Emergency department administration

Within the emergency department (ED), ED administration is responsible for day-to-day operations. ED operations are responsible for various tasks, including developing policies and procedures, meeting operational metrics, utilizing clinical informatics, and managing human resources. Patient flow and throughput in the ED is the movement from arrival to disposition. Typically, the ED charges patients using a fee-for-service structure based on several factors, such as patient complexity and disposition. The role of the ED continues to evolve within the health care system as it faces new challenges, from ED overcrowding to caring for an aging population.

This article pertains primarily to ED administration issues in the United States.

The following is focused on ED management within the United States, but certain elements may be applicable to international health systems.

ED leadership structure

• Department chair
  • Responsible for the department overall
  • Liaison for hospital leadership
• Vice chair: responsible for specific operations under the department chair (e.g., research, quality improvement)
• Medical director: oversees clinical operations
• Residency director: responsible for resident education
• Nursing leadership (e.g., nursing manager): responsible for nursing operations such as scheduling and policies and procedures

Core responsibilities ^[1]

Core responsibilities for departmental operations may rest with a single person (e.g., medical director) or be delegated to multiple individuals. These responsibilities include:

• Fostering interdepartmental and intradepartmental collaboration and teamwork
• Developing departmental policies and procedures
• Monitoring patient flow and throughput
• Leading quality improvement initiatives
• Staffing and scheduling
• Ensuring regulatory compliance
• Overseeing the education of trainees (e.g., residents, medical students)

ED operations

Policies and procedures

• Policies and procedures to guide all operations are developed by hospital and departmental management and often include a set of standard operating procedures.
• Examples
  • Trauma activation criteria
  • Stroke response protocol
  • Cardiac cath lab activation
  • Guidelines for interactions with consultants (e.g., expected response times, procedures for settling disagreements between services)

Operational metrics

• Data acquisition is often performed using clinical informatics.
• Metrics are varied and may include:
  • Department throughput (e.g., door-to-doctor time, left without being seen rate)
  • Clinician productivity (e.g., patients per hour, relative value units generated)
  • Acuity (e.g., estimated severity index)

Clinical informatics

• Electronic health record: a digital record of a patient's health information
• Clinical decision support systems: analyzes data within the electronic health record to assist with clinical decision-making (e.g., SIRS criteria, drug interactions)
• Health information exchange ^[2]
  • Development and utilization of frameworks that allow patients and health care providers to share medical information across health care systems
  • Aims to reduce readmissions, medication errors, and duplicate testing

Human resource management

Human resource management is generally responsible for carrying out employee-related policy, e.g., recruitment, hiring, onboarding, and compliance.

• Staffing and scheduling: focuses on adequate physician and staff coverage for the ED based on factors such as expected patient volumes, safe staff-to-patient ratios, and clinician productivity ^[3]
• Credentialing ^[4]
  • Definition: verification of a clinician's qualifications before appointing them to the medical staff
  • Ongoing assessment of clinical competence and delineation of clinical privileges is generally performed by the ED medical director.
• Allied health professions ^[5]
  • Includes pharmacists, respiratory therapists, occupational therapists, physical therapists
  • Benefits include reductions in adverse events, unnecessary admissions, and readmissions.

Accreditation

• Definition: a designation given to health care organizations by accrediting organizations (e.g., Joint Commission, Council on Accreditation) upon achieving specific safety and quality standards
• Purpose
  • Assurance of quality care
  • Adherence to industrial standards
  • Required for CMS reimbursement

ED flow

• Definition: the movement of patients through the ED from arrival through disposition; directly related to throughput
• Comprises myriad factors (e.g., triage, crowding, available resources)
• There are multiple flow models, which vary by facility.

Patient triage and classification

• 5-level triage systems include the Canadian Triage and Acuity Scale (CTAS), Manchester Triage Scale (MTS), and Emergency Severity Index (ESI). ^[6]
• In the US, patients arriving to the ED are typically triaged using the ESI, which is based on predicted acuity and resource requirements. ^[7]
  • ESI I: requires immediate intervention
  • ESI II: high-risk, altered mental status, or in distress
  • ESI III: may require many resources; generally no abnormal vital signs
  • ESI IV: few resources required
  • ESI V: no resources required
• Alternative triage models to help improve patient flow include: ^[8][9]
  • Split flow: Patients are separated into high and low acuity; low acuity patients are seen in ED fast track.
  • Vertical split flow: in addition to the split-flow model, assigns some ESI 3 patients to chairs instead of beds to increase patient capacity
  • Physician-led triage: Initial evaluation by a physician allows for immediate order placement or disposition, reducing waiting time.

Hospital crowding and diversion ^[10]

• ED overcrowding
  • Definition: a state in which ED resources are insufficient to meet patient care needs
  • Results in increased waiting times, delays in care, worsening patient morbidity and mortality, and patients leaving before being seen
  • Factors that contribute to overcrowding include:
    • Internal factors: bed availability, staffing, consultant availability, diagnostic processing times
    • External factors: inpatient bed capacity, transport delays, inpatient staffing
• Boarding ^[11]
  • Definition: keeping patients in the ED after they have been admitted to the hospital due to a lack of inpatient capacity
  • Splits resource allocation between admitted and new ED patients
  • Associated with worse clinical outcomes for critically ill patients
• Diversion ^[12]
  • Definition: redirection of ambulances to an alternative facility when the initial facility is overwhelmed or has a disruption in patient care
  • Aims to reduce stress on hospitals and clinicians
  • Controversial practice due to various ethical concerns (e.g., rationing care)
  • Policies are generally established at the local or hospital level.

ED overcrowding, boarding, and diversion are associated with poor patient outcomes and should be avoided when possible. ^[10][11][13]

Observation units and fast track

• ED observation unit ^[14]
  • Definition: a hospital unit for ED patients who require an additional 6–24 hours of care to determine their disposition
  • Aims to decrease boarding by facilitating ED bed turnover
  • Patients appropriate for observation can generally be treated with an algorithmic care plan, e.g.:
    • Awaiting psychiatric evaluation
    • Negative initial workup for ACS with intermediate risk
    • Response to cellulitis after initial treatment
    • Diagnostic evaluation for syncope
• ED fast track ^[15]
  • Definition: an ED pathway in which patients with relatively benign conditions are rapidly evaluated, treated, and discharged, often in a separate, high-throughput area
  • Aims to increase ED flow
  • Usually staffed by advanced practice providers (i.e., nurse practitioners, physician assistants)
  • Appropriate for patients who can be treated and discharged, e.g., those with:
    • URIs
    • UTIs
    • Minor traumatic injuries

ED discharge planning

• Purpose
  • To provide patients with resources, instructions, and access to further care
  • To reduce the rate of boarding, repeat ED visits, admissions, and/or readmission
• Planning and/or interventions may include:
  • Providing comprehensive discharge instructions
  • Organizing home health care visits
  • Coordination with allied health professions, e.g., social work, physical therapy, occupational therapy
  • Patient placement in an alternative facility (e.g., skilled nursing facility, psychiatric hospital)

The following pertains to principles of finances and billing within the United States.

Financial principles ^[16]

• ED visits are classified as inpatient or outpatient, depending on patient disposition.
• Patient charges are based on disposition, payer type, and services provided, including :
  • ED services
  • Ancillary services, e.g.:
    • Laboratory studies
    • Radiology studies
  • Facility fees
  • Physician fees
• Payment models are mostly fee-for-service; alternative value-based models include bundled payment and capitation (see also “Health care payment models”).

Contracts and practice models ^[17]

Physicians in emergency medicine generally work in one of four different practice types, which may overlap.

• Academic
  • Focuses on research and training medical students and residents
  • Contracts may be held individually or by a group that contracts with the facility.
• Private group
  • Generally owned by physicians
  • Some groups are democratic, with physicians earning equity through a partnership track.
  • Contracts are usually held with a hospital or medical system at a local/city level.
• Corporate group
  • Generally owned by investors (e.g., private equity)
  • Contracts are usually held on a larger scale compared to private groups.
• Hospital employee
  • Ownership and equity vary
  • Contracts are held individually between the physician and hospital.

Billing and coding ^[18]

• ED patients are generally billed based on the level of service required (i.e., complexity of care), which is documented using a current procedural terminology (CPT) code.
• Level of service codes range from level I (most simple) to level V (most complex) based on numerous factors (e.g., complexity of medical decision-making, number of diagnostics needed, monitoring requirements, procedures).
• Critical care time may be billed based on required interventions and/or conditions treated (e.g., ventilator management, CPR, cardioversion).
• Procedures and diagnostic tests may be billed separately.
• Billing and coding is often performed by specialized hospital departments or contracted companies.

Reimbursement issues

Difficulties with reimbursement for ED services include:

• Declining Medicare reimbursement rates ^[19]
• Changes in payer mix decreasing reimbursement ^[20]
• Patients leaving the ED before treatment is complete (e.g., left before being seen) ^[21]

Health care coordination

Health care coordination in the ED may include:

• Determining advanced health care directives
• Coordinating initial care for patients requiring evaluation by multiple specialists within the ED or at admission
• Arranging outpatient services (e.g., wound care, specialty clinic referrals, allied health services, home care)
• Placing patients in alternative facilities (e.g., skilled nursing facility, psychiatric hospital)
• Initiating palliative care (e.g., hospice care)
• Coordinating organ donation

Regionalization of emergency care ^[22]

• Definition: the formation of networks through which time-sensitive conditions (e.g., stroke, burns, STEMI) can be treated at specialized centers to reduce delays and improve outcomes
• Centers around regional protocols that facilitate urgent access to emergency specialized care, including:
  • Bypassing hospitals without specialty coverage (e.g., transporting patients directly to stroke or trauma centers)
  • Employing centralized command structures to guide EMS
  • Stratifying regional health care facilities based on resource availability
  • Public education and outreach

Evolving trends in health care delivery

The following factors affect the provision and delivery of health care and emergency services. Clinicians should be aware of their impact and the policies in place to respond to them.

• ED overcrowding
• Aging population ^[23]
• Social aspects of health care
• Corporate practice of medicine ^[24]
  • Private equity investment in and acquisition of staffing companies is increasing.
  • There are concerns over patient billing, higher costs, and quality of care; data is currently lacking.