One ED, One solution

1
One ED, One solution

• David John MD FACEP
• Middlesex Healthcare System
• American College of Emergency Physicians

2
How many of you have taken a friend or family
Member to the Emergency Department (ED)?
3
How many of you have been patients in the ED?
4
Both groups please raise your hands.
5
Who uses the ED?

• At some point all of us are in an ED.
• Bank CEOs with chest pain.
• A single mom with a sick child.
• A homeless person who is cold and hungry.
• An athlete with a broken ankle.

6
Who we are

• We are open 24 hours a day, 365 days a year.
• Like the police and firefighters, your local
  emergency department is a public resource.
• We are Americas healthcare safety net.

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ED/Hospital Overcrowding

• Did you ever wait to be seen in an ED?
• When the Healthcare System is overwhelmed, the ED
  goes into surge capacity.
• This is an everyday event.
• Eventually everything grinds to a halt.

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Access to care

• External events that impact on surge capacity
  impact on all of our access to care.

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Causes of Overcrowding

• Living longer/aging of the population.
• By 2020 over one half of our population will be
  over the age of 65.
• Our population is increasing.
• The number of In-patient medical and mental
  health beds are inadequate.

10
Then and Now

• In 1960 there were 650,000 in-patient mental
  health beds.
• In 2000 there were 57,000.
• Are we curing mental illness?

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Its not just medical

• Domestic violence.
• Rape.
• Substance abuse.
• Elder abuse.
• The elderly at risk population.
• The list goes on.

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The ED is where the rubber meets the road for
society and healthcare.
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Why are we crowded?

• The Texas Experience

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Number of Emergency Departments

• 1980s- nearly 6000
• 1998- 4041
• 2003- 4079
• The difference between Emergency Room (ER) and
  Emergency Department (ED).
• Bob Dole and Viagra.

15
Connecticut Experience

• CT- richest state in the union in terms of per
  capita income.
• CT- worst per capita access to mental health and
  addictive services.
• My ED is situated in a locale with some of the
  only state-run mental health and addictive
  services programs in the state.

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The scope of care

• Our Behavioral Health population is large even
  by Connecticut standards.
• The slogan for Emergency Medicine No shirt, no
  shoes, no sanity, no problem.

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Time-line

• 5 years ago we ware-housed our Behavioral Health
  patients until they could be placed.
• Patients rarely got appropriate therapy,
  medications, or common conveniences while held in
  the ED. At times they were not adequately
  medically cleared.
• The elderly and very young, less than 12 years,
  often spent days to weeks with us.

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The Make-Over

• We spent several million dollars and 2
  re-incarnations of the BHU and ECA.
• We changed the name. People from across the state
  were coming to us because they thought we were a
  treatment center and not an ED struggling to
  provide adequate care for an under-served
  population.

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Crisis Clinicians

• RNs, MSWs, and clinical psychologists
  facilitate disposition once the patient is
  medically cleared.
• Our staffing has increased to meet the needs of
  this growing population.
• These changes were data driven (handout).

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ED Psychiatrists

• They round on these patients twice a day 7 days a
  week.
• They initiate therapy, assist with disposition,
  and adjust medications.
• They also have administrative roles in our
  in-patient unit.

21
Quality and Patient Safety

• We have improved therapy and privacy for
  patients, and safety for patients and staff.
• Behavioral Health and medical clearance have been
  a major focus for our quality initiatives for 4
  years.

22
Guidelines

• Guidelines and pathways were established.
• We have ECA specific order sheets including
  standing orders for Lorazepam, Ibuprofen, and
  Nicotine patches in addition to chronic
  medication.
• We have had no medical clearance issues in over a
  year (hypoglycemia, subdural hematoma, ethylene
  glycol toxicity, DTs, etc.).

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Substance Abuse

• We do not have detoxification facilities at our
  hospital.
• We no longer place chronic recidivist substance
  abusers but we do provide resources for
  patients and families requiring these facilities
  (see handout).
• There is a dramatic drop in length of stay for
  this group.

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Better Communication

• The first provider does a priority dictation. The
  patients history and plan is available to
  subsequent providers over shifts and days.
• Chronic and PRN medications are provided at the
  initial encounter.
• Pharmacists review all medications on patients
  held in the ED.

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Reality

• In spite of our time, effort, and dollars we have
  not fixed the problem.
• Last week I started a 7 am shift with 24
  Behavioral Health patients. We are a 21 bed ED.

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The Diner Theory

• People do not eat at a diner because the food is
  good. They go there because it is open and they
  are hungry.
• We cannot provide the best care, but we are
  providing care the best way that we can.

27
Putting paint on an old car

• We need to come up with creative and
  cost-effective solutions to mental health and
  addictive care.
• If not, all of our access to Emergency Care will
  suffer.