Role of the Emergency Department in 30-Day Readmission Reduction

If you asked most ED providers what their role in 30-day readmissions was, you would probably get a blank stare. While the majority of readmissions come through the ED, the providers there are focused on caring for their patients in a limited time, and with a limited amount of background information. Most of the time, they are unaware that a patient either is a readmission or is at risk of becoming one.

While most readmissions have a PCP, that physician is usually not involved when they enter the ED. Some patients enter the ED while in the care of a specialist. Patients undergoing operations or a Cath, or who were admitted to the care of a psychiatrist may end up in the ED without the knowledge of their PCP. Other patients may come from nursing homes, rehab centers, group homes, homeless shelters, home care agencies, or even prison. Whether or not these patients have a PCP, they arrive in the ED without medical records or a handoff from a PCP. Instead, the ED providers have, on average, about 180 min or less to evaluate, treat, and decide how to disposition each patient. There’s little time to search for background information, much less to connect with PCPs. This disconnect between primary care and emergency care is a major cause of the readmission problem.

The disposition options available to most ED physicians are:

  • (a) Treat and release
  • (b) Hospitalize

a. ICU

b. Acute med/surg

c. Observation

(c) Transfer to alternate facility

It is fairly rare for a PCP to be available or consulted in this process, a fact which results in higher readmission rates due to lack of background information and knowledge on the part of ED providers.

A few simple changes to the ED process—and provider expectations, can have an impact on these types of readmission risks. Currently, ED providers have no idea whether the patient they are seeing was an inpatient admission in the last 30 days. Because of this, they disposition the patient regardless of this crucial fact, possibly impacting quality of care and outcome, and at the very least a loss of revenue. Obviously, this information is of little consequence when dispositioning an acute life-threatening event. But even in extreme cases, the awareness of prior admits can be important to quality of care and disposition decision making. For example, a physician would want to know that a myocardial infarction patient was recently admitted for a cardiac event.

With today’s electronic records, it is possible for ED practitioners to be supplied with admission histories and even medical background information of incoming patients. With this information, providers can consider a range of options to better disposition 30-day readmission patients and may better be able to care for patients at risk of becoming a readmission.

Once the ED provider is aware that the patient they are seeing is indeed someone who had an inpatient admission within the last 30 days, the provider can consider the best disposition for that patient while minimizing the impact of the readmission.

They can consider additional options:

  • • Treat and Release—provider contacts the PCP to ensure a timely follow-up or, if there is no PCP, arranges to provide one
  • • Acute Emergent Inpatient—provider contacts the PCP to update patient’s status and expected length of stay.
  • • Non-emergent Hospitalization:
    • 1. Nursing Home Placement—If the patient is on Medicare and had an inpatient hospital admission in the last 30 days, the patient already satisfies the eligibility criteria for NH placement. Commercial payers will often authorize these transfers. A Social worker or care management assistance may be needed to arrange acceptance, transfer, etc. Examples of patients that may be eligible would be patients with COPD, CHF, or uncontrolled diabetes. PCP contact is again an important component here.
    • 2. Observation—Patients that need hospitalization but are ineligible for transfer to a NH and do not meet defined criteria (InterQual or Milliman) for acute inpatient admission after review, are best managed in a closed observation unit with appropriate staffing and resources. Even patients with a prior related admission in the last 30 days will be authorized for this type of hospital stay. The PCP is updated on the patient’s status and expected length of stay.

3. Patients eligible for inpatient med/surg hospitalization based on InterQual or Milliman criteria. PCP contact to inform them of the plan and status.

 
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