Research Forum Abstracts

illnesses further diminished the vaccination rate. If confirmed in larger studies, thesefindings have implications for utilization of EDs for immunization.

145 Analysis of Downstream Revenue to an AcademicMedical Center From the Emergency Department

McGuire T, Madsen T, Barton E, Hopkins C/University of Utah, Salt Lake City,UT

Study Objectives: Over the past several years, academic emergency departments(AEDs) have come under increased scrutiny to demonstrate financial viability andindependence. Because of changes in patient profiles, payer mix, and operationalexpenses (24/7 operation), many AEDs have found it difficult to achieve bothacademic and financial success. Most AEDs have financial support arrangements withthe institutions in which they operate and the assumption has been that thedownstream revenues generated by the clinical activity justified this support.However, the cost of providing emergency care continues to rise while reimbursementrates have typically declined. It has become increasingly important for AEDs toquantify the revenues generated by inpatient admissions, outpatient follow-up care,and professional revenues to other departments in the institution. This studyexamines the downstream revenues generated from a single AED at a university-basedhospital.

Methods: Financial records from January 1, 2008 to December 31, 2009, from asingle-site AED with an annual census of 38,000 visits were broken down into threecategories: 1.) charges and collections for inpatient admissions from the AED, 2.)outpatient follow-up care, and 3.) professional revenues from inpatient andoutpatient services. A conservative weighting system was used to account for the factthat all revenues generated after a single ED visit may not necessarily be a result ofthat visit.

Results: The analysis showed net hospital admission revenues from AED visitswere $116M in 2008 and $124M in 2009, nearly 50 times the institutional financialsupport of the department for each of those years. Outpatient follow-up care netrevenues were $6.2M in 2008 and $7.2M in 2009. Net professional revenues to otheracademic departments in the university totaled $45M in 2008 and $48M in 2009.Total net revenues, including all three categories, were nearly $170M in 2008 and$180M in 2009. Finally, each patient seen in the AED during 2008 and 2009resulted in nearly $4500 in net downstream revenues for the health system.

Conclusion: This study demonstrates that the total revenues contributed to theuniversity medical center far exceed the charges generated by the individual AED.Additionally, it is possible to quantify the financial contribution of an AED to thehospital by dividing downstream revenues into categories and weighting the value offollow-up care. The AED remains a financially beneficial “front-door” to theinstitution.

146 Reducing the Emergency Department Door toIntensive Care Unit Bed Occupancy Time forCritically Ill Patients Admitted Through theEmergency Department: Intervention andImprovement

Dubin J, Frohna B, Goyal M, Milad R, Desai S, Milzman D/Washington HospitalCenter, Washington, DC

Background: With the impact of ED crowding being directly linked to bedavailability, many EDs are forced to board critically ill patients requiring ICU care forextended time periods. Few studies have focused on the actual reasons for patientmovement delays and offered concrete solutions to this problem. Prior studies havefound that critical resuscitations are achieved better in the ICU and have also founddelays in initiating ICU care leads to worse outcomes for the patients.

Study Objectives: Identify barriers to reducing the ED door to medical intensivecare unit (MICU) and door to medical intermediate care unit (MIMC) occupancytime of critically ill patients in the emergency department (ED). Interventions weredeveloped to speed time out of the ED to the ICU and MIMC and the impact ofthese changes was then compared to the existing historical data.

Methods: This prospective observational study was performed at an urban, Level1 Trauma, tertiary referral academic hospital. 80% of MICU and MIMC patientsoriginate from the ED. Baseline data was collected for one month for ED patientsadmitted the MICU and MIMC. After analysis of baseline data, multipleinterventions were enacted and their impact on door to occupancy time was studied

over two subsequent months. Interventions included: defining objective criteria for

Volume , . : September

MICU admissions; developing rapid MICU/MIMC consult tool; early notification ofbed management of need for MICU bed; creating dashboards in the MICU and bedmanagement offices to identify ED patients awaiting MICU and MIMC beds; andexpediting full registration of patients in need of MICU and MIMC beds. Pre- andPost- comparisons were made using descriptive statistics, fisher’s exact and student’st-test with p �0.05.

Results: The mean ED door to MICU (n� 128) occupancy time decreased froma PRE (baseline): 6.9 hours 95% CI (4.5-7.5) to POST-INTERVENTION: 5.2hours (95% CI: 3.9 - 6.3); p � 0.05. The removal of triage decision time for patientsmeeting MICU admission criteria resulted in immediate 22% time reduction andtrends in 50% reduction in decision to assign time from 2.1 hours to 1.2 hours; p�0.05 and resulted in greater speed to ICU bed availability. The mean ED door toMIMC (n�115) occupancy time, decreased from:10.0 hours (95%CI: 8.6-11.3)versus POST: 8.2 hours (95%: 7.3-9.4); p �0.04. MICU length of stay (LOS)during the study period was noted to trend toward reduction from PRE: 3.82 days toPOST (1 month) 3.68; n� 76 ( p � .23, and POST: 3.14 days; p� 0.08.

Conclusion: ED door to critical care unit admission time can be significantly reducedby studying the multiple steps required in obtaining an ICU bed and implementingchanges to minimize these barriers. During the study period there was a decrease inMICU LOS, possibly due to limiting boarding time in the ED of critically ill patients.

147 Perceptions of Quality Improvement Practices InAcademic Emergency Medicine

DelliFraine J, Langabeer II J, King B/University of Texas Health Science Centerat Houston, Houston, TX; The University of Texas Houston Medical School,Houston, TX

Study Objectives: Physician training in quality improvement programs has thepotential to prevent medical errors by training emergency physicians to identify andcorrect process and systemic weaknesses. The objective of this study is to assessacademic emergency medicine chairs’ perceptions of value, both realized andpotential, of quality improvement training programs.

Methods: The target population for this study is the chairs of academicemergency departments in the U.S. A voluntary anonymous 20-item survey wasdistributed face to face and online to a sample of academic chairs of emergencymedicine through the Association of Academic Chairs of Emergency Medicine(AACEM). Descriptive analyses, correlation analyses and qualitative analyses wereused to determine the association between perceived impact of QI training, perceivedchange in practice and behavior, and type of training received. Qualitative analyseswere used to examine open-ended questions, and themes of behavioral and practicechanges were analyzed to determine specific changes related to receiving QI training.

Results: The response rate to the survey was 69% (N � 59). 59.3% of academicemergency medicine (AEM) chairs report that their hospital has a formal qualityimprovement program for physicians. Chairs received training in a variety of qualityimprovement programs. The type of quality improvement (QI) program used byrespondents had no impact on goals achieved by QI (�2 � 12.382; p � 0.260);however, there was a statistically significant (�2 � 14.383; p � 0.006) relationshipbetween whether or not goals were achieved and AEM chairs feelings about return oninvestment for QI training. Only 22% of chairs responded that they have alreadymade changes as a result of the QI training. 78.8% of AEM chairs responded thatquality programs could have a significant positive impact on their practice and thehealth care industry. Chairs felt that QI programs had the most potential value in theareas of understanding and reducing medical errors and improving patientflow/throughput. Other areas of potential value of QI include improving specificclinical indicators and standardizing physician care.

Conclusions: AEM chairs felt that quality improvement programs were aneffective way to drive needed improvements. The results suggest that there is a highlevel of interest in quality improvement, but a low level of adoption of QI trainingand implementation. However, adoption and use of QI methods is especiallyimportant for AEM chairs, who serve as leaders, mentors, and role models to AEMphysicians in the march towards health care quality.

148 Utilization of a Low Flow/High Flow State toDecrease Door to Provider Time

Davis-Moon LJ, Mathew RG, Storer A/Thomas Jefferson University, Philadelphia, PA

Study Objectives: To determine if creating a patient intake model grounded inUHC best practices proactively managed the high level LWBS rates and poor patient

satisfaction scores associated with crowding in ED high flow states.

Annals of Emergency Medicine S49