ED management : the monthly update on emergency department management
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Even though the U. S. Supreme Court has upheld the bulk of President Obama's signature health care legislation, the Accountable Care Act (ACA), the prospects for full implementation of the law remain uncertain as political opponents still vow to strike down portions of the law at the earliest opportunity. ⋯ Some experts predict that EDs will see a flood of new patients when the Medicaid expansion provisions go into effect in 2014, but this trend may be tempered by the fact that newly insured patients will be able to seek care in other settings. The health reform transition is expected to be most difficult in states with large uninsured populations, and experts agree that a shortage of primary care physicians will drive ED volume in many communities. Hospitals and health care business interests are putting pressure on states to opt in to the ACA's Medicaid expansion provisions because it will make federal dollars available to cover 100% of the cost to cover newly insured Medicaid patients for three years, and 90% of the cost after that.
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The Joint Commission has revised its standards regarding ED patient flow and patient boarding so that hospital leaders must establish measures, set goals, and take responsibility for resolving throughput challenges. Some experts applaud the change, noting that problems with ED crowding often require system-level solutions. ⋯ Hospitals and EDs need to look at how they will address behavioral health patients who are waiting for transfer to another facility. Safety needs to be the key consideration.
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With volume and the left-without-being-seen (LWBS) rate on the increase, Mercy Hospital in Springfield, MO, created a new ED flow facilitator position to take charge of throughput. The ED flow facilitator is a nurse who assigns patients to the east and west zones of the department, and also handles all ambulance calls. The approach has helped the ED bring the LWBS rate from 8% to the 3% to 5% range, and it has also made a dent in length-of-stay and door-to-bed times, but rising volume continues to be a challenge. ⋯ Good flow facilitators are nurses with supervisor potential who typically prefer to stay involved with nursing care. They need to be able to multi-task and handle high levels of stress. Hospital administrators note that patient flow patterns need to be under constant review in order to fashion solutions that make sense for the ED.
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Recognizing that sepsis is the leading cause of death in hospitalized patients and a huge drain on health care resources, The Joint Commission's Center for Transforming Health Care, is taking aim at the problem in a new project that is already underway. Six participating health care systems are working to develop a targeted solutions tool that Joint Commission members can use to reduce the incidence of sepsis in their own settings. ⋯ For example, ED physicians in many systems no longer place central lines, a key component of care in serious sepsis cases. Screening tools used to identify sepsis in adults have no validity in children, making identification of sepsis in youngsters particularly difficult.