Case Study #4: Emergency Department High Alert Program

EMERGENCY DEPARTMENT SETTING:

  • Suburban hospital in large city
  • 40,000 annual ED visits
  • 27 ED beds

GOALS:

  • Identify-high risk patients:
    • At risk for violence toward staff
    • At risk for self-directed violence (National Patient Safety Goals)
    • At risk for dependent behaviors
  • Reduce unnecessary visits
  • Reduce complaints
  • Reduce conflict between patient and caregivers
  • Improve care

PROCESS:

  • Patient identifier within HIS
  • Referrals by nursing staff, physicians, and social service
  • Visit review by Medical Director
  • Database input
  • Development of care plan by Medical Director
  • Notification of patient
  • Input from primary care providers
  • Follow-through

CRITERIA FOR REVIEW:

  • Greater or equal to 4 visits in one month
  • Greater or equal to 10 visits in one year
  • False alias
  • High-risk diagnosis
  • Specific behaviors
  • Failure to follow up as directed
  • Specific concern from care providers

CARE PLANS:

  • Generic plans modified for individual patient
  • Example: migraine
  • Referral to appropriate specialist or medical home
  • Call to PCP, specialist each visit
  • Rescue pain relief only – identify agent
  • No prescription or 1-day supply only

BENEFITS:

  • Superior and more effective alternative to triaging out programs
  • Costs savings – reduce unnecessary visits and diagnostics
  • Improve patient care:
    • Pain specialist referrals
    • PCP referrals
  • Decrease friction between patients and caregivers
  • Improve safety:
    • Staff
    • Patient
    • Visitors
  • Compliance – National Patient Safety Goals (NPSG)
  • Decreased time spent on patient complaints

PHYSICIAN REFERRAL:

  • Physician referral system, high-risk diagnosis:
    • Chronic back pain
    • Shoulder pain
    • Dental problems
  • Discharge instructions, referral to case manager for help
  • 2 free passes and out (into High Alert)
  • Patient self-identification

RESOURCES NEEDED:

  • Physician
    • Referrals
    • Visit review
  • Nursing
    • Referrals
    • Buy-in
  • Hospital
    • Patient identifier
    • Database
    • Case manager
    • Discharge instructions
  • Medical Staff
    • Pain management
    • Medical homes

RESULTS:

  • Reduced complaints
  • Increased staff and physician satisfaction
  • Compliance with JCAHO and National Patient Safety Goals
  • Increased patient satisfaction
  • Predictable patient encounters across visits
  • Implementation at all hospitals in system
  • Cost savings in one system of more than $500,000
  • Visit reduction of up to 80% in identified population