By Guy Boulton
Milwaukee Journal Sentinel
MILWAUKEE — An emergency room clogged with patients is an unwelcome sight for everyone involved — patients, doctors and other caregivers alike.
Hospitals responded in the past by sending incoming ambulances to other hospitals, sometimes 10 to 15 critical minutes away.
But under a policy that took effect this month, hospitals in Milwaukee County are no longer allowed to divert ambulances when their emergency departments have a high volume of patients.
“We needed to do better for the patients,” said M. Riccardo Colella, director of medical services for the Milwaukee County Office of Emergency Management.
The new policy has been planned for several years, so hospitals had begun following it before the official deadline. Aurora Health Care, for instance, has had a no-diversion policy in place since Nov. 1.
An initial step went into effect in January 2015, when hospitals could no longer divert an ambulance transporting a patient who was having a possible heart attack or stroke — conditions in which minutes matter.
“Patients critically ill were being diverted to more distant hospitals,” said Colella, an emergency medicine physician and an associate professor at the Medical College of Wisconsin.
Diversions also had a domino effect, with other hospitals going on diversion once one did. And diversions were becoming increasingly common.
Trauma patients, such as those injured in a serious car accident or fall or with gunshot wounds, were always taken to Froedtert Hospital, the hospital designated to handle the most serious trauma cases. And patients with serious burns were always taken to Columbia St. Mary’s Hospital in Milwaukee, which operates a regional burn center.
But other patients often would not end up at the hospital of their choice, where their physicians practiced and where their medical records were readily available.
A diversion also could cause potential headaches — and unpleasant surprises — if the hospital was not in the patient’s insurance network. By law, health plans must cover emergency care. But coverage for subsequent care can vary by health plan.
“This is going to help everybody at the end,” Colella said. “It is going to cause hospitals to be more efficiently lean, and patients will have a chance to go where they want go.”
Backdoor bottleneck
Preparing for the new policy, though, required health systems to redesign their processes not only in emergency departments but also throughout their hospitals.
“It’s the backdoor of the ER that’s the bottleneck,” Colella said.
How long does it take to get test results from the lab or radiology? How quickly can a room be prepared for a new patient? What are the steps for admitting a patient to the hospital? How does the hospital staff for unusual increases in the number of patients?
Consequently, the changes from the new policy affect the entire organization, said Kevin Kluesner, vice president of clinical services for Columbia St. Mary’s.
The health system’s hospital in Milwaukee moved to a no-diversion policy on March 8 and hasn’t diverted an ambulance since Feb. 17.
The hospital staffed eight additional beds in its emergency department about a year ago and now has 42 beds, or exam rooms. It also drew on Ascension Health, its parent organization, and on other hospitals for advice on how to make its emergency department more efficient.
One change was setting up a triage area where a nurse practitioner or physician assistant can do an initial assessment and order any needed tests, so the results are available when a physician sees the patient.
At Aurora Health Care, meetings were held every two weeks for 10 months to prepare for the new policy, said Steve Francaviglia, who oversees Aurora’s hospitals in Milwaukee County.
“It’s really a team effort to make this work,” he said.
It entailed an array of changes in their processes.
For example, for patients who didn’t need immediate care, X-rays and other imaging tests used to be sent in batches of three or four to a radiologist to be read. Now the tests are sent immediately. And when a patient was admitted, a nurse in the emergency department would call a nurse in the appropriate unit. Now those reports are sent electronically.
“We really looked at this as a whole,” Francaviglia said.
The minutes add up: Patients are getting treated sooner and getting in and out the emergency departments faster.
Aurora formerly had a diversion rate of 6% to 18% in a month.
“We agree that it is the right thing for the community,” Francaviglia said.
A manufacturing model
Wheaton-Franciscan-St. Joseph campus, which has the busiest emergency department in the state, stopped diverting ambulances on Feb. 1, and it, too, put considerable work into preparing for the new policy.
“We knew that, based on the volume of our ED, we had to improve our processes,” said Debra Standridge, president of Wheaton Franciscan Healthcare’s North Market.
The health care system hired Virginia Mason Institute in Seattle to help redesign its processes using principles first developed in manufacturing.
One key change was getting patients admitted more quickly.
“It unclogs the ED,” Standridge said.
About 85% of the hospital’s patients are admitted through the emergency department.
It also set up an area in the emergency room to treat patients who show no signs of needing emergency care, such as patients with sore throats or who need medication refills.
That’s not uncommon. Only a small percentage of patients who go to ERs — about one in eight in 2010 — require emergency or immediate care, according to the federal Centers for Disease Control and Prevention.
Heart attacks, strokes, fractures and drug overdoses are examples of the most serious injuries. In contrast, most visits are for urgent care or less. They include conditions such as sinus infections, urinary tract infections and sore throats, which could be seen in less-costly settings.
That said, a severe strep throat or sinus infection can seem like a medical emergency to the person with the condition.
“A lay person doesn’t know how sick they are,” said Heidi Ziemendorf, the nursing director of the emergency department at Columbia St. Mary’s.
The peak hours at Columbia St. Mary’s emergency department in Milwaukee are often in the mornings and after five o’clock when people get off work.
Hospitals by law must assess anyone who shows up at an emergency department, and the health system in the Milwaukee area said that recommending that people get care elsewhere can quickly be seen as turning people away.
The hospitals have care managers, typically nurses or social workers, who work in their emergency departments and who try to connect patients with primary care physicians.
“We are trying to educate the community that you have alternative resources,” Francaviglia said. “It’s really about education.”
That, too, would reduce the demands on emergency departments.
But, for now, they apparently are prepared for the new policy. And Colella said he is not worried about the change.
“Hospitals,” he said, “have been incredibly responsive.”
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©2016 the Milwaukee Journal Sentinel