82 The “Gold Card”: A Novel Discharge Process to Guarantee Timely Specialist Follow-Up

Abstract

Study Objectives: Within the current climate of ED crowding, hospitals are continually experimenting with new ways to streamline patient throughput. One option to prevent crowding is early discharge of patients whose specialist evaluation could safely be provided in the outpatient setting. However, reluctance on the part of the patient, the specialist, and emergency physician to discharge patients without confirmed follow-up leads to increased observation and admission of certain patient groups. At our institution, we noted that a significant number of patients were waiting on both the inpatient floor and the ED observation unit for specialty consultations, which could have been done in the outpatient setting were follow-up guaranteed. Our objective was to determine if initiating a novel 'gold card' program, where patients were guaranteed follow-up with a group of participating specialists within two business days would be feasible in the community hospital setting.Methods: From August 2016 to March 2017, we conducted a prospective observational study of all discharged ED patients who participated in the 'gold card' program. This study was performed through a community hospital ED with 98,324 annual visits. All adult (age > 18) patients who were deemed by the treating emergency physician as candidates for a 'gold card' were screened by a care coordinator to confirm insurance eligibility and provided a 'gold card.' This 'gold card' guaranteed an appointment with the selected specialist within two business days. All patients who participated in the program were contacted to evaluate the feasibility of the process. Our primary outcome measure was the number of 'gold card' recipients who completed an appointment within two business days of discharge. Our secondary outcomes included: 1) patient satisfaction with the process, 2) reasons for not completing a gold card appointment, and 3) an analysis of utilized specialists. The data was analyzed using descriptive statistics.Results: From August 2016 through March 2017, there were 65,912 visits to our ED. 42,886 (65%) of these patients were discharged home, 17,202 (26%) were admitted, and 5,824 (9%) were sent to ED observation. Of the total ED discharges during this period, 1,508 patients (3.5%) received a gold card. Within that cohort, 119 patients (7.8%) chose not to go to the appointment: 86 (72%) canceled and 33 (28%) no showed. Of the 1,389 remaining gold card patients, 1,264 (91%) were seen within two business days, 109 (8%) were seen within more than two business days, 15 (1.07%) were unable to schedule an appointment, and 1 patient (<1%) was readmitted. A follow-up phone survey was completed on 1,009 patients (74%), demonstrating an average monthly patient satisfaction rate of 98.7% with the program, alongside increasing 'gold card' usage (See Figure 1). There was a broad range of specialty participation with gastroenterology (22.7%), cardiology (13.4%), and neurology (13.0%) encompassing almost half of all referrals.Conclusions: The 'gold card' program represent...