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The Role of the Emergency Department in Reducing Readmissions Leslie S Zun, MD, MBA, FAAEM Chairman and Professor Department of Emergency Medicine RFUMS/Chicago.

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Presentation on theme: "The Role of the Emergency Department in Reducing Readmissions Leslie S Zun, MD, MBA, FAAEM Chairman and Professor Department of Emergency Medicine RFUMS/Chicago."— Presentation transcript:

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

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: % 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:w 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 Mobile Crisis Units 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 Jan 20;180(2): doi: /cmaj Leff B Defining and disseminating the hospital-at-home model. 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: ,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


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