At the University of New Mexico Hospital, Albuquerque, stationing a full-time RCP in the emergency department reduces lengths of stay and costs.
The emergency department (ED) of any hospital is one of the most costly locations in which to perform a patient-care intervention. The ED of University Hospital, a 378-bed teaching facility that is part of the University of New Mexico Health Sciences Center, Albuquerque, is no exception. To maximize the efficiency of the pulmonary services department in its provision of ED services, an assertive care delivery system was developed, implemented, and monitored for outcomes. The model that was developed uses an interdisciplinary team approach, employs an algorithmic treatment methodology, and uses an RCP as a consultant in the ED.
The Consultation Model
Under this model, the provision of all pulmonary patient care is based on the RCP’s assessment of the patient upon his or her presentation to the ED. The anticipated outcome is determined by an assertive patient-care delivery system that maximizes time and expense efficiencies for the treatment of the outpatient population. Application of the model also has an impact on the average length of stay (ALOS) of inpatients admitted through the ED, and an overall reduction in care-related expenses is one result.
The model was applied as the RCP Consult Protocol Project, which began on September 15, 1995 as a pilot project and ended on June 30, 1996. Subsequent to pilot-model analysis using a Gantt chart process that called for monthly and quarterly review, evaluation, and revision, the pilot project was changed into an accepted protocol for fiscal year (FY) 1997 (which began on July 1, 1996). Data presented here cover both the pilot and protocol phases of the project.
In FY 1994, RCPs were assigned to multiple patient care areas within University Hospital. The ED’s needs for respiratory care services were communicated to RCPs via the hospital’s pager system. This staffing pattern remained in place until June 1995 because of personnel shortages within the pulmonary services department.
Each time a treatment performed by the pulmonary services department was prescribed by a physician, a premodality physician assessment had to be acquired. Afterward, a postmodality physician assessment had to be performed to ascertain the appropriateness of the chosen modality and evaluate whether any medication used had produced the desired effects.
The lack of pulmonary services department staff and the delays that this caused in the RCP’s response to the ED’s patient care needs created a problem; the physician-driven patient care order/assessment system added its own delays because ED physicians must see multiple patients at one time. The timely delivery of patient care was compromised.
In June 1995, enough staff time became available to permit support of the ED RCP Consult Protocol Project. This allowed creation of the project model to commence through an interdisciplinary, collaborative discussion and planning process. A team composed of representatives from the pulmonary services department, ED medical staff, and ED nursing staff was used to analyze the situation. The team evaluated:
- eight relevant age-specific patient diagnosis groups;
- age-specific patient-care procedural performance for the previous FY;
- age-specific patient admission data from the ED for the previous FY;
- system inefficiencies such as response-time patterns attributable to the multiple responsibilities of physicians and RCPs;
- response-time patterns of RCPs;
- response-time patterns of ED physicians.
Based on this analysis, a pilot goal and objectives were developed. The goal was to improve the delivery of pulmonary-related patient care modalities in the ED while demonstrating the cost-effectiveness of assigning a full-time RCP to that area.
The first program objective was to develop, implement, and monitor algorithmic treatment-delivery models that provided assertive pulmonary care. To accomplish this, the interdisciplinary team collaborated in the development and implementation of treatment-delivery models for ED patients with selected pulmonary-related disorders.
Data collection for the evaluation of these models was done using a form that included the number of patients treated, the number of patients who revisited the ED within 72 hours, and the number of procedures administered. It also covered the number of handheld nebulizer and metered-dose inhaler (MDI) treatments administered according to model protocols, along with the number of modality changes specified by the models. These represented conversions of handheld nebulizer treatments to continuous bronchodilator administration or MDI treatments, of MDI treatments to handheld nebulizer treatments, and of changes made to pulmonary function testing or pulmonary consultation orders. Pulmonary patient assessments and therapy contraindications were also tracked.
The second objective of the project was to monitor selected populations of both pediatric and adult patients in order to determine the effectiveness of the model. The interdisciplinary team identified age-specific patient populations and evaluated them during the pilot project (and each FY thereafter). These groups included patients with croup, upper respiratory infection, pneumonia, bronchitis, asthma, chronic obstructive pulmonary disease, and wheeze and cough of unknown origin.
The study assumed that placing a full-time RCP in the ED would drastically improve response times for appropriate interventions and that employing an algorithmic treatment model that used the RCP as a consultant would lead to timely and assertive interventions. This was expected to reduce the ALOS for the designated diagnosis groups. Statistical analysis included data collected from the internal University of New Mexico Hospital accounting and reimbursement departments, as well as information collected by the pulmonary services department’s RCPs. The data analyzed per diagnosis group included the number of inpatient admissions, the number of days per admission, the ALOS per admission, and patient-charge procedures. A comparison of data from FY 1995 with those from FY 1996 and FY 1997 was conducted.
The third objective was to eliminate impediments to the timely delivery of pulmonary-related patient-care interventions (such as the difference in response times between paged RCPs and those stationed in the ED). This was accomplished through an internal time-motion study evaluation process in which RCPs covering the ED in 12-hour shifts were studied over a period of 30 days.
A group of RCPs who volunteered for participation in the project served as the control group for data analysis; salary calculations were based on the volunteers’ average hourly wages.
The pulmonary services department found that in FY 1995, RCPs spent approximately 20 minutes, or 0.33 hours, traveling from other hospital locations when responding to being paged to come to the ED; this delay was attributable not only to distance, but to the fact that RCPs could not respond during procedures that they had already initiated elsewhere in the facility. During a 30-day evaluation period, we placed an RCP in the ED for one 12-hour shift per day. The result was a response time of 7 minutes, an improvement in response time of 13 minutes. If this value can be considered consistent, it would represent a significant savings in in-hospital travel time alone, thus demonstrating a decrease in personnel expenses. This would correspond with an operational cost savings of approximately $20,223 per year.
Monitoring of the utility of the treatment protocols was performed by the ED RCP and recorded on a form developed by the pulmonary services department. These forms were completed for each patient who received care under the project’s protocols. Monthly and quarterly scrutiny by the interdisciplinary team was used to determine the success of the algorithms and processes that constituted the protocols.
Data collection was conducted for procedures performed; admissions and discharges; ED-to-bed admission rates; ALOS information by defined patient diagnosis group; and projected expense savings per admitted patient, as related to ALOS and approximated average daily hospitalization expenses. Further analysis demonstrated that patients who received assertive pulmonary-related care in the ED through the RCP protocols had shortened ALOS, in comparison to accounting/reimbursement data for patients admitted prior to program implementation.
The administrative staff of the pulmonary services department explored cost comparisons for care delivery before and after the protocol model was implemented. For FY 1995, the average hourly wage for an RCP was $15.90. In FY 1996, it was $16.25 ( 2.7%ring the same period, and for reasons unrelated to the protocol model, the number of adult respiratory care procedures performed in the ED increased from 6,454 to 8,703 and the number of pediatric procedures decreased from 2,257 to 2,020, for a total increase of 2,486 procedures. The cost of RCP time spent in responding to calls for these procedures (including 20 minutes of travel time for FY 1995 and 7 minutes for FY 1996) was determined by multiplying the average RCP wage by the response-time factor (0.333 hours for FY 1995 or 0.117 hours for FY 1996). The resulting response cost was then multiplied by the total number of procedures performed. The total cost of RCP response time for FY 1995 was $45,706; for FY 1996, it was $20,223. This represented a time savings of $25,483. The time saved was used to make it possible for RCPs to intervene earlier in the triage process, thus permitting even earlier initiation of therapy. Maintaining a full-time RCP in the ED improved operational efficiency and decreased expenses.
When a collaborative approach to process improvement is embraced by all members of the health care team, an effective model can be used; this, in turn, will have a positive impact on patient care and overall operational expenses. A program that is developed, implemented, and monitored well, and that provides assertive care delivery in the ED, will decrease a patient’s ALOS if the patient is admitted, thus supporting the RCP’s role as an ED consultant.
Gary J. Hospodar, RRT, RCP, is director of respiratory care and pulmonary function at California Pacific Medical Center, San Francisco.
The author would like to thank the following pulmonary services department RCPs for their hard work, dedication, and constant monitoring of the consultation program: Phil Mercurio, RRT; Larry Garland, RRT; Toni Lyons, RRT; Rose Rios, RRT; Deborah Gonzales, RRT; Joseph Morelos, RRT; Victor Proo, RRT; Ann Stoner, RRT; Penni Borque, RRT; Darlene Furrow, CRTT; Elizabeth Borbas, RRT; and Sandra Young, RRT.