital discharge?
Was a one day admission necessary?

12. Admission Criteria Does the Patient Need to Be Admitted?
Not always an easy decision
Reliance on criteria such as the Interqual IS/SI
Use of admission criteria or guidelines for many conditions
Pneumonia, DVT, CHF, PID, asthma
Alternatives to inpatient stay

13. Alternatives to Inpatient Admission
Observational care
Psychiatric Patients
Acute psychiatric stabilization
Crisis respite
Day hospitals
Living room care
Hospital at Home care

14. Discharge to Hospital at Home Leff B: Defining and disseminating the hospital-at-home model. CMAJ. 2009 Jan 20;180(2): doi: /cmaj
Have EPs, PCPs, and home care staff identify patients to benefit from receiving hospital-level care at home
Physician visits, at least once daily, and 24-hour coverage
Nursing visits, once or twice daily
Telehealth nurses providing remote support
Remote monitoring of key health indicators.
$1,500 less than a comparable inpatient stay

15. Acute Psychiatric Stabilization
Medical evaluation followed by a psychiatric evaluation
Acute Stabilization Unit
Accept transfers from other institutions
Observation from hours
Re-start psychiatric medications
Determine need for inpatient care
Clarify diagnosis
Connect with outpatient resources

16. Psychiatric Admission Criteria Does the Patient Need to Be Admitted?
Not always an easy decision
Use of admission criteria or guidelines for many conditions
Risk to self
Risk to others
Unable to care for self
Alternatives to inpatient stay

17. Admission Criteria
Decision support tool Lyons, JS, et l: Predicting psychiatric emergency admissions and hospital outcome. Ed Care 1997;35:
Criteria: Suicide potential, Danger to others, Severity of symptoms
Predicted 73% of the admissions
Crisis Triage Rating Scale Bengelsdorf, H, et al: A crisis triage rating scale: brief dispositional assessment of patients at risk for hospitalization. J Nerv Mental Disease 1984;172:
Scores three categories 1-5
A. Dangerousness
B. Support system
C. Ability to cooperative
Scoring
9 or more – outpatient/crisis intervention
8 or less - admit

18. Determination of Suicide Risk Myths
Not all suicidal patients need to be admitted
All patients who want to harm themselves or others need admission
Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated
All teenagers with suicide gestures or thoughts need admission
Can the Suicidal Patient Go Home Kennedy, SP: Emergency department management of suicidal adolescents. Ann Emerg Med 2004;43:
Medical treatment not needed
No prior suicidal attempt
No actively suicidal
Adult in house with good relationship and adult agrees to monitor
Adult will move guns and medications
Whom to contact for deterioration
Follow up arranged

19. Psychiatric Patients ED Treatment Interventions
Brief intervention Fleishmann: Effectiveness of brief intervention and contact for suicide attempters: a randomized controlled trial in five countries Bull WHO 2008;86:
International study of 8 EDS
Brief intervention and enhanced follow up
Reduced number of deaths
Psychiatric service provided in ED Damas, C, et al: Economic impact of crisis intervention in emergency psychiatry: a naturalist stud. Eur Psych 2005;20:
Psychotherapeutic approach to considering the crisis an event
Counseling of patient and family
Before and after cost and reduction of hospitalizations
Reduced voluntary hospitalizations 19.5% and increased outpatient consultations 14.4%

20. Psychiatric Patients ED Treatment Interventions
Rapid response Greenfield: A rapid-response outpatient model for reducing hospitalization rates among suicidal adolescents Psych Services 2002;53:
Suicidal adolescents in a pediatric ED
Rapid response team psychiatrist & RN with assessment, meds & community follow-up
Lower hospitalization rate
Crisis Plans Ruchlewska, A, et al: The effects of crisis plans for patients with psychotic and bipolar disorders: a randomized controlled trial. BMC Psych 2009;41:1-8.
Plans for crisis intervention for patient, patient advocate and/or clinician

21. Medication Re-start prior meds Start new medications
Psychiatry via telepsychiatry
Assistance from C and L service
Medications to start in ED
Antidepressants
Antipsychotics
Mood stabilizers
Benzodiazepines

22. For Admitted Patients ED’s Role
Start patient in care management in ED
Case management
Social work
Discharge planning
Pharmacy
Occupational and speech therapy
Nutritional service
Identify patients that are at risk for readmission

23. ED Discharge
Set up follow up appointments Sharma, G, et al: Outpatient follow-up visits and 30 day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease. Arch Intern Med 2010:170:
62,746 COPD patients , 66.9% had PCP follow up
Patients who follow up visit reduced the risk of an ED visit and readmission
Begin case management Gil, M, et al: Impact of a combined pharmacist and social worker program to reduce hospital readmission J Mang Care Pharm 2013;19:
Involve social work and pharmacy
Set up home health services
Med reconciliation and F/U phone calls
Communicate with PCP Pang, PS, et al: Patients with acute heart failure in the emergency department: do they all need to be admitted? J Cardiac Fail 2012;18:
Hand off to primary care

24. For Discharged Patients ED’s Role
Clear, detailed discharge plans tailored to patient, family, clinicians, case managers and payers
Teach self-care
Improved instructions and instruction process
Patient read back
Encourage self-management
Telehealth technology to monitor at home
ED physician/nurse/social worker phone calls
Assign a patient navigator

25. Value of Patient Navigator Balaban, R, et al:A randomized controlled trial of a patient navigator intervention in reduce hospital readmissions in a safety new healthcare system. CMAR 2013:3:
Role of patient navigator
Support and guidance throughout healthcare continuum
Coordinates appointments
Maintains communications
Arranges interpreter services
Arranges patient transportation
Facilitates linkages to follow up
Study of patient navigators
423 patient navigator and 513 in control
12.1% were readmitted in patient navigator group and 13.6% in control group.

26. What Can the Emergency Department Do?
Before patient arrives
Identify high risk patients
During patient’s ED stay
Use admission criteria
Limit inappropriate admissions
Hospital admissions
Consider alternatives sites of care
Start processes in ED
After the patient is discharged from ED
Connect pt with out patient resources

27. What Can the Emergency Department Do about Psychiatric Patients?
Before patient arrives
Defection programs – mobile crisis and law enforcement collaborations
During patient’s ED stay
ED interventions
Hospital admissions
Appropriate admission criteria
After the patient is discharged from ED
Connect pt with out patient resources

28. Contact Information
Leslie Zun, MD
Mount Sinai Hospital
1501 S California
Chicago, IL  60608 28