Acute Care

Is the integration of urgent, emergent, inpatient and
care of patients with
acute medical conditions.


Emergency Department Triage: A Physician In Triage (PIT) Collaborative Process

By Nicholas Metzger, MBA, BSN, RN; Michelle Gunnett, MSN, RN, CEN; Catherine Prante, MSN, RN, NE-BC; Kevin Daly, MD, FACEP; Bruce Friedberg, MD, FAAEM; and Jaime Rivas, MD, FACEP

Editor's note: When the Palomar Medical Center emergency department relocated to a new, state-of-the-art facility in August 2012, the team anticipated an increase in patient volume. However, patient numbers soon rocketed beyond their predictions, resulting in increased wait times for patients.

To meet this new demand, the team decided to redesign its input system. The initiative has resulted in significant increases in throughput and patient satisfaction. The following report is adapted from a poster presented at CEP America's annual conference in September 2013.


On August 19, 2012, Palomar Medical Center (PMC) relocated to a new hospital and new emergency department (ED). The new ED is a Level 2 trauma center, EMS base station and a STEMI- and stoke-receiving facility. Our projected volume included 75,000 annual visits with an admission rate of 23 percent.

The move increased bed space from 29 to 54 beds. The new ED is divided into three pods (A, B and C), each with a care team that includes an MD, PA, RNs, techs and unit secretaries. The design includes a quick view RN and immediate registration. Direct bedding is done until capacity is exceeded, and then secondary triage is implemented.

Quickly upon settling into our new department, PMC saw a sharp rise above our predicted pattern in EMS arrivals and overall daily patient volumes, which in turn led to rising waiting room times, triage delays and an increase in Left Without Being Seen (LWBS) patients.

Infographic: Payer Mix Update

In this infographic, see what the data from CEP America's 94 EDs across the country tells us about how the payer mix has shifted after many of the new healthcare reform measures took effect. Does this match what you're seeing at your practice? Leave your observations in the comments section.

Don't Be a Dodo: Three Crucial Steps to Evolving Your Healthcare Organization (Part 3 of 3)

By David Birdsall, MD

fd32c46a2d9dda865cda33a1f48062c1_m.jpgWelcome to my third and last article in this series on change management for healthcare leaders.

Part 1 started with a reference to the dodo and the need to change or risk extinction. In Part 2, we touched on getting our wings and prepping for change. Specifically, that means doing your pre-work, picking your team and developing your timeline.

Step 3: Stay the Course

Now it is time to take flight and embark on making your change. This flight can be a bit tumultuous at times. But fortunately we have a map: namely, Quint Studer's 5 Stages of Change, to guide us.

These stages are universal, consistent, predictable and help the leader navigate the journey.

Community Paramedicine: Bridging the Gaps in Healthcare Delivery

By Michael Sequeira, MD, FACEP

11paramedic.jpgAs healthcare organizations work toward greater integration, one key player has rarely been mentioned. Emergency medical services (EMS), which play a crucial role in the health of our communities, were largely ignored by the Affordable Care Act.

It's true that in some ways, EMS stands apart from the rest of the Acute Care Continuum. After all, these services are funded not by hospitals but by local governments (e.g., fire departments), foundations and/or private ambulance companies. However, this distinction is somewhat artificial in practice, because EMS usually maintains close ties with local emergency departments (EDs) and the providers working there.

As former paramedic coordinator for the Oregon Board of Medical Examiners and physician director of four different ambulance services, I have a lot of experience with paramedicine. I've even coauthored a clinical book for EMS personnel. And I've seen firsthand how these professionals can play key roles in delivering quality, cost-effective care. For example, in some of Oregon's rural hospitals, the EMS unit is actually stationed at the ED and assists with patient care between 911 calls.

So I really believe that by leaving EMS out of the conversation, we're missing a golden opportunity to further the goals of healthcare reform.

Lately, I've been pleased to see growing interest in the concept of community paramedicine (CP), or "mobile integrated health" as it's sometimes called in the literature.

A Little EQ in the ED Goes a Long Way. Trust Me.

By Imamu Tomlinson, MD, MBA

robinson_101001_thu2_056a2.jpgAsk almost any physician why they chose medicine, and they'll answer, "I wanted to make a difference in the lives of patients."

But in today's high-pressure healthcare environment, it's easy to get caught up in performance metrics and obsessed with efficiency. We tell ourselves, "It's OK, as long as we're delivering great clinical care, we're delivering great care. After all, the massive heart attack was averted. The wound was stitched. What more could our patients want?"

We sometimes forget that we're caring for human beings who are going through the most frightening, painful and significant experiences of their lives.

I can relate. I'm an emergency physician, and my wife Tasha is a hospitalist. We know the pressures providers face every day. But about seven years ago, we went through an experience that changed our perspective forever.

Hospitals Hedge Their Bets by Purchasing Physician Practices

By Ellis Weeker, MD, FACEP, and Martin Ogle, MD, FACEP

monopoly-WEB.jpgIn recent years, many hospitals have been scrambling to purchase local physician practices. According to a recent Modern Healthcare article, this strategy often results in increased overhead for these hospitals.

However, hospital leaders say that employing physicians helps their organizations improve care coordination and quality while containing costs. They also hope the employed physicians will position them to take advantage of new value-based reimbursement strategies. In fact, physician employment has become so pervasive that physician recruitment firm Merritt Hawkins reports that 90 percent of its job openings are now for employed positions.

But could the strategy of buying up physician practices backfire for hospitals? And what are the implications for physicians, patients and the practice of medicine? In this post, Ellis Weeker, a founding Partner of CEP America, and Martin Ogle, a vice president at CEP America, weigh in on this timely issue.

The Results Are In! Predicting the Long-Term Effects of Healthcare Reform

Back in June on Reform Realtime, providers on the front lines shared their predictions about the long-term effects of healthcare reform:

"I think you're going to see a lot more team-based practices, because that's the only way we're going to address all of these patients coming to us with the number of providers that we have." — Cyndy Flores, PA-C

"If we don't have enough providers to care for all of these patients, access is going to be a huge factor into how this is all going to play out." — Matthew Stilson, MD

"I think the desire of policymakers is to move somewhere towards a single-payer system, which would give the government complete control over pricing and allow them to reign in the costs that healthcare has taken out of the economy." — Martin Ogle, MD

That was their take. But what did you think?

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