No abstract

With the passage of the Affordable Care Act, increased emphasis has been placed on optimizing quality and reducing expenditures. The use of an emergency department case manager (EDCM) is reemerging as an important initiative in the quest to provide high-quality care and decrease unnecessary hospital admissions. A pilot study of the use of EDCMs was conducted in one of the authors' EDs during a 6-month trial period. By using evidence-based criteria, the EDCM helped in real time to verify admission criteria, assisted with inpatient versus outpatient designation, found community alternatives to hospital admission, and initiated discharge planning for patients who required admission and were at high risk for readmission. EDCMs also worked with pharmacists to assist with medication management for patients who required assistance with obtaining prescriptions. Because of the pilot study's success, the authors' health care system will be implementing EDCMs throughout the organization.

Introduction: The American Heart and American Stroke Associations’ revised guidelines for acute ischemic stroke recommend rapid transfer of patients with large vessel occlusions (LVO) eligible to receive mechanical endovascular procedures (MEP) if initial receiving facility does not offer MEP. Initiating the transfer process to MEP capable facilities is often delayed until LVO is confirmed on imaging. Hypothesis: We hypothesized that initiating a pre-notification process (PNP) by which emergency medical system (EMS) is notified of patients arriving to the emergency department (ED) with symptoms of LVO would reduce transfer turn-around-times (TATs). Methods: A pre- and post-interventional study involving 735 patients presenting to 2 EDs in a 5 campus hospital system from January 2014-June 2015. Both EDs began a PNP to alert EMS of potential MEP candidates. EMS then dispatched a critical care transport (CCT) ambulance with a CCT nurse to the ED to await transfer decision. Transfer TATs pre- and post-process change were reviewed. Inclusion criteria: patients with stroke code (SC) initiations in the ED who were transferred for possible MEP, or had PNP to EMS initiated. Exclusion criteria: patients with SC initiations that were not transferred or did not have PNP initiated. Results: Sixty patients met inclusion criteria; 52 were transferred pre-process change, and 8 were transferred post-process change with PNP initiated. Median time from decision to EMS arrival in the ED decreased from 22.5 minutes to -1 minute, with ambulance arriving to ED prior to decision. Median time of decision to EMS departure from ED decreased from 56 to 39 minutes, and overall median transfer TATs to MEP capable facility decreased from 78 to 69.5 minutes. Of the 8 patients with PNP to EMS, 6 (75%) were transferred to MEP capable facility. Conclusions: Pre-notification from ED to EMS of patients arriving with symptoms of LVO can reduce transfer times to an MEP capable facility. This study highlights the importance of early EMS involvement upon initial recognition of potential LVO patients, and implementation of rapid transfer protocols. Additional opportunities may exist to streamline care within the ED to further reduce transfer TATs.