Category: Emergency Department

The occupancy rate of a hospital is the percentage of available staffed beds that are currently occupied by patients. As the number of COVID cases surges this month, we are about to see our country’s hospitals more fully occupied than ever before.

The need to improve hospital financial efficiency has led many hospitals to try to keep their average occupancy as high as possible, often 90% or higher. But if the occupancy rate is too high, then inefficiencies arise that can be just as detrimental to hospital finances as when occupancy rates are too low. One danger of keeping the average occupancy rate too high is that the hospital cannot accommodate unexpected surges in admissions. This has been a significant problem for hospitals across the U.S. during the various case surges during the COVID-19 pandemic and will be even more so in the next few weeks.

What is occupancy? Most hospitals use the “midnight census” to track their occupancy rate. This is the number of patients in a bed at midnight each day. This metric works well for hotels since there is a defined check-out time in the morning and check-in time in the afternoon each day. However, this number can be misleading for hospitals because hotels, hospital admissions and discharges occur at continuously throughout the day and night with the result that the hospital census at noon is almost always higher than the census at midnight as morning admissions start to pile up while afternoon discharges are still occupying beds. As a consequence, a hospital may have 15% empty beds at midnight but have no empty beds at 2:00 PM. Therefore, the midnight census is useful from a financial standpoint but real-time census is more important from an operational standpoint.

It takes more than just a room with a bed… Not only do you have to have a physical place to put patients, but you have to have the nurses, doctors, pharmacists, and respiratory therapists to take care of them. During the COVID pandemic, at any given time, large numbers of these healthcare workers were unable to work due to having COVID themselves, having to isolate because of a COVID exposure, or having to stay home to take care of  child who was unable to attend school due to COVID. A single nurse can only safely take care of so many patients and if that number of patients is exceeded, then patient care can suffer. Moreover, nursing contracts and nursing units often place a limit on the number of patients a nurse can take care of and a limit on the number of hours per week a nurse can work. When the hospital lacks the personnel to care for patients, it has to “block-out” rooms from use.

Not all hospital beds are equal. Hospitals will try to group similar patients on a single nursing unit. This allows nurses to develop expertise in managing specific types of patients, for example, cardiac, pediatric, psychiatric, post-surgical, and maternity. This also creates better efficiency for the doctors so that, for example, a surgeon does not need to go to 7 different nursing units to round on his/her 7 post-op patients. But as nursing units become more and more specialized, it becomes less desirable to admit one kind patient to a different kind of unit. So, for example, having a lot of open beds in the addiction medicine ward does not really help you if you are trying to find a bed for a post-op neurosurgery patient and all of the surgical nursing units are full. Most hospitals will have a lot of “med-surg” units that can accommodate general medical patients or surgery patients.

What happens when there are no beds?

The need to accommodate the constant flow of admissions has resulted in hospitals putting a lot of resources into capacity management. Smaller hospitals often utilize a “nursing supervisor” who keeps up-to-date information on which patients are projected to be discharged and which patients are awaiting admission. Larger hospitals will utilize a admission control center staffed by multiple nurses whose sole responsibility is directing the flow of hospital admissions and patients being transferred from other hospitals; this is called “bed placement”. In most hospitals, the electronic medical record will facilitate this process by having dashboards that list open beds and beds occupied by patients who will be discharged later that day.

But what happens when all of the beds are full and there are more projected admissions than discharges for the rest of the day? That is when the hospital medical director generally gets involved. Here are the some of the available options:

1. Expedite discharges. This is usually the first action taken and involves contacting all of the hospitalists and other attending physicians to ask them to hasten discharges. Most of the time, this only results in moving otherwise planned admissions up by a couple of hours but even that can help free up a few beds to help decompress admission bottlenecks. Simply having a discharge order does not ensure that an empty bed will be created, however. Nursing and case management can also expedite discharges by arranging earlier transportation home, by locating nursing homes with available beds, and by using “discharge suites” where discharged patents can wait for their rides.
2. Focus on long-length-of-stay patients. Every hospital has a group of inpatients that have been admitted for many weeks or months. Often, these are patients who are difficult to get placed in nursing homes because they are uninsured or because they have behavioral problems. By creating  multidisciplinary workgroup to identify and overcome the barriers to discharge of these patients, desperately needed hospital beds can be opened up.
3. Board admitted patients in the emergency department. There are a lot of reasons why boarder patients are undesirable (see my previous post). But in the short run, this is often the easiest way to accommodate a surge in admissions. If the number of boarders in the ER becomes too high, then the ER becomes congested and unable to provide care for regular emergency patients.
4. Board post-surgical patients in the post-op recovery unit. Most patients recover in the recovery unit and then go to a regular hospital room to spend the night (for outpatient surgeries that require overnight observation) or spend several nights (for elective inpatient surgeries). Keeping patients in the recovery room longer can allow extra time needed to get other patients discharged and get those rooms cleaned and ready for the post-op patients. However, at some point, the recovery unit becomes full creating a bottleneck in patient flow in the operating rooms. One solution to this is multi-use space that can serve as pre-op beds in the morning and post-op beds in the afternoons. However, if patients remain in the recovery area into the evening or night, then you have to have the nurses to care for those patients and this either means keeping the post-op recovery area nurses overtime or “floating” nurses from other floors to the recovery area.
5. Stop accepting hospital transfers. This is a tactic that only works for larger referral hospitals that normally have transfers comprise a significant percentage of their admissions. These transfers are usually patients with complex medical or surgical conditions coming from small hospitals that are not equipped to manage them and so these patients still need to be transferred somewhere. If all of the other referral hospitals in the area are also full, this can mean that the patient in a small hospital may need to be transported to a hospital in a far-away city or even another state. During the first surge in COVID cases in January 2021, it was not uncommon for me to get a call about transferring a patient with respiratory failure from a physician in a town such as Defiance, Ohio who had already had his patient turned down for transfer from all of the referral hospitals in Toledo, Dayton, Cincinnati, and Cleveland.
6. Put the emergency department on divert. When the emergency department goes on divert status, emergency squads are directed to take patients to other emergency departments. This is undesirable from a community standpoint because it can result in delays in caring for critically ill patients by having the squads travel to emergency departments that are further away. There are a lot of reasons why an emergency department might go on divert: too many patients backed up in the waiting areas, a bolus of cardiac arrest or trauma patients that temporarily requires all of the available ER staff to manage, a hospital power failure, too many inpatient boarders in the ER, etc. During the COVID surges, there were days when all of the hospitals in Columbus were at full inpatient capacity and all of the emergency departments went on divert – when this happens, the agency that oversees regional trauma care institutes “city-wide divert”. In this situation, the region’s emergency squads go to hospitals on a rotational basis so that all hospitals share the excess patients equally.
7. Cancel elective admissions. This mainly affects surgeries – both elective inpatient surgeries (such as spine surgery) and outpatient surgeries that require an overnight stay (such as knee replacement surgery). Hospital leaders hate to do this because these surgeries are very financially lucrative. The result is replacing a surgery patient that the hospital can make money on with a medical patient that the hospital can at best hope to break even on. In addition, by canceling surgeries, the surgeons and anesthesiologists are idle and the hospital usually ends up paying the salaries for these highly-paid physicians since they cannot earn their income in the operating room.
8. Open up new beds. In a crisis, hospitals can convert many areas of the hospital into emergency-use patient care areas: decommissioned nursing units, the endoscopy suite, the sleep lab, the cardiac cath lab recovery area, etc. There is an inherent inefficiency to using these areas for inpatients as they are not equipped to care for inpatients and the normal nurses for these areas are unaccustomed to regular inpatient care. Also, when these areas are used for inpatients, they cannot be used for their normal purposes and this results in canceling  elective procedures.
9. Create new space. When the hospital has maximized available space within the building, the next step is often to create temporary hospital space . During the initial surge in COVID cases, we erected a large tent in the parking lot adjacent to the emergency department to do triage and care for low-acuity emergency room patients. The Ohio National Guard helped to convert the Columbus Convention Center into a several hundred bed hospital area for low-acuity inpatients (that we fortunately never needed to utilize). Other hospitals converted parking garages, college dormitories, and hotel rooms into temporary patient care areas.
10. Ration healthcare. This is usually done only as a last resort. Although often discussed in the U.S. during COVID surges, it was rarely, if ever implemented in our country. But in underdeveloped nations, this is a fact of daily life. If there are only 3 ventilators in a hospital with no others within several hundred miles, then the doctors have to choose which three patients get to use the ventilators. Even in developed countries, such as Italy, the first surge of COVID resulted in rationing of ventilators and ICU beds to only those patients felt to be most likely to survive.

Where do you find more doctors and nurses?

When hospitals start opening up new beds or new space for inpatients, those beds are only useful if there are doctors, nurses, and other staff available to cover them. During January 2021, we staffed new COVID ICU areas with anesthesiologists, hospitalists, trauma surgeons, and emergency medicine physicians rather than critical care internists. Recovery room nurses, addiction medicine nurses, and cardiac cath lab nurses were sent to staff med-surg nursing units and ICUs. We brought in general internists and family physicians who normally worked in outpatient clinics to function as hospitalists. CMS made an emergency allowance that residents and fellows in training could be temporarily credentialed as attending physicians and were allowed to bill for inpatient services. Many hospitals turned to recently retired physicians and nurses. “Traveler” nurses and locum tenens physicians (frequently from out of state) were often brought in to help with inpatient care.

Currently in Ohio, the governor has deployed the National Guard to the most crowded hospitals to assist. The problem with the National Guard is that most of the doctors and nurses in the National Guard are already tied up caring for patients in their own hospitals during the current COVID surge and so the only members of the National Guard available to help are non-healthcare workers who can only assist with support activities in hospitals.

Keeping up morale

When hospitals run out of beds and operate at full capacity (or over full capacity), it puts enormous strain on the mental health of the healthcare workers: Nurses who are caring for patients with conditions that they are not familiar with. Doctors who are taking care of more patients than they normally manage in a day. Everyone exhausted from working extra shifts. Angry patients and families lashing out at healthcare workers. Experiencing mounting numbers of deaths. All of these contribute to burn out. Even if the hospital administrators can open new physical beds, those beds are useless if the healthcare workers call-off work or quit due to burnout. Also, a toxic doctor or nurse may provide a needed warm body in the short run but will poison the workplace for other doctors and nurses in the long run. Fortunately, there are some things that medical directors can do.

1. Communicate. This is probably the single most important tool that medical directors have to combat staff burnout. Times of crisis create information vacuums and unless hospital leaders communicate regularly, that vacuum will be filled by rumors and conspiracy theories. In-person town hall meetings, virtual Zoom meetings, daily website posts, and emails all have their roles and it is best to use a combination in order to ensure the largest audience possible.
2. Be a cheerleader. More than any other time, during high capacity periods, medical directors and other hospital leaders need to get out of their offices and get into the patient care areas. It is essential that you are visible to the doctors and nurses and show that you are there to serve them. Look for excuses to give compliments. Show up at code blues, STEMI alerts, and trauma alerts. And don’t forget about the night shift staff.
3. Recognize burnout. Knowing the signs of burnout can allow you to intervene early when burnout is still reversible. The worst thing you can do is to deny that burnout exists.
4. Offer help. Counselors and other mental health professionals can help build resilience in the healthcare workers and making them freely available to hospital staff is a must.
5. Offer accommodations. This could be as simple as allowing staff to do non-standard length shifts so that they can be home to take care of children. It could include reserving a block of hotel rooms for nurses who live out of town to stay in order to avoid long-distance commutes.
6. Offer perks. Minor services  such as paying the cost of grocery delivery, Uber rides, baby sitting costs, and laundry services are relatively inexpensive for hospitals but can go a long way toward preventing burnout during times of healthcare worker stress from high inpatient capacity. Periodically buying pizza and cookies is a small measure but shows the staff that you are thinking about them.
7. Pay them. Overtime compensation and bonuses are powerful prevention against disgruntlement. When the hospital is full for prolonged periods of time, it is probably losing money from canceled surgeries, etc. But this is why hospitals maintain a certain number of days cash on hand and the hospital should not be afraid to use those reserves.

U.S. hospitals are about to fill up

As of January 14, 2022, the United States is seeing not only the highest number of daily cases of COVID-19 than at anytime in the pandemic (red line in the graph above) but we are also seeing the highest number of patients hospitalized with COVID (yellow line in the graph above). From experience, we know that hospitalizations do not peak until 2-3 weeks after case numbers peak so our hospitals are only going to become more full before the end of this month. The good news is that the percent test positivity peaks about a week or so before the case numbers peak and the most recent data from the CDC suggests that the percent test positivity is just starting to come down (yellow line in the graph below). If this trend continues, then we should see the case numbers begin to fall within the next week or so.

But COVID does not affect different parts of the country at the same time and many cities and states may not see the peaks in case numbers and hospitalizations for several weeks.

Regardless, we are about to see our nation’s hospitals more full of patients than ever before and each hospital needs to develop plans for how it will get through the next month.

January 16, 2022

Suicide is the master thief. He steals from our family, from our friends, and from those that we admire. These are the faces of some of the lives that he has stolen. Although we have greater fear of his brother homicide, suicide takes more lives each year than homicide. Sometimes, suicide slips into our homes after we’ve feared him, after we thought we locked the doors and closed the windows to keep him out. Sometimes, he catches us off guard and we wake up in the morning and find that he’s stolen a life when we least expected it. He doesn’t discriminate by age or race or gender. He’ll strike the rich and the poor, the famous and the unknown, the strong and the weak. He has preyed on men and women for as long as humans have walked on the earth. Many people turn to him hoping that he can relieve their pain but all together too often, the pain goes on just as intensely in those who are left behind. Sometimes he whispers his intentions in our ears before he comes but all too often, we just don’t hear him or we don’t understand what he is saying to us. As physicians, whether we are primary care providers, emergency room physicians, specialists, or hospitalists, we are often in the best position to hear those whispers and to identify patients who are suicidal early on, when intervention can save lives.

Suicide is an enormous public health problem in the United States. It is the 10th leading cause of death in our country and the 2nd leading cause of death in persons age 10 – 34 years old. One American dies by suicide every 11 minutes. But this is not just a U.S. problem. In fact, the United States has just the 37th highest suicide rate in the world, led by Greenland which has the highest suicide rate at 83 per 100,000 population.

There is a gender paradox to suicide: in the United States, women are 3 times more likely to attempt suicide than men but men are 3.5 times more likely to die by suicide than women. Part of the reason is in the gender differences in method of suicide. Men most commonly use guns and women most commonly use poisoning – firearms are considerably more effective as a means of death than poisoning. Overall, guns account for 50% of all U.S. suicides followed by poisoning at 14%, suffocation at 28%, and miscellaneous other methods at 8%.

There are racial differences in suicide with caucasians having the highest suicide rate at 15.85 per 100,000 population followed by native Americans at 13.42, African Americans at 6.61, and Asian Americans at 6.59 per 100,000. Western states and Alaska have the highest suicide rate. Suicide is increasing – in 2001, the U.S. suicide rate was 10.7 per 100,000 population but by 2017, it was up to 14.0 per 100,000 population – a 30% increase in just a decade and a half.

45% of people who die by suicide saw their primary care physician within a month prior to their death. So what can we do in our office practices and our emergency rooms to identify those patients at risk for suicide and get them the psychiatric care that can save their lives? Fortunately, there are easy assessment tools that we can use that will help identify at-risk patients. There are many suicide screening questionnaires available – two that are commonly used in healthcare settings are the ED-SAFE and the Columbia screening tools.

The ED-SAFE tool (click on the attached images to enlarge) was originated as a National Institutes of Mental Health study performed at 8 emergency departments in the United States to determine the impact of suicide screening in emergency departments. It is available free of charge at the Suicide Prevention Resource Center website. It consists of two parts. The first part is the Patient Safety Screener (PSS-3) which consists of 3 questions and can be administer by nurses doing triage in the emergency department. Patients screening positive on the PSS-3 are then asked questions from the second part which is the ED-SAFE Patient Secondary Screener (ESS-3) which consists of 6 additional questions. The responses to the ESS-3 will stratify patients into (1) negligible risk, (2) low risk, (3) moderate risk, or (4) high risk. The risk categories then provide mitigation and recommended care for patients such as 1:1 observation and use of ligature-resistant rooms.

The Columbia Suicide Severity Rating Scale (click on the attached image to enlarge) was created by Columbia University, the University of Philadelphia, and the University of Pittsburgh with sponsorship by the National Institutes of Mental Health. It is available on-line free of charge at the CSSRS website. It was designed to identify those patients at risk of suicide in general settings and healthcare setting and has been endorsed by the CDC, FDA, NIH, Department of Defense, and other organizations. Based on patients responses to 6 different questions, there are recommendations for either (1) behavioral health referral at discharge, (2) behavioral health consult and consider patient safety precautions, or (3) psychiatric consultation and patient safety precautions.

These screening tools are the first step but frequently, a more detailed suicide assessment is necessary and this may require a more nuanced history from the patient. Major risk factors for completed suicide include:

1. Prior suicide attempts
2. Family history of suicidal behavior
3. Mental illness, especially mood disorders
4. Alcohol or drug abuse
5. Access to lethal means of suicide (especially firearms)

There are other risk factors to consider as well:

1. Caucasian
2. Male
3. Divorce or significant loss
4. Traumatic brain injury
5. Physicians
6. Prisoners
7. History of sexual abuse
8. Recent psychiatric hospitalization
9. Attention deficit hyperactivity disorder (ADHD)
10. Lesbian, gay, bisexual, or transgender
11. Self-injurious behavior

But in addition to risks, there are also protective factors that can sometimes offset suicide risks for individual patients. These protective factors can often make the difference between a patient being at moderate risk or high risk of suicide:

1. Family
2. Pets
3. The person’s individual morals
4. Religious faith

Suicide assessment is not just the purview of the psychiatrist. It is up to all of us: emergency medicine physicians, primary care physicians, hospitalists, and specialists. In an era when a hip replacement surgery costs $32,000 and immunotherapy for lung cancer with the drug nivolumab costs $150,000/year, we could save thousands of lives at the cost of just asking a few questions.

November 9, 2019

The EMTALA law was enacted 33 years ago as an “anti-dumping” law. EMTALA fundamentally has 2 main implications for the hospital: how you manage patients in the emergency room and how you manage hospital transfers. It stands for the Emergency Medical Treatment and Active Labor Act and it placed requirements on hospitals receiving Medicare payments; because almost all hospitals accept Medicare, in practice, it affects nearly all U.S. hospitals.

There are 3 obligations that hospitals have under EMTALA:

1. The emergency department must provide a medical screening exam to any patient who requests emergency care, regardless of their health insurance status, their ability to pay, or their citizenship.
2. If the medical screening exam indicates that the patient has an emergency medical condition, then the hospital must provide treatment until the condition resolves or stabilizes and the patient can provide self-care after discharge.
3. If the hospital does not have the capability to treat the patient’s condition, then it must make an appropriate transfer to another hospital that has the capability of treating the patient’s condition and provide medical records to the accepting hospital. Hospitals with specialized capabilities must accept these transfers and provide treatment.

Why did EMTALA come to be?

In the 1980’s, some hospitals and doctors flat out refused to treat patients in their emergency departments if the patients could not pay. Other hospitals would transfer unstable patients to public hospitals without doing even a basic medical assessment or providing initial treatment to stabilize patients. Physicians at Cook County Hospital in Chicago reported that 87% of patients transferred to their hospital were sent because they lacked health insurance, only 6% of those patients actually gave written consent for transfer, and 24% were transferred in medically unstable condition. Thus emerged the term “patient dumping”. A 1985 exposé on the CBS news show 60 Minutes titled “The Billfold Biopsy” helped raise public awareness of the national scope of the problem.

But if you look a bit closer, EMTALA was, at least in part, designed to protect Medicare patients. Three years earlier, congress had enacted legislation that created DRGs, meaning that hospitals got paid based on the diagnosis rather than being paid based on charges. Legislators were concerned that hospitals would try to game the DRG system by providing substandard care to reduce costs in order to profit by DRG payments by Medicare. EMTALA directly addressed this by requiring hospitals to provide the same emergency care to patients whether they had commercial insurance or Medicare/Medicaid.

What about free-standing emergency rooms?

EMTALA applies to hospital emergency rooms, whether they are physically part of the hospital building or geographically separated from the hospital. In the past 15 years, there has been a nationwide proliferation of free-standing emergency rooms that are located many miles away from its parent hospital, generally in suburban areas. When asked why he robbed banks, Willie Sutton famously said “Because that’s where the money is”. So why do hospitals build satellite emergency departments in the suburbs? Because that is where the money is – lots of commercially insured patients with relatively fewer Medicaid and uninsured patients. These outlying emergency rooms can serve as conduits to direct well-insured patients needing profitable surgeries or inpatient admissions to the host hospital. This type of free-standing emergency room is subject to EMTALA requirements just as if they were physically attached to the host hospital.

There is a second type of free-standing emergency room. These are privately-owned and not associated with a local hospital. Currently, there is uncertainty about whether these facilities fall under the EMTALA requirements and there are state-specific laws and legal precedents about whether or not they must adhere to all of the elements of EMTALA. However, since these emergency rooms are not associated with a hospital, they cannot provide inpatient treatment for emergency medical conditions and so the emergency room physicians can transfer a patient requiring inpatient care to any hospital they choose.

What are the implications for physicians?

The focus of EMTALA was initially on emergency room physicians – that they must do a medical screening exam and provide basic emergent care to all patients. However, when I am on call at night for our intensive care units, EMTALA also applies to my decision making. As a tertiary care medical center, our ICU has the capability of providing a higher level of care than most other ICUs in the region. Many hospitals lack critical care physicians, infectious disease specialists, cardiothoracic surgeons, and other specialists. Because we have residents, nurse practitioners, and fellows in our various ICUs at night to handle most patient care-related calls, the most common calls I get are from other hospitals asking about transferring patients to our medical intensive care units. If we have empty ICU beds, we are usually obligated to take those critically ill patients. However, despite EMTALA being decades old, I am still called by outlying emergency room physicians about transferring uninsured patients purely because the physician considers ours to be a charity hospital since we are a state-supported university. It can often be a fine line to walk: we are obligated to accept in transfer any patient whose medical needs cannot be met at these outlying hospitals but we are not obligated to accept patients simply because they are uninsured. Experienced attending emergency room physicians know about EMTALA requirements but the questionable calls most commonly come from residents in training or junior attending physicians in ERs at hospitals that are part of a larger healthcare system that includes tertiary care hospitals. These less-experienced physicians often do not realize their (and their hospital’s) requirements under EMTALA and as a consequence, “patient dumping” to academic medical centers still occurs.

Overall, EMTALA has improved the care to vulnerable patient populations. But EMTALA is still just as important today as it was 33 years ago and it is incumbent on us to insure that our emergency room physicians, our hospitalists, and our critical care physicians understand EMTALA’s implications for their clinical practices.

October 28, 2019

When the average person thinks of donating blood, the first words that come to mind are “Red Cross”. However, the American Red Cross only supplies about 40% of transfused blood in the United States. What most people don’t realize is that the U.S. uses a free-market approach to maintain its blood supply with the result that there are dozens of different blood suppliers for our nation’s hospitals and they compete with each other.

Every day, 35,000 units of packed red blood cells, 7,000 units of platelets, and 10,000 units of plasma are transfused in the United States. In order to meet the needs, there has to be a continuous flow of donated blood into the country’s blood banking system because blood has a short self-life: 42 days for red blood cells and 5 days for platelets. However, red blood cells can be frozen for up to 10 years.

Most countries use a single, government-directed supplier for the blood supply but the U.S. utilizes a network of non-profit blood services that are overseen by federal regulations. As of 2016, there were 786 registered blood establishments that collect blood plus 725 hospital and non-hospital blood banks. Blood centers account for 93% of all collected blood and hospital blood banks account for 7% of collected blood.

We do not transfuse as much blood as we used to. Lower transfusion thresholds (from previous thresholds of 8-9 g/dL hemoglobin to current thresholds of 7 g/dL), a trend toward less-invasive surgeries, the increased use of erythropoietin, hospital blood management programs, and improved medical technology have led to a reduced utilization of blood; the number of units transfused has dropped by 25% since 2008. As the demand for blood has fallen, there has been more competition between the various blood suppliers and many suppliers have gone out of business. So, who are all of these blood suppliers?

• The American Red Cross. This is the most visible and publicly recognizable blood supplier and accounts for about 40% of the nation’s blood.
• America’s Blood Centers. This is a network of more than 50 independent, local blood suppliers that supply about 50% of the nation’s blood. Its member organizations manage more than 600 donation sites in 45 states. Two of the largest members are Vitalant (western United States) and Versiti (midwestern United States).
• The Armed Services Blood Program. This supports the military and their beneficiaries.

Blood is a unique commodity in that it is almost entirely donated for free by volunteers. The cost of blood is therefore primarily due to the expense of processing, storage, and distribution. Hospitals will typically contract with a particularly blood supplier based on (1) per-unit cost to the hospital and (2) quality of service from the blood supplier. Because of the declining demand for blood and because the U.S. has experienced a period of hospital consolidation into large hospital systems that can compete aggressively for blood pricing, the financial margin for most blood centers are razor thin and many operate at an annual financial loss.

Because 92-95% of blood is transfused into hospital inpatients, the cost of blood is absorbed into the hospital’s general expenses rather than being passed directly to the consumer (i.e., the patient). This is because hospitals are paid by a DRG price that is fixed based on an inpatient’s diagnosis and the hospital gets paid the same whether 1 unit of blood is transfused or 20 units of blood is transfused. Most blood is sold on a consignment model – the hospital stores blood but only charges the blood centers for the units actually transfused; therefore, the blood centers bear the cost of outdated units. The net result is that the blood suppliers are happy when more blood is transfused and the hospitals are happy when less blood is transfused. The average price paid from hospitals to blood centers in 2013 was $225 per unit.

About 38% of the U.S. population is eligible to donate blood but only a fraction of eligible persons actually donate. All blood is subject to testing for communicable diseases including:

• Hepatitis B surface antigen (HBsAg)
• Hepatitis B core antibody (anti-HBc)
• Hepatitis C virus antibody (anti-HCV)
• HIV-1 and HIV-2 antibody (anti-HIV-1 and anti-HIV-2)
• HTLV-I and HTLV-II antibody (anti-HTLV-I and anti-HTLV-II)
• Serologic test for syphilis
• Nucleic acid amplification testing (NAT) for HIV-1 ribonucleic acid (RNA), HCV RNA and WNV RNA
• Nucleic acid amplification testing (NAT) for HBV deoxyribonucleic acid
• Antibody test for Trypanosoma cruzi, the agent of Chagas disease

The most common blood type is O+ followed by A+. People with type O- blood are known as universal donors because anyone can received type O- red blood cells. Persons with type AB+ are known as universal recipients because they can receive blood of any type. Like 9% of Americans, I’m B+ so I can receive blood from people with blood types B+, B-, O+, and O- (in other words, 59% of of the population); I can donate blood to people with blood types B+ and AB+ (in other words, 13% of the population). There are differences in blood types between countries and between racial/ethnic groups. For example, 11% of South Koreans are AB+ (universal recipients) whereas only 0.5% of Ecuadorians are AB+. On the other hand, only 0.1% of South Koreans are O- (universal donors) whereas 11% of people in the United Kingdom are O-.

On my 16th birthday, the first thing I did the day I got my driver’s license was to drive to the American Red Cross blood donation center to give blood. Except for a few years during residency and fellowship (when I was regularly exposed to HIV secretions and blood in the ICU), I gave blood every 2-4 months for the next 40 years. About 3 years ago, the Red Cross raised the minimum hemoglobin necessary to donate blood and I found myself too anemic to donate. After anemia tests showed iron deficiency and a work-up for GI bleeding was negative, the conclusion was that I donated too frequently and didn’t eat enough meat. So, I started taking iron supplements for a week before and after blood donations, cut back my donation frequency to every 4 months, and learned to love grilled ribeyes again.

The average donor is male, married, college-educated, with an above-average income, white, and between the ages of 30-50. However, 45% of donors are over age 50. So there is a great need to recruit younger people into the donation pool as the current donor pool ages out. In addition, given the ethnic and racial differences in blood types, there is a need to ensure that our nation’s blood donor demographics more closely represents the nation’s ethnic and racial demographics  so that tomorrow’s blood supply optimally meets tomorrow’s blood demands. We need to eliminate the current disparities that exist in blood donation.

Our nation’s blood supply is a business but a business that is a unique hybrid of volunteers and commercial enterprises that is like no other business in the world. The dynamics of our blood supply is changing based on changes in healthcare financing and some healthcare experts believe that the blood supply system as we currently know it is in peril. But regardless of the changes in economics, patients will still need blood and volunteer donors will still be the ultimate suppliers of that blood. So what am I going to do about it? I do what I’ve always done. I’ll take iron supplements for the next few days and then donate a pint.

May 8, 2019

Our hospital recently became a level III trauma center. Across town, the larger tertiary care Ohio State University hospital is a level I trauma center. In total, in Columbus, we have two level I trauma centers, two level II centers, one level III center and one pediatric level I center. So what is the difference between them?

There are 5 levels of trauma centers: I, II, III, IV, and V. In addition, there is a separate set of criteria for pediatric level I & II trauma centers. The trauma center levels are determined by the kinds of trauma resources available at the hospital and the number of trauma patients admitted each year. The level of a trauma center is determined by the verification status of the hospital by the American College of Surgeons. This post will focus on levels I, II, and III trauma centers (non-pediatric).

Level I Trauma Centers

A level I trauma center provides the most comprehensive trauma care. There must be a trauma/general surgeon in the hospital 24-hours a day. If a surgical resident is in the hospital 24-hours a day, then the attending surgeon can take call from outside the hospital but must be able to respond within 15 minutes. There must also be an anesthesiologist and full OR staff available in the hospital 24-hours a day as well as a critical care physician 24-hours a day. If anesthesia residents or CRNAs are take in-hospital night call, an attending anesthesiologist must be available from home within 30 minutes. There must also be immediate availability of an orthopedic surgeon, neurosurgeon, radiologist, plastic surgeon, and oral/maxillofacial surgeon. There must be > 1,200 trauma admissions per year. The key physician liaisons to the trauma program (trauma surgeon, emergency medicine physician, neurosurgeon, orthopedic surgeon, critical care physician) must all do at least 16 hours of trauma-related CME per year.  These centers must participate in research and have at least 20 publications per year.

Level II Trauma Centers

A level II trauma center also has 24-hour coverage by an in-hospital general/trauma surgeon as well as an anesthesiologist. There are several minor differences between a level I and II trauma center but the main difference is that the level II trauma center does not have the research and publication requirements of a level I trauma center.

Level III Trauma Centers

A level III trauma center does not require an in-hospital general/trauma surgeon 24-hours a day but a surgeon must be on-call and able to come into the hospital within 30 minutes of being called. Anesthesia and OR staff are also not required to be in the hospital 24-hours a day but must also be available within 30 minutes. Level III centers must have transfer arrangements so that trauma patients requiring services not available at the hospital can be transferred to a level II or III trauma center. Patients with fall-related injuries and fractures are generally a large percentage of the trauma population cared for at level III trauma centers.

The American College of Surgeons oversees the verification of hospitals as meeting the requirements for level I, II, or III trauma center and the entire document of requirements is 30 pages long but the key differences are summarized in the table below.

A key element of level I and II trauma centers is the ability to manage the most complex trauma patients with a spectrum of surgical specialists including orthopedic surgery, neurosurgery, cardiac surgery, thoracic surgery, vascular surgery, hand surgery, microvascular surgery, plastic surgery, obstetric & gynecologic surgery, ophthalmology, otolaryngology, and urology. In addition, level I and II trauma centers must have a spectrum of medical specialists including cardiology, internal medicine, gastroenterology, infectious disease, pulmonary medicine, and nephrology.

Level III trauma centers do not have as extensive requirements for specialists on-staff and only require general surgery, orthopedic surgery and internal medicine.

Here in Ohio, we have 12 level I trauma centers, 10 level II trauma centers, and 20 level III trauma centers. In addition, we have 3 level I pediatric trauma centers and 5 level II pediatric trauma centers (not shown). The location of Ohio’s trauma centers means that most Ohioans live within 25 miles of a level I, II, or III trauma center hospital. And all Ohioans live within 60 miles of a trauma center (when including trauma centers located in our bordering states).

So, what does this mean for the individual person who has suffered a traumatic injury? Most patients will not perceive much difference between a level I and level II trauma center; both will have emergency medicine physicians, general surgeons, and anesthesia services immediately available within 15 minutes, 24-hours a day. From the patient’s viewpoint, the main difference between a level III trauma center and a level I/II trauma center, is that these services will be available within 30 minutes rather than 15 minutes. If a patient has injuries that require a surgical specialist such as a neurosurgeon, cardiothoracic surgeon, oral-maxillofacial surgeon, or plastic surgeon, then that patent may require transfer from a level III trauma center to a level I or II trauma center after initial stabilization, depending on the availability of surgical specialists at that particular hospital.

If the trauma injury is orthopedic in nature, then the response time by an orthopedic surgeon is going to be similar, whether it is a level I, II, or III trauma center – the majority of fractures require repair within 24 hours but not within minutes of arrival in the emergency department. With orthopedic injuries, the main difference will be that more complex injuries (such as an extensive pelvic fractures) will be best managed at a level I trauma center where there is a fellowship-trained orthopedic traumatologist available.

For nearly all trauma patients, the most important factors that dictate survival are the initial assessment of the injury and initial resuscitation with fluids and blood transfusions that occurs in the emergency department. Therefore, getting to the closest trauma center of any kind should be the priority for the severely injured trauma patient – if a level II trauma center is an extra 20-minute drive further than a level III trauma center, then the patient is better off stopping at the level III trauma center.

December 9, 2018

Last week in Kearney, Nebraska, the state patrol seized 120 pounds of fentanyl during a routine traffic stop. Let me put that in perspective. I use fentanyl to sedate patients undergoing bronchoscopy and 120 pounds of fentanyl would be enough to do a half a million bronchoscopies.

Fentanyl is about 25-50 times stronger than heroin and typically gets into the United States through the regular mail from producers in places like China where it can be ordered on-line over the internet. Like most American cities, Columbus has been flooded with fentanyl and its cousin, carfentanil, which is about 100 times more potent than fentanyl and is often mixed in with other drugs, such as heroin. The result is that the potency of street drugs is often unpredictable and it is easier than ever before to overdose. In fact, here in Columbus, we average 1-2 overdose deaths per day. Nationwide, about 64,000 Americans die of drug overdose every year. That’s more than the number of Americans who died in the entire 20 years of the Vietnam War. It is the 8^th leading cause of death in the United States. Many people who overdose on opioids die before anyone can help them but increasingly, our first responders and emergency departments encounter patients when they are unconscious but still alive.

But overdoses don’t just happen in the streets, they increasingly happen in our hospitals. When my pager goes off with a message: “Code blue, outside the front entrance to the hospital” or “Code blue, room XXX, visitor”, then more times than not, it will be an opioid overdose, often with a needle still in the person’s arm.

Given the ubiquity of opioid overdose, it is now necessary for all physicians to be able to rapidly assess an unresponsive person and determine if they likely took an overdose of an opioid because if so, then immediate administration of the drug naloxone can be life-saving. One of the most important clues is to look at the pupils.

In an overdose, the pupils will be tiny and constricted. Although there are other conditions that can cause pinpoint pupils (Horner’s syndrome, cerebral hemorrhage, prescription eye drops, etc.), opioid overdose is at the top of the list, particularly if both pupils are constricted equally. Normal-sized pupils do not entirely rule out opioid overdose because if a person is simultaneously taking another drug that can cause pupil dilation, then the pupils may appear normal in size.

On the other hand, if an unconscious person has dilated pupils, then think about alcohol intoxication. Other things that can cause dilated pupils include prescription medications (decongestants, antihistamines, anti-epileptic drugs, tricyclic antidepressants, Sinemet, etc.), certain street drugs (amphetamines, cocaine, LSD), cerebral edema, or previous eye injury.

The reason that rapid diagnosis of opioid overdose is so important is that intranasal naloxone can save the person’s life. Naloxone can be administered to the nose in two ways – either a pre-prepared intranasal device containing naloxone (sold under the brand name Narcan) or by attaching a spray adaptor to the end of a syringe containing naloxone. The former is more expensive but more convenient, the latter is less expensive but less convenient.

So, when faced with an unexpectedly unconscious and or not-breathing patient, be a pupil of the pupils.

May 30, 2018

Freestanding emergency departments can provide emergency care in locations not immediately served by emergency departments contained in a hospital and in theory, this should improve access to healthcare, particularly in rural areas.  However, there are hidden costs of freestanding emergency departments that can lower the overall value of healthcare in the community.

Beginning in 2004, Medicare allowed payment for services provided at freestanding emergency departments. By 2016, there were 566 freestanding EDs, almost all of which were in metropolitan areas. In contrast, there are about 7,000 urgent care centers and 2,800 retail clinics (generally in pharmacies). A major difference between freestanding emergency departments versus urgent care centers is the availability of more advanced imaging and laboratory testing and this results in higher costs per visit for any given medical problem in freestanding emergency departments as shown in this graph of data from Colorado.

As opposed to hospital-associated emergency departments, freestanding emergency departments do not accept trauma patients and the patients seen have an overall lower acuity. Data from Medicare indicates that in freestanding emergency departments, 44.7% of patients are low acuity (acuity level 1 or 2) whereas in hospital-associated emergency departments, only 11.0% of patients are low acuity. In contrast, hospital-associated emergency departments, 60.0% of patients are high acuity (acuity level 4 or 5), whereas in freestanding emergency departments, only 15.4% of patients are high acuity. The vast majority of patients who go to freestanding emergency departments are walk-ins (95%) as opposed to arriving by emergency squad. Furthermore only a very small percentage of patients at freestanding EDs require hospital admission (<5% as opposed to 15-35% at hospital-associated EDs). In other words, the patients are less sick and less likely to be brought by emergency squad.

Freestanding emergency departments are most commonly located in high-income areas. The three states with the largest numbers of freestanding EDs are Colorado, Texas, and Ohio. In an article from The Annals of Emergency Medicine in 2017, it was found that freestanding emergency departments were considerably more likely to be located in high-income ZIP code areas with a greater percentage of the population covered by commercial health insurance compared to those ZIP codes without freestanding EDs. Thus, freestanding EDs are located in areas with the best payer mix.

An article from 2017 found that for every additional freestanding ED in a county, the cost per Medicare beneficiary increases by $55 per person. This is consistent with other studies that have shown that if there is a hospital in a county, the overall Medicare costs per beneficiary goes up – in other words, if there is more access to healthcare in an area, there is more utilization of healthcare resources.

There are 9 acute care hospitals in Central Ohio (green dots). In addition, there are 9 freestanding emergency departments (red dots). The free standing EDs tend to be more in the suburban areas as opposed to the central city area where the acute care hospitals are clustered. The are also located in the areas with the highest income density, that is population density x average income (darker brown shaded ZIP codes).  In 2 cases, there is a freestanding ED in close proximity to an acute care hospital – in both cases, the freestanding ED is owned by a different hospital system than the acute care hospital resulting in local competition for ED patients.

Advocates for freestanding emergency departments state that they bring healthcare resources to areas not served by hospital-associated emergency departments. This map indicates that this is generally true but they are located in high income areas close to the I-270 outer belt where they can intercept patients coming from rural areas not served by emergency care and then direct those patients to a hospital owned by that health system for admission or further testing. Advocates also state that freestanding EDs can reduce wait times in local emergency departments and improve patient satisfaction. These statements are likely true.

The downside of freestanding emergency departments is that they increase overall healthcare costs by making it easier for patients to go to an ED than to seek alternative sites of care for acute medical problems. In Central Ohio, they are located in suburban areas with high income and in high penetrance of commercial insurance. The result of this is that hospital-associated emergency departments will increasingly see a greater percentage of patients who are lower income and have a lower payer mix (Medicaid and uninsured) and will become less profitable than the freestanding emergency departments. From a business standpoint, freestanding EDs are a great business decision – they are placed where they can improve a health system’s access to people with the highest income. But from a society standpoint, they do not improve the overall access to healthcare to the majority of people.

April 29, 2018

In the emergency room, boarders are patients who need to be admitted to the hospital but there are either no hospital beds to put them in or no doctors to admit them to. In Catholic doctrine, Purgatory is a holding place that souls go to in order to purge their sins before they go to heaven. From a patient’s viewpoint, being a boarder is a bit like being in purgatory – only it is disease rather than sins that need to be purged.

The problem with being a boarder is that the patient is not really an ER patient and not really a hospitalized patient but somewhere in between.  Sometimes, it is the ER physician who is overseeing the patient’s care – but the ER physician is really good at taking care of ER patients but not so experienced with managing admitted patients. Sometimes, it is the hospitalist who is overseeing the patient’s care – but the hospitalist spends most of his/her time at the nursing units and ICUs, not the ER so the patient is often “out of sight, out of mind”. It is not just the doctors, but also the nurses – the usual activities of an ER nurse are very different than the usual activities of an inpatient unit nurse.

A study in the Annals of Emergency Medicine found that boarders are more likely to have delays in order completion or orders missed altogether compared to patients admitted to an inpatient nursing unit. A study in Academic Emergency Medicine found that boarders have a higher mortality rate than non-boarders. A study in Critical Care Medicine found that boarders have a longer hospital length of stay than non-boarders. A study in Academic Emergency Medicine found that boarders have a lower patient satisfaction than non-boarders. All-in-all, boarding is bad.

So, if boarding is so bad, why is it so prevalent in our country’s hospitals? As usual, there is not one single reason but some of them include:

1. Increased demand on hospitals to achieve higher levels of operational efficiency. In order to solve the boarding problem, a hospital has to have excess capacity and excess capacity often translates to higher costs. You have to have more rooms, more nurses, more pharmacists available on any given day in order to accommodate the occasional surge in patient admissions. And all of those extra rooms, nurses, and pharmacists cost money – a lot of money. A hospital administrator cannot afford to run the hospital at 60% capacity most of the time in order to accommodate the occasional time that it is at 100% capacity.
2. Inpatient census caps on residents. At many hospitals (particularly academic hospitals), residents historically did most of the admissions to the hospital. Beginning in the late 1980’s and stimulated by the Libby Zion case, the ACGME began to place duty hour restrictions on residents (how many hours they could work per week) and census caps restrictions on residents (how many patients they could take care of). As a result, teaching hospitals were no longer able to accommodate census surges using resident coverage. Today, hospitals that exceed the ACGME-required census caps run the risk of losing their ACGME accreditation and this can be a lethal blow to the hospital’s residency program. Therefore, at teaching hospitals, admissions can back up in the emergency department while waiting for a teaching service to have census capacity, even if there are empty beds on the inpatient nursing units.
3. Hospitalist census caps. 20 years ago, there was no such thing as a census cap on an inpatient medical service. A physician took care of all of the patients admitted to his/her care and if there were a lot of patients, the doctor just stayed late into the night caring for them. With the emergence of hospitalists as the dominant model of inpatient care, things have changed. Hospitalist work shifts and there is a finite number of patients that they can see during one shift. Hospitalists are also tasked with meeting certain quality goals, such as keeping a low length-of-stay and getting patients discharged early in the day. In order to meet these quality of care goals, hospitalists need to maintain a manageable number of patients under their care. Furthermore, today’s hospitalists trained in an era of ACGME-mandated census caps for residents and those census cap expectations have carried over into their own practice. Hospitals compete with each other for the best hospitalists and if a hospital regularly exceeds the expected inpatient census per hospitalist, then those hospitalists are going to leave to go practice at a competing hospital.

So, what are the solutions? It would be easy if a hospital could do just one thing and solve the boarder problem in a cost-effective manner. But as with most issues involving process improvement, it takes a multi-step approach:

1. Create flexible inpatient capacity. Ideally, a hospital should have at least one nursing unit that can be opened and closed as needed in order to meet inpatient demand. This requires not only the physical beds but also requires a pool of nurses who can be brought in on-demand to staff those beds during times of need. Flexible staffing often requires paying those on-demand nurses a little more but it can be worth it if it results in fewer boarders.
2. Analyze daily and weekly ER admission trends. Mondays and the day after holidays tend to have the highest number of patients admitted through the emergency department. Anticipating this weekly surge in admissions with appropriate staffing can allow for the hospital to flex up in anticipation of more admissions. This may require scheduling more nurses or an additional hospitalist on those days.
3. Analyze daily and weekly surgical admission trends. Certain types of surgeries result in hospital admissions, for example, coronary artery bypass operations and joint replacement operations. If surgeons who do these types of operations have their operating room time all clustered on a single day of the week, then there will be a surge in admissions on that day. By strategically scheduling these surgeons’ operating days, the hospital can control the daily number of admissions, thus spreading out the demand for inpatient beds.
4. Encourage early morning discharges. Hospitalist and resident census caps are fixed but as soon as that doctor discharges one patient, they can take another admission and stay within their cap. By discharging some patients earlier in the day, there will be both bed and physician capacity to admit patients from the ED earlier in the day.
5. Educate the hospital CFO. Creating flexible inpatient capacity to avoid boarding patients in the ED costs money and on the surface, it can appear that the hospital’s cost are going up. However if by spending money to accommodate these admissions and avoid ER boarding, the hospital is able to reduce length of stay, improve mortality rates, and reduce emergency department diversion hours, then the overall financial metrics of cost per hospital admission, etc. can actually improve.

Human disease does not occur with precise predictability and so the hospital has to be creative in devising strategies to accommodate surges in inpatient demand. The hospital’s goal is to be able to have enough doctors so as to prevent ER boarders. You want to always avoid having boarders without doctors.

April 15, 2018