The Evolution of Emergency Medicine: Freestanding EDs Meet Patients Where They Are

Daniel Varga, M.D., Chief Clinical Officer and Senior Executive Vice President for Health Resources

Ricardo Martinez, M.D., FACEP, Chief Medical Officer,

Access to immediate, quality emergency treatment is a cornerstone of any healthcare system.

Each year, millions of Americans rely on hospital-based emergency departments (ED) to treat serious illness and injury, but these care systems are overburdened. Due to social and medical trends, Americans require emergency care more than ever, but hospital EDs are constrained by space, staff and resources resulting in overcrowded hospitals across the country. Making matters worse, over the last decade, the number of hospital EDs have declined and rural hospitals are failing, removing access points for emergency care to millions of people.

According to a 2014 report by the American College of Emergency Physicians, the state of EDs across the country has deteriorated to a near-failing grade.1 The U.S. lacked in all five of the major categories measured in the report, including access to emergency care, quality and patient safety, medical liability, public and injury prevention and disaster preparedness.

But this issue is not new. In fact, it has been growing for quite a long time. In 2006, the Institute of Medicine released a report that described a national epidemic of overcrowded EDs, which underscored the fragmentation of emergency care and raised issues of access, patient safety and quality associated with an overburdened system. It called for major change.2 As early as 1990, the American College of Emergency Physicians Overcrowding Task Force published results stating that Americans faced a crisis in healthcare with the overcrowding, limited access and the quality of emergency care.3 Overcrowding is well-recognized to affect patient care quality, patient experience and patient outcomes. Overcrowding also affects other quality metrics such as timeliness, efficiency and safety.4 The impact is felt by caregivers as well, with emergency medicine physicians holding one of the highest burnout rates for medical professionals.

Two major changes exacerbate this trend. First, the American population is aging and more likely to have chronic diseases, requiring more complex workups and greater utilization of resources in the emergency department.5 In 2013, a RAND Corporation report noted that both primary care and specialists increasingly rely on the resources and expertise of the emergency department to evaluate and treat patients with time-sensitive conditions or symptoms.6 Second, alterations in healthcare policy have put greater focus on the ED. The Affordable Care Act focused on better management of patients with chronic disease and on providing health insurance for the uninsured. It did not address acute disease or time-sensitive conditions. This is an issue as patients increasingly turn, or are sent, to EDs to treat their acute conditions.

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For decades, hospitals have repeatedly expanded emergency departments, added more staff and built larger waiting rooms. They have also been the one access point that accepted patients at any time of the day or night. But still, ED overcrowding has been called a chronic disease in itself. 7

The current model is broken.

A New Model of Emergency Care

Healthcare professionals have not been able to reconcile the new reality of emergency care within the constraints of the traditional hospital-based model. A new model of emergency care must be created to address the growing demand for such services. Adeptus Health is leading the transition from centralized hospital-based emergency departments to a more distributed access model of emergency care that incorporates freestanding emergency departments (FSED) that are integrated into the healthcare system. It is a model of moving emergency care to where the patients are – and their healthcare needs must be met.

FSEDs offer patients emergency services that are equal to or surpass hospital-based facilities. The acuity levels for patients seen in FSEDs are similar to hospital-based EDs, with EMS culling out specific conditions to specialized hospitals (acute stroke, STEMI, burn, trauma). All EDs – including freestanding facilities – are present to address immediate medical threats and stabilize patients for discharge or transfer to specialized care providers. Like hospital EDs, patients needing specialized care get their initial evaluation and early treatment at the FSED and then may be transferred to the specialty center or scheduled follow up appointments with appropriate providers as part of a coordination of care. Overall, the percent of patients admitted or transferred from FSEDs is about half of what hospital EDs transfer or admit, reflecting the ability to spend more time with the patient and caregivers to develop effective outpatient care plans.

A key difference between hospital EDs and FSEDs is how the latter distributed model of care eliminates overcrowding by hosting lower patient volumes with shorter wait times, leading to more timely and efficient treatment by physicians. Instead of one crowded central ED serving a population or community, multiple FSED locations can be built to provide more widespread access to care for patients.

Time is critical when dealing with life-threatening conditions and the centralized model of emergency care requires longer travel times, and often extended waits, for many patients. With well-located facilities in the community, FSEDs offer little or no delay in evaluation and care, faster diagnostics and early clinical intervention. Just as the creation of EMS allowed “out of hospital” care to reach into the community, the spread of FSEDs expands the reach of emergency care into communities and allows patients to be seen by a board- certified physician faster. For example, physicians can administer front-line, emergency care to a patient with a heart attack before transferring them to a cardiac catheterization lab. That early intervention provides greater

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opportunity for tissue rescue and research shows that these patients have “door-to-balloon” cardiac measurement times that surpass national goals. With access only at a central hospital, that same patient would require longer travel time before being evaluated, diagnosed and treatment was begun. They may face additional delays as the cardiac catheterization lab was notified and readied. With the FSED model, many of these steps can start earlier and begin concurrently.

In addition to seeing patients faster, FSEDs are able to educate individuals on appropriate care options and to help them avoid major emergency care fees. Utilization of EDs by people who do not require their full resources is an ongoing issue. FSEDs conduct an initial medical screening exam with patients and educate those with lower acuity conditions about lower cost medical care options. Adeptus Health’s philosophy is to ensure that patients receive the right care at the right place at the right cost. In fact, FSED referrals to urgent care clinics have led to an increase in urgent care patient volumes in other markets across the country. Similarly, often the highest referrals to FSEDs are from nearby urgent care clinics and primary care providers, indicating this model of care fulfilled both a need and an important role in communities.

That said, the vast majority of FSED patients are high acuity, and have time-sensitive conditions that require emergent evaluation and care. These medical issues include broken bones, burns, chest pain, abdominal pain, pulmonary symptoms, head traumas and concussions. Although most FSED patients need emergency care, FSEDs have lower transfer rates since physicians have more time to evaluate patients, and they utilize fewer tests during a work up, which drives down healthcare costs. Also, the accessibility of FSEDs increases the ease of access to evaluation and treatment of potentially life-threatening conditions for patients hesitant to navigate a hectic central hospital ED.

A New Future for Emergency Care

As healthcare professionals continue to look for ways to improve emergency care, FSEDs will provide new flows of insightful data in addition to immediate access to care. FSEDs will generate more information on the types of patients and acuity treated; system and facilities’ quality care performance and best approaches to time sensitive conditions. They will help to better understand patient distribution for crowding quality care and safety; optimal integration with EMS within the spectrum of healthcare facilities; incorporation with public health, disease surveillance and disaster preparedness; overall cost-effectiveness and total cost of care; and optimal value in the care continuum. All of this is required to integrate emergency care into a meaningful whole that puts patient needs first.

FSEDs are also finding new ways to partner with hospital networks. Adeptus Health’s joint venture with is a recent example. Adeptus Health’s network of FSEDs are now aligned with Texas Health’s 25 acute-care and short-stay hospitals, which expands access to care to over 7 million residents in 16 counties in the -Fort Worth metropolitan area. With the addition of Adeptus Health’s FSEDs, Texas Health now has

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more than 350 points of access, from hospital and outpatient centers to doctors’ offices and imaging centers throughout North Texas.

The evolution of emergency medicine is not an “us versus them” phenomenon. FSEDs are not working in competition to hospital-based EDs, but instead in collaboration with them to address the rising need for more distributed emergency care. With more FSEDs, healthcare professionals can work together to build a new future of emergency care for all patients, communities and the profession itself.

About the Authors

Dr. Daniel Varga joined Texas Health Resources in January 2013 as the system's first Chief Clinical Officer (CCO) and Senior Executive Vice President. As CCO he is responsible for achieving full and seamless integration of the entire Texas Health clinical enterprise, including quality, patient safety, and patient experience initiatives. He also oversees physician relationships, clinical integration, care design, and clinical research and education.

Dr. Varga comes to Texas Health with 24 years of combined experience in patient practice, medical education and health care administration. He served in a number of senior clinical leadership roles in large health care organizations, most recently as the Chief Clinical Officer at KentuckyOne Health, the largest health system in Kentucky.

Prior to this position, he served as Chief Medical Officer at Saint Joseph Health System in Lexington, Ky., Regional Vice President-CMO at SSM Healthcare-Saint Louis, Senior Vice President and CMO at Norton Healthcare in Louisville, Ky., and Founder and President of Community Medical Associates, a large primary care physician group.

Dr. Varga received a bachelor's degree at the University of Kentucky and his medical education was at the University of Louisville. He is board certified in internal medicine.

Dr. Ricardo Martinez is a nationally recognized board-certified emergency physician and has practiced emergency medicine clinically for more than 30 years, and held senior roles in business, academia, and the federal government. Before joining Adeptus Health, Dr. Martinez was Chief Medical Officer of North Highland Worldwide Consulting, where a major focus of his work was collaborating with physician leadership to enhance their effectiveness in providing high-value care,

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building data-driven patient-centered teams, and driving cultural change. Dr. Martinez also served as the Executive Vice President of Medical Affairs for the Schumacher Group, a leading emergency medicine practice management company, and was previously appointed Federal Administrator of the National Highway Traffic Safety Administration (NHTSA) by President Clinton. He currently serves as faculty at Emory University School of Medicine and previously held roles at Stanford University School of Medicine and as Executive Director of the Medical Leadership Academy.

Dr. Martinez has been a senior medical advisor to the National Football League since 1988, facilitating medical care, emergency planning, preparedness and public health for The Super Bowl. He was elected to the Institute of Medicine of the National Academy of Sciences in 2004 and served on the Board of Directors of the Public Health Foundation.

Martinez pursued undergraduate studies from State University, an M.D. from Louisiana State University School of Medicine, and his residency at LSU-Charity Hospital at New Orleans, where he was Chief Resident.

References

1. American College of Emergency Physicians. America’s Emergency Care Environment: A State by State Report Card. 2014. 2. Institute of Medicine of the National Academies. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: National Academies Press. 2006. 3. American College of Emergency Physicians Overcrowding Task Force. Measures to Deal with Emergency Department Overcrowding. Ann Emerg Med. 1990; 19:944-94. 4. Carter E, Pouch S, Larson. The Relationship Between Emergency Department Crowding and Patient Outcomes: A Systematic Review. E J Nurs Scholarsh. 2014; 46(2): 106–115. 5. Pitts SR, Pines JM, Handrigan MT, Kellermann AL. National Trends in Emergency Department Occupancy, 2001 to 2008: Effect of Inpatient Admissions Versus Emergency Department Practice Intensity. Ann Emerg Med. 2012; 60:679–686. 6. Morganti, K, Bauhoff, S, et al. The Evolving Role of Emergency Departments in the United States. RAND Corporation. 2013. 7. Kocher K, Asplin B. Emergency Department Crowding 2.0- Coping With a Dysfunctional System. Ann Emerg Med. 2012; 60:6: 687-691.

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