1. The ED as the Gatekeeper
in
Transitions of Care
James Hoekstra, MD
Professor and Chairman
Department of Emergency Medicine
Wake Forest University Health Sciences

2. Dr. Hoekstra’s Disclosures
 Consultant: Daichi Sankyo, Merck,
Astra Zeneca, Janssen, Verathon
 Research Support: Sanofi-Aventis
 None of this has anything to do with this
presentation

3. Objectives
 Participants will understand the concept of
transitions of care
 Participants will understand the importance of
the ED in communication with
primary/specialty providers in transitions of
care
 Participants will understand the role of the
ED in determining observation versus
admissions
 Participants will understand the role of the
ED in reducing admissions for HF, MI, and
PNA

4. The ED as a Gatekeeper
 Classic Emergency Medicine:
– “Who’s Sick, Who’s Not”
– Sick = Admit. Not Sick=D/C
 The “New World” of Emergency
Medicine:
– ICU versus Tele versus Med/Surg versus
Obs versus D/C
– And don’t forget Hospice

5. The Role of the ED in Transitions
of Care
Observation versus Admission

6. Initial Risk Stratification Scheme
Chest Pain
History, Physical
EKG, TnI
UA/NSTEMI/ Definite
STEMI Inter Risk Low Risk Non-Cardiac
High Risk

7. NSTE ACS
Risk Stratification Levels
Clinical Criteria
•STEMI: ST elevation or New LBBB
•Hi Risk: Dynamic ECG, +Tn, or TIMI >3
•Intermediate Risk: -ECG, -Tn, TIMI 2-3
•Low Risk: -ECG, -Tn, TIMI 0-1

8. NSTE ACS
Risk Stratification Levels
Patient Disposition
•Hi Risk: Invasive Strategy: Cath < 24 hours
• CCU Admit
• ASA, Clop, UFH/Enox, ?GPI, Cath
•Intermediate Risk: -ECG, -Tn, TIMI 2-3
• Tele Admit, ? Obs Unit
• ASA, ? Clop, ?LMWH, serial ECG and Tn, Stress or
Cath
•Low Risk: -ECG, -Tn, TIMI 0-1
• Obs Unit
• ASA, serial ECG and Tn, CTA or Stress

9. Patients Eligible for Observation
 Chest Pain, R/O ACS  DVT
 Asthma  Hyperemesis
 CHF  Sickle Cell
 Dehydration  TIA
 Hyperglycemia  Allergic Reaction
 Hypoglycemia  Renal Colic
 Cellulitis  Pain Syndromes
 Pyelonephritis

10. What Do We Have to Know?
 Diagnosis (Eligible?)
 Care Pathway or Protocol (Doable?)
 Planned
intervention/treatment/diagnostics
 Stability (Too Sick?/Interqual Criteria)
 Start Time/Finish Time >8 hours, <24
hours
 Documentation at start and finish of
care.

11. The Role of the ED in Transitions
of Care
Determining and Transmitting
Patient Acuity Level
ICU versus IMC versus Tele versus Floor

12. Transmitting Acuity Level
 SBA
– Situation
– Background
– Assessment
– Recommendation
 Include information to determine not
only admission, but level of care

13. Transmitting Acuity Level
 CC, Reason for Admission
 Pertinent H and P/Comorbidities
 First and last vital signs
 Interventions/Drips/Drugs
 Risk Scores (TIMI, PORT, EWS)
 Discussion of
Obs/MedSurg/Tele/IMC/ICU
 Send them up or see them in the ER?

14. The Role of the ED in Transitions
of Care
Protocol Driven Care
Care Pathways started in the ED
continue on the floors.
Guideline adherence leads to better outcomes

15. Protocol Driven Care:
Guideline Based
 Chest Pain/AMI
 PNA (HAP and CAP)
 Sepsis/Fever/Fever and Neutropenia
 Asthma
 CHF
 DKA
 Discuss with admitting MD, track
adherence, start in the ED.

16. The Role of the ED in Transitions
of Care
Avoiding Readmission
PNA, CHF, MI

17. The Role of the ED in Readmissions
 CMS tracked for MI, PNA, CHF
 Highest in academic centers
 Medicare and Medicaid populations
 Poor outpatient follow up
 Poor home care
 Poor SNF, NH care

18. The Role of the ED in Readmissions
 “Bounce Backs” can be admissions,
observation, or discharges
 Coordination of care at the ED site can
lead to reduced admission
 Med reconciliation, appropriate ED
follow up, and judicious use of
observation can reduce readmission
rates

19. Focus Group Surveys: Identified Drivers for
Readmissions
Drivers Percent of
Responses
Communication Across Providers/Settings 35%
Medication/Medication Reconciliation 35%
Patient Education/Health Literacy 32%
Financial Issues 25%
Social/Family Issues 21%
Physician Follow-up 21%
Lack of Community Resources 15%

20. The Role of the ED in Readmissions
 Discharges:
– Automated outpatient physician follow
up/discharge planning
– SBAR referrals/contact
– Med reconciliation
– Home health arrangements
– Social services/medication supplies

21. The Role of the ED in Readmissions
 Admissions/Observation:
– Prefer Obs if possible
– Admit back to same service/MD if admit
– Care coordination
– Social services
– Start discharge planning asap
– Reduce LOS, reduce admission versus
observation

22. The Role of the ED in Transitions
of Care
Hospice and Palliative Care
Reducing Inpatient Mortality

23. Hospice/Palliative Care
 Patients admitted but dying within 24
hours count on the hospital mortality
rates
 Mortality rates are public knowledge for
AMI, HF, PNA
 Physicians can identify these patients
 Mechanisms to “grease the skids” for
hospice/palliative care can reduce
unnecessary admissions/mortality

24. Hospice/Palliative Care
 Palliative Care Service admissions
– 24 hours a day, 7 days a week
– On-line or immediate ED consultation
ability for “the discussions” with family
– Physicians/Social Workers, readily
available to the bedside.
– Outpatient hospice sites for placement

25. The Role of the ED as Gatekeeper
in Transitions of Care
It Ain’t That Easy Any More
QUESTIONS?