We determined the additional cost of an extended emergency department (ED) length of stay for chest pain patients awaiting non-ICU, monitored (telemetry) beds.
This was a prospective cohort study of ...all ED chest pain patients aged 24 years or older and admitted to a telemetry bed in an urban university hospital during a 12-month period. Structured ED data collection included demographics, chest pain presentation, medical history, and laboratory test and ECG results. Hospital course was monitored daily, followed by a 30-day telephone follow-up. Risk severity scores (Goldman, Acute Cardiac Ischemia–Time-Insensitive Predictive Instrument, and Charlson) were calculated. Hospital charges, real costs, and revenues were obtained at discharge and 2 years later. The main outcome measure was risk-adjusted additional cost to the hospital of a delayed ED admission. Clinical outcome was a secondary measure.
Of the 817 patients with chest pain presenting to the ED during the study period, there were 904 hospitalizations. Of these, 825 patients waited more than 3 hours for their bed (91%). There were 21 patient visits with a final diagnosis of acute myocardial infarction. ED length of stay was not associated with total hospital length of stay (
r=0.01), hospital costs, or hospital or professional charges, revenues, or collection rates. The annual opportunity cost in lost hospital revenue for chest pain patients was US$168,300 (US$204 per patient waiting >3 hours for a hospital bed).
Extended ED length of stay demonstrated no association with total hospital costs or revenues or total hospital length of stay but imposed substantial ED opportunity costs, with decreased potential revenue. Interventions that reduce ED delays in hospital admissions have the potential to significantly increase hospital revenues.
Expansion of the preadmission process for same-day-admit (SDA) surgery patients through our Admissions Evaluation Center has provided an efficient and convenient means for complete patient evaluation ...up to 30 days in advance of surgery. Traditionally, collection of blood samples for the pretransfusion testing that is necessary to select compatible blood for transfusion occurs within 72 hours of admission, consistent with standards to ensure detection of red blood cell (RBC) alloantibodies formed as a result of recent transfusion or pregnancy. As a result, samples for many SDA patients were submitted Stat the morning of surgery, resulting in an unwieldy amount of testing and delay in blood availability. To address this problem, the time interval for collection of patient blood samples for pretransfusion testing was extended to 30 days prior to surgery. To ensure safety, this change required documentation of patient transfusion and pregnancy history at 2 specific timepoints. Input from a multidisciplinary team was vital to assess the process of blood ordering and administration and to determine the best means to accomplish these steps. Implementation of the new process resulted in a decreased number of emergent requests for compatibility testing, decreased delays in blood delivery, and elimination of canceled surgery due to cases with unexpected RBC antibodies.
The dramatic changes that have occurred in health care legislation in the past 20 years have changed the practice of anesthesiology. Anesthesiologists not only provide intraoperative care, but they ...also now play an important role in the design and implementation of disease management protocols, especially those likely to require surgical intervention or the management of chronic pain. Although an extensive battery of “routine” preoperative testing modalities was at one time required for all surgical patients, the clinical yield and cost-effectiveness of this approach is unacceptably low in contemporary practice and it should be abandoned. Instead, preoperative testing of surgical patients should be directed by physical status, disease, and the surgical procedure itself. Although the AEC has documented success, the continued pressures of increased managed care penetration, decreased reimbursement, and concerns regarding the quality of care necessitate that every preadmission program continuously monitor and reassess their value.
The AEC is an ideal environment to examine preoperative interventions and then uniformly apply these best practices to optimize patterns of perioperative care. Outcome research, which emphasizes prevention of perioperative events, is an obvious target for health care research in the 21st century. Expanding the role of the anesthesiologist outside the operating room is also critical to our specialty. We must provide administrative support and insight for health system priorities such as disease management and the admission process if we are to be recognized by our peers as a vital component of an integrated health care system. We must also become perioperative physicians for the surgical patient, not just intraoperative caregivers, if we are to continue to attract the brightest students from medical schools to our specialty.
