Breaking News: Greet and Street: Streamlining the ED or Taking Risks?

Posted by BestPractices on April 2 2012

Shaw, Gina

Emergency Medicine News:
March 2012 – Volume 34 – Issue 3 – pp 1,22
Breaking News

Sometimes a headache is just a headache. But sometimes it’s a subarachnoid hemorrhage.

The triage process in the emergency department is meant to distinguish between such cases and prioritize the most critical patients. At Halifax Health System in Daytona Beach, FL, a new cost-saving policy aimed at reducing unnecessary ED use has recently raised the stakes for accurate triage.

Beginning in mid-May, all patients 18 to 64 deemed not to be emergencies are directed to an on-site health clinic charging $48 per visit or are given a list of community resources. If they really want to be seen in the emergency department, they can pay their insurance co-pay or $350 in cash up front.

Director of Emergency Services Peter Springer, MD, explained that likely nonemergent cases are identified by chief complaint, for which they did a literature review to establish categories, such as chronic tooth and ear pain, sore throats and minor cold and flu symptoms, suture removals, hemorrhoids and constipation, and nonacute psychiatric presentations. Patients are given a quick, focused physical by a physician or physician assistant. “If it really is a nonemergent case, we give them some choices,” he said.

Halifax is not alone in this policy, which some have dubbed “greet and street.” Those who swear by it say it’s EMTALA-compliant: as long as every patient seeking emergency care is given a screening exam, EMTALA doesn’t mandate that the hospital has any further obligations if that exam does not reveal an emergent medical condition. Indeed, Central Florida Regional Hospital in nearby Sanford implemented a similar rule to little fanfare a couple of years ago. Like many hospitals, Halifax is facing budget constraints, and notes that about a third of its bad debt is generated by its emergency departments.

“We’re trying to appropriately utilize our resources so we have the capacity to effectively treat the true emergencies,” Dr. Springer said.

But what are the risks of such a strict triage policy? And will it really cut costs?

Timothy Platts-Mills, MD, an assistant professor of emergency medicine at the University of North Carolina School of Medicine, has written about ED crowding and the accuracy of triage. He noted that Halifax’s exclusion of very young and elderly patients from the new approach mitigates some of the hazards. “In a study we conducted of older adult triage, we found that for roughly a quarter of patients who required an immediate intervention, the need for an immediate intervention was not identified at the time of triage,” he said. “Older adults are more likely to have life-threatening illness or injury, and identifying emergencies in older adults is probably more difficult. To the extent that these providers feel the need to have a policy of diverting nonurgent patients, I think these age limit exclusions make sense.”

The question remains if the rest of patients presenting to the ED — the 18- to 64-year-olds — can be triaged safely to an outpatient setting. “The answer depends on a number of things, including the characteristics of the triage process and the capacity of the outpatient clinic to provide care and recognize when a mis-triage has occurred,” Dr. Platts-Mills said. “If practitioners have limited time to complete triage assessments or if they face external pressure to triage patients into a nonurgent category, I think there is risk to patients. No one is perfect. A triage system that uses a chief complaint alone to identify nonurgent patients would almost certainly be unsafe because for almost any complaint [including common, seemingly mundane complaints such as back pain or dental pain], there will be some patients with that complaint who have a life-threatening condition.”

Halifax has tried to minimize such risks with an err-on-the-side-of-caution rule for the physicians and midlevel clinicians who conduct triage. “We’ve made it perfectly clear that if anything at all makes the provider concerned or uncomfortable, we will go ahead and treat the patient. We don’t take chances like that,” said Dr. Springer.

Then there’s the question of what happens to those patients with real but nonemergent medical needs who are turned away from the emergency department. In the mid-1990s, Robert Derlet, MD, now a professor emeritus of emergency medicine at the University of California-Davis, described that institution’s system for triaging nonemergent patients out of the ED in articles published in Academic Emergency Medicine. (2004;11[1]:38, 1994;1[3]:204.) But today, it’s a different world, Dr. Derlet said.

“When we did this, there were free clinics in the Sacramento area that had capacity to see our nonemergent patients when we referred them out,” he noted. “We could send them somewhere, and they’d be seen that afternoon. But as time has passed, there’s no more capacity in the system for that. I do believe that ERs are for emergencies, and I think Kaiser is a fantastic example of a system where they have a number of urgent care clinics, so if a patient comes to the ED they can internally refer the patient under the same umbrella. But you have to take care of the problem.”

Dr. Springer said he actually first heard of externally triaging nonemergent cases when he was a resident at UC-Irvine some 15 years ago, during Dr. Derlet’s tenure. He said he appreciates his mentor’s concerns. “We’re trying to appropriately address the tax on these clinics,” he said. “With our community clinic, we added a PA to the staff, anticipating that their numbers would go up.”

Dr. Platts-Mills said he also worries that people who hear about these new ED policies may be discouraged from presenting to the emergency department in the first place. “If the public thinks that they are going to be asked for money before receiving care, maybe they will decide not to come in or delay coming in. And that delay could also be dangerous,” he said.

He recalled a patient in the midst of a heart attack who drove herself to the ED, and went into cardiac arrest within two minutes of arriving. “Fortunately it wasn’t busy, she had been placed directly into a bed, and a nurse was at the bedside. She lived. I have often wondered how it would have played out if she had encountered one extra red light,” Dr. Platts-Mills said. “Not all patients know they have a life-threatening condition, and if they think they will be charged up front, there may be some patients who will delay their care with profound consequences.”

It also remains to be seen just how much money greet-and-street policies will really save hospitals. It’s often claimed that a significant percentage of ED patients present without true emergencies, but national data suggest otherwise. The 2008 National Hospital Ambulatory Medical Care Survey found that ED patients were triaged as needing to be seen immediately (3.7%); emergently (within one to 14 minutes; 11.9%); urgently (within 15 to 60 minutes; 38.9%); or semi-urgently (within one to two hours; 21.2%). Just eight percent of patients were nonurgent, and able to wait two to 24 hours to be seen. For the remainder, triage status was unknown.

Dr. Derlet said he’s disappointed by the greet-and-street trend. “I think every person in this country deserves health care,” he said. “Hospitals and communities need to find a way to provide free or very low-cost clinics for people who don’t have emergency conditions so that they can be taken care of. They will say they can’t afford it, but if you look at the salaries of top officers, they’re doing better than they claim. Hospitals can do more. They really can.”

But Dr. Springer said he believes the policy is improving care, at least at his hospital. “While it’s still early days, we’re looking at anywhere from 10 to 20 fewer visits per day. That means much quicker throughput in our triage areas for the true emergent cases,” he said. “And several people — people with insurance, actually — have come in and said they didn’t realize that their condition could be treated by their primary care provider, and they were glad we told them that. And we’ve had chronic patients — those who come in on a frequent basis for the same complaints — actually utilize resources, and talk with our case manager about their options.”

Speaking Engagements

There are no upcoming speaking engagements.