Alternatives to Emergency Department Overcrowding Are Being Tested at the Local Level

Given ongoing crises in America’s emergency departments—short staffing, stress and burnout, violent incidents with patients and families, overcrowding and patient boarding, ambulance crews left waiting “on the wall,” lack of acute beds for transferring patients, and assorted other hangovers from the COVID pandemic—it seems more important than ever to explore alternatives to the traditional emergency room encounter.

A web search identified many current examples of models intended to extend timely access to the professional skills of emergency medicine. In Boca Raton, Fla., the new Fast Track Emergency Department (ED) at West Boca Medical Center quickly funnels walk-ins and ambulance drop-offs with lower acuity conditions and less urgent needs to a room directly adjacent to the main ED. Stocked with comfortable recliner chairs, rather than gurneys, the Fast Track ED frees up beds and reduces pressure on the main ER.

A split-flow determination is typically made right at the registration desk to send patients either to a regular ED bay or to the Fast Track ED. “Our waiting room is not really a waiting room anymore; it’s more like an entrance hall,” explains the hospital’s emergency department medical director Cory Harow, MD.

Ambulance crews can bring appropriate patients directly to recliners in the Fast Track ED, freeing up the crew to get back out on the road within a targeted time frame of 10 minutes from arrival to departure. “We find the crews like to transport, transfer, and be on their way,” Dr. Harow says.

The Fast Track ED is different from urgent care because the resources of the entire hospital are near at hand. It is staffed by a dedicated nurse, paramedic, and provider—either a doctor or advanced practice nurse—whose team goal is to quickly conduct interdisciplinary evaluation, treatment, and discharge, typically within an hour. That goal is often surpassed, says Dr. Harow.

A typical day on Fast Track is “busy, busy, busy,” he adds. “We selected from among our hospital-employed techs those who are more experienced and acclimated to such a pace, and can thrive in a high-speed environment.” Typical fast-track admissions include patients seeking medication refills or those with upper respiratory symptoms, extremity injuries, coughs and colds, eye injuries, sore throats, and lacerations.

It may happen that a patient diverted to Fast Track turns out to have a more serious medical need than was indicated in their admitting complaint. But for them it’s just a few steps back to the main ED, Dr. Harow says.

The program emerged from the aftermath of COVID and the significant hospital overcrowding it generated, he added. “We’ve struggled with the problem of ED crowding. We’re very proud of this alternative to help prevent it.” Preliminary results suggest significantly reduced lengths of stay for the whole department.

Talk to an Emergency Doctor

An alternative approach to appropriate disposition of 911 calls was recently implemented at Elliot Hospital in Manchester, N.H., using telemedicine to connect patients with emergency providers without them having to come to the ER in person. “We are an emergency medicine group at a Level 2 Trauma Center with three affiliated, super-charged urgent care centers. We found post-COVID that there was a greater need for emergency care—but with fewer resources available. So our aim is to get the physician closer to the patient,” says the hospital’s director of emergency medicine, Matthew Dayno, MD.

The VirtualER program was built on the growing ability of technology to harness a virtual component to emergency medical services, Dr. Dayno says. Local 911 calls typically fall into three categories. One group needs emergency medicine, a second needs urgent care, and the third category—representing about 70% of EMS calls—could manage if its medical needs are diagnosed and addressed virtually.

People use a mobile device to contact the hospital’s ED through its website. They book a 15-minute virtual visit on the online platform and are connected with an emergency doctor. The doctors typically work 8-hour shifts, from late morning through early evening.

“Patients contacting 911 may not know where they need to go,” Dr. Dayno says. “We can triage and offer alternatives: You can be seen at urgent care or the ED, or we can respond to your questions virtually. But it’s the same emergency physician you would see in the hospital,” he says.

“We can also order tests, putting in an order for the patient to present at our outpatient lab and X-ray departments—or we can give them an outpatient physician appointment.” There is always the option for a patient on a virtual call to hang up and just call 911. “We can also expedite connections with an ambulance crew.”

 The VirtualER program started in January. Future plans include working with local EMS agencies to augment ambulance calls with virtual physician visits supporting the crews in the field. “It’s a natural fit and an area where we see continued growth,” Dr. Dayno said.

Specializing in Emergency Medicine

The crisis in emergency care often is more severe in rural and frontier areas, with some rural critical access hospitals going out of business, leaving their communities a discouraging distance from the nearest acute hospital. That puts greater pressure on rural EMS agencies, which often are strictly volunteer. Many of those rural EMS are struggling with a shortage of volunteer staff and the need to replace those who are reaching retirement age.

A new federal program called the Rural Emergency Hospital (REH) was implemented by the Centers for Medicare and Medicaid Services on January 1, 2023. A rural hospital chooses to give up its acute beds while preserving its full emergency department service line, with corresponding cost savings and additional federal subsidies, says Anna Anna of the Rural Emergency Hospital Technical Assistance Center.

The REH is a way for rural hospitals to maintain basic services in their communities, including 24-hour emergency medical care, with the ability to hold patients for observation without having to continue providing all of the mandated services and expenses of an acute hospital. However, patients who need acute inpatient care would still need to transfer to another hospital, typically by ambulance.

At least 22 rural hospitals have made this change, with another 10 or 12 in various stages of application, Anna notes. “What that says to me is there’s definitely a need for this designation to help save some of these hospitals, although it’s not the answer for every rural hospital. I’ve talked to hospitals that have converted and they take a strong pride in being able to continue to save lives in their community,” she says.

“What we do here at the Rural Emergency Hospital Technical Assistance Center is to work with hospitals, giving them the education they need, filling them in on what it would mean as far as the regulations go and what services they must have and can have. Then we help them consider it financially.”

The problem, says Gary Wingrove, president of the Paramedic Foundation, is the impact on EMS services in rural communities. If a critical access hospital converts to a rural emergency hospital, every patient who needs acute care now has to be transported a longer distance by ambulance. Are EMS volunteers going to stick around if each transport now takes several hours round-trip? It may be possible to stop at the REH for stabilization before the next stage of the journey, or it may make more sense to head directly to the larger hospital.

Legislation authorizing REHs didn’t provide for adequate, cost-based reimbursement for the ambulance, which now may be spending several-hour drives out of service to its local community in order to get the patient to an acute hospital, Wingrove says. “So closing the rural hospital has a snowball effect on local ambulance services, which may not be able to keep their volunteers, because of the added burdens on them.”

Bring the Hospital to the Home

But do all of these patients even need to be transported? The hospital-at-home concept pioneered at Johns Hopkins Medical Center in Baltimore, Md., is starting to gain traction in rural areas, says Scott Willits, a consultant and expert on this model. Hospital at home is only one of a number of experimental program models, including the “ED to Home Program” developed at the University of California-Davis, described as the “next frontier of emergency medicine,” Medically Home’s “ED in Home” program, bringing the emergency department to patients at home, and Blue Shield of California’s Urgent Care At-Home.

Typically, hospital at home involves a paramedic or nurse making twice daily visits to the home of the patient who has acute-level medical needs but an ability to receive care at home, bringing with them the high-tech equipment of the acute hospital and satellite-linked video technology for a physician or advanced provider to offer consultation and guidance virtually.

A version of this approach has been tested in rural settings by the University of Utah Health, supported by H@H researchers at Brigham and Women’s Hospital in Boston, starting in 2019. Three other health systems are now involved in a three-year pilot, developed with Harvard’s Ariadne Labs, to test hospitals at home in areas where resources are limited.

The American Hospital Association estimates that a third of rural emergency patients could be treated in their homes as part of a hospital-at-home program. Willits suggests that offering hospital at-home, ED in-home or similar types of programs requires a skill set and a medication and equipment formulary that most ambulances currently don’t carry. “Even in your rural settings, it requires a higher level of training and education and dedicated or paid staff with those skill sets,” he says.

Are mobile integrated networks in EMS able to expand options and help enhance these kinds of collaborations in rural settings? Maybe the first call for help doesn’t have to start with 911 if publicized triage nurse lines are available. Paramedics can play multiple roles—such as helping out in the ER until an ambulance call comes in, and then going out when that’s needed. (See EMS World, May 2, 2023, for more on the community paramedic’s role in the hospital at home.)
What’s needed to make the system work better for rural communities? “First, we have to shore up the rural ambulance service,” Winstone says. That means a change in budgetary policy at CMS. “Then, we can make greater use of community paramedics and virtual visits to the home.”

Wingrove says he hopes EMS professionals can be part of finding solutions—not just complaining about what doesn’t work. Legislators need to know what is working and is not. Even if EMS advocates can’t make a trip to the nation’s capital, lawmakers have offices back home and could be invited to go on ride-a-longs.