As many primary care and emergency physicians across the country are already aware, this year’s flu season promises to be not only earlier than usual but also unusually aggressive. In addition, we are seeing regional outbreaks of norovirus and the worst whooping cough outbreak in the last 60 years. During my last shift, the emergency department was filled with patients with severe diarrhea and dehydration or influenza and/or influenza-like symptoms. As expected, the winter months also bring an increase in emergency patients with significant pulmonary and cardiovascular diseases. This combination of multiple viral “epidemics” with an increase in patients with two of the most common system illnesses creates a patient volume surge situation for many emergency departments.
To be cost-efficient, emergency departments cannot and do not routinely staff up for the worst case scenario. To do so would dramatically raise the cost of care and result in inefficient use of resources during the non-surge periods. Emergency departments are constantly balancing the need for efficiency with the ability to rapidly accommodate ED surge. Failure in either direction ultimately risks the welfare of our patients. By integrating services across the Acute Care Continuum, we have discovered that we can successfully adapt to surges in patient volume with often nearly fixed resources by using a multi-tiered response with greater sharing of responsibilities. What does this mean? The Doctor’s Medical Center of San Pablo response to the Richmond, CA oil refinery fire illustrates how integrating services across the Acute Care Continuum allows for a coordinated response to even a very significant patient volume surge.
During the summer of 2012, the Richmond oil refinery fire resulted in a dramatic increase in patient volume at DMC San Pablo for a sustained period of time. The smoke and debris from the fire lingered for days, and even two weeks later, the ED was seeing significant patient volumes. More than 6,000 patients were seen over a 12 day period, with a peak volume of 773 patients in a 24 hour period. During that day, the ED, which typically saw 100 patients/day, had only a 2% left without being seen.
At DMC San Pablo, where emergency physicians and hospitalists are all part of an integrated ED/Hospital team, we were able to rapidly mobilize additional physician and other hospital resources to respond to an unprecedented surge in the ED patient volume. We recognized that the majority of patients could be evaluated and discharged, and that those who required observation for smoke inhalation and significant pulmonary complications required rapid movement to an inpatient setting in order to free ED bed availability. Thus, we stationed our hospitalists in the ED alongside our emergency physicians, so that the hospitalists could see smoke inhalation and toxic exposure patients and immediately discharge those patients who did not require prolonged observation. In addition, the emergency physicians rapidly assessed and admitted patients who required observation or inpatient management without hospitalist input. For non-inhalation injury patients requiring admission, the emergency physicians completed the necessary inpatient evaluation--including the initial holding orders--so that the hospitalists were not distracted, and could operate with maximal efficiency.
Communication, trust, and pre-arranged agreements were the key to success. I saw a willingness to share responsibility between providers, pre-determined standardized ED work-ups for patients requiring admission operating seamlessly, and standardized holding orders for various admission diagnoses expediting care – all of which made it possible to move patients from service to service without requiring multiple clinicians to first see the patient. By integrating care across the Acute Care Continuum, we were able to coordinate care and develop efficiencies that allow our hospitals to better handle the unpredictable yet anticipated and expected surges in patient volume.
Not planning for unpredictable but expected events makes no sense. Eliminating silos and the turf mentality by managing across the Acute Care Continuum allows for efficiency and resource sharing and creates flexibility that can successfully address the unpredictable but anticipated nature of patient volume surge.
I am confident that DMC San Pablo will weather this season’s flu epidemic better than most emergency departments, and that practitioners will be less stressed and better able to provide quality care. There are many factors driving the changes in health care, from how we pay for care to the expected long-term increase in emergency department volumes, and the need for efficiency. Together, they all mean that successfully integrating and managing the Acute Care Continuum will no longer be an innovation or an option, but a standard practice and a necessity.