One of the biggest challenges for the health care system, as it focuses on providing more value while limiting skyrocketing costs, is to figure out how to deliver the appropriate care for patients in the right place, and at the right time. A good chunk of that means limiting use of the emergency room to what truly constitutes emergency care, and instead providing better access to routine services and preventive care in a less costly, less resource intensive setting.
Recent recipients of organ transplants would seem to be prime candidates for avoiding the emergency room. Given the special circumstances, one would think they would have more immediate access to specialized care in the event they start showing signs of infection or other issues with their transplant. But a recent study at Northwestern University showed that nearly 40 percent of patients who had received organ transplants over a six-year period sought care in the emergency department. A majority of them were readmitted to the hospital, but then discharged in less than 24 hours. A majority of these visits also happened when the transplant clinic was open.
In an editorial about this study, Bryan Becker, MD, Vice President of Clinical Integration at the University of Chicago Medicine, and his wife, Yolanda Becker, MD, director of the kidney and pancreas transplant program, wrote, “In a value-based environment, this is an opportunity to reconfigure care delivery toward the caregiver who knows more about the patient, his or her condition, and potentially important features of specialty-specific treatments.”
In other words, it’s a prime opportunity to redirect them to the transplant clinic, with doctors and nurses who understand their specific needs. But this isn’t as easy as it sounds.
In most cases, patients do have 24/7 access to a patient care coordinator who can talk them through what’s going on. Sometimes they may decide they really do need to go to the emergency room; if not, perhaps they can wait until the clinic is open the next day.
“That care coordination process is dependent on clinic hours though,” Bryan Becker said in an interview. “If your clinic’s not open beyond normal work hours, or if you don’t have an alternative care solution, the default is still the emergency department. We need to have the alternative in place and communicate readily.”
He said those alternatives could include longer transplant clinic hours, obviously, but also developing guidelines for treating transplant recipients when they do come to the emergency room. For instance, the transplant specialists could work with emergency department staff to create specific protocols for treating transplant recipients who present with certain symptoms, say, dehydration or fever. That way they could bridge their care more effectively until the transplant specialists are available.
The most effective long-term solution, though, may be educating the patients themselves so they understand the follow up care they need, including what constitutes an emergency. This, combined with more efficient processes for routing patients to the right specialists, could limit their use of the emergency room while still providing them the best care.
“The educational process for the patient starts in advance of the transplant,” Becker said. “Then we have to look at clinic staffing, and how their services interact with the observation services we have in the emergency department. Together this will give us a better gauge on how to best manage these patients without having to send them to the ED.”