ACADEMIC EMERGENCY MEDICINE • November 2001, Volume 8, Number 11
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unique health care system. Described in greater means, referral to the ED increased. Second, stan-
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detail elsewhere, components of the system in- dards of practice led to increased utilization of
cluded community-rated insurance, formal com- technology (e.g., computed tomography scans as a
munity health care planning, and early and wide- new standard of diagnosis for appendicitis), in-
spread entry of managed care dominated by a creasing referrals to the ED. Third, in the model
single payer. Rochester became known for its low of limiting resources to reduce utilization, radiol-
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inpatient bed utilization. Managed care developed ogy resources were limited and contributed to pa-
rapidly. By the late 1980s, 65% of the employed tient delays. Fourth, the most successful observa-
population was enrolled in a managed care pro- tion unit closed due to changes in Medicare
gram.
reimbursement, presumably resulting in addi-
There were many successful outcomes of the tional inpatient admissions. Fifth, an increase in
Rochester system. As reported in 1992, Rochester the uninsured population (up to 16% of ED regis-
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had achieved lower per-capita health care costs trations) contributed to the overcrowding.
than New York State overall, as well as nationally
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(
$775 vs. $1,064 vs. $811). However, despite the Study Protocol.
successes of the Rochester system, there were con-
cerns. An effect of the system was to intentionally
restrict resources and allow issues of access to
limit utilization. Hospital occupancy within the six
Phase 1 Interventions. Ambulance diversion was
used to control flow into EDs. In the late 1980s, a
community effort was made to decrease diversion.
A consortium of emergency medical services
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hospitals averaged 87.8% in 1992. Emergency de-
(
EMS), county health department, and hospital
partment overcrowding and delays in admission of
patients were common. When demand for inpa-
tient beds exceeded supply, inpatients were kept in
the ED until beds were ready. The treatment of
new, acutely ill patients took place wherever space
was available.
leaders established uniform criteria for ambulance
diversion (‘‘code red’’). Each hospital agreed to im-
plement code red only when three of the following
conditions were met: no available inpatient beds;
no available intensive care unit (ICU) beds; 40% of
beds in the ED occupied by inpatients; delays in
evaluation of waiting room patients (patients tri-
aged and not yet placed in rooms) exceeding four
hours. The ED medical directors and EMS lead-
ership met monthly to monitor code red, investi-
gate any violations, and discuss problems of mu-
tual concern.
In the mid-1990s, hospitals and EDs through-
out the United States experienced a decrease in
demand. In Rochester, despite a long history of
managed care and managed resource utilization,
inpatient services had a similar decrease in de-
mand. Hospital occupancy dropped below the 80%
mark. Licensed beds decreased from 2,300 in 1985
As code red hours increased, pressure was
placed on the EDs to reduce patient throughput
times. The ED directors collected data on the
causes of code red, and the most significant factor
proved to be inpatient presence in the ED. The di-
rectors presented these findings to individual hos-
pitals and to the area hospital consortium. Lead-
ership groups were invited on several occasions to
play the simulation game ‘‘Friday night in the ER,’’
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to 1,832 in 1998 (20% reduction). Beds were per-
manently eliminated from many physical struc-
tures through remodeling. The number of hospital
patient days/1,000 population declined from 961 in
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980 to 607 in 1997 (37% reduction). An inner-city
acute care facility and ED closed in 2000, with pas-
sive distribution of 30,000 annual ED visits. The
closed facility still functions as an urgent care and
walk-in psychiatry unit but does not accept am-
bulance patients and transfers all patients who re- stream effect of bottlenecks.
quire inpatient care. In March 2001, the third larg-
a business game that vividly illustrates the down-
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The EDs began to hold selected inpatients in-
est hospital in Rochester went into foreclosure and definitely (known as ‘‘boarding’’) to ensure beds for
limited services. It eventually closed in early May, sicker, more care-intensive patients. Observation
including its 30,000 annual visit ED.
areas were opened in the two largest hospitals.
As a medical-nursing best practice, hospitals
Hospital utilization and ED visits experienced
a marked increase in the late 1990s–2000, both used cohorting of patients (i.e., neurology with
nationally and in Rochester. Several factors played neurology, cardiology with cardiology). Unfortu-
a role in the increase locally. First, during the nately, in a setting of high occupancy rates, this
changes of the mid-1990s, hospitals began to em- led to further delays (one admission office esti-
ploy large numbers of primary care physicians in mated two inpatient moves were needed for every
an attempt to secure inpatient and specialty refer- ED admission to ensure the correct bed cohort). To
rals. Anecdotally, these salaried physicians pro- address these delays, one hospital opened a short-
vided fewer off-hour services. Though 50% of ED stay unit with cardiac telemetry, accepting undif-
patients called their physician prior to coming to ferentiated ED patients until a cohorted inpatient
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the ED and potentially had care provided by other bed could be found.