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New York City Council Hearing: Safety of New York City Emergency Departments

Eric Wei, M.D., Chief Quality Officer
Monday, February 24, 2020

Good morning Chairperson Rivera and members of the Committee on Hospitals. I am Dr. Eric Wei, Chief Quality Officer at NYC Health + Hospitals (Health + Hospitals). I am joined by Dr. Natalia Cineas, Chief Nursing Executive at Health + Hospitals. Thank you for the opportunity to testify before you today on the safety of Health + Hospitals emergency departments.

Health + Hospitals has full-service emergency departments (ED) staffed by experienced and caring physicians, nurses, social workers and other health care professionals. Our EDs are busy, with over 1 million visits in 2019. In fact, two of Health + Hospitals facilities – NYC Health + Hospitals/Lincoln and NYC Health + Hospitals/Kings County – are among the top 14 busiest EDs in the country.1

Health + Hospitals operates five Level I Trauma Centers – NYC Health + Hospitals/Bellevue, Elmhurst, Jacobi, Kings County, and Lincoln, which means these facilities are capable of providing total care for every aspect of injury – from prevention through rehabilitation. We also operate seven adult, and one child & adolescent comprehensive psychiatric emergency programs (CPEPs), which include psychiatric emergency rooms, extended observation beds, mobile crisis intervention services, and access to crisis beds. Last year, there were more than 66,000 adult and 3,300 child/adolescent visits to Health + Hospitals psychiatric emergency rooms.

Our EDs experience many of the same challenges – overcrowding, wait times, staffing – that many of the large health systems in New York City face, which can lead to an unsafe environment in our EDs. As such, a top priority of Health + Hospitals is developing and maintaining a “Culture of Safety” for our patients and staff in order to minimize adverse events, and learn from opportunities for improvement in our EDs.

Implementing a “Culture of Safety”

We have proactively implemented initiatives to measure and mitigate risks of adverse events for our patients including:

  • Patient identification: leveraging our new electronic medical record (Epic) and barcode scanning to ensure correct patient identification.
  • Debriefing: holding short discussions after significant events to reinforce what went well to hardwire for next time and identify opportunities for improvement and what to do differently next time.
  • Managing agitated patients: having standard screening, prevention, de-escalation, and behavioral response teams throughout the system.
  • RL Datix incident reporting system: moving from paper to electronic incident reporting system to encourage increased reporting of good catches and other opportunities for improvement.
  • QAPI/RCAs: optimizing our formal quality assurance, performance improvement, patient safety, and risk management processes to continuous learn and improve our system.
  • Enterprise-wide shared electronic medical record (EPIC): allows patients’ medical records to move with them seamlessly throughout the system, which gives staff a full picture of the patients’ health without having to unnecessarily repeat tests.
  • DnA: embarked on a new data and analytics strategy in 2019 to improve data literacy, quality, and access in order to make data informed decision.

Likewise, we have implemented initiatives to support providers after difficult experiences and to improve staff wellness and engagement so they are able to give their best to patients. Our 18 Helping Healers Heal (H3) teams across the system have trained over 1,000 peer support champions who have provided over 600 1:1 and group debriefs surrounding emotionally and psychologically traumatizing events. This is to ensure that our staff are supported through these events and connected to additional resources as needed so they can best care of themselves and our patients. We are implementing the Institute for Healthcare Improvement (IHI) Joy in Work Framework, which connects staff back to their “why” in working in healthcare. We believe that engaged, happy, supported, and joyous staff will provide the highest quality and safest care with the best patient experience.

Addressing wait times/overcrowding

As mentioned before, overcrowding and wait times can lead to an unsafe environment in the ED. There are several factors that contribute to increased wait times/overcrowding, including patient demand, and the historical difficulty in getting primary care or express care services at Health + Hospitals. It is important to note that if you have a very serious injury there is no wait time in the ED – the most urgent patients are always triaged and they don’t wait. For less urgent visits, a sprained ankle, a bad cold – there can be a wait if the ED is busy. With new hiring of nurses and physicians, improved workflows, and investments in express care and primary care, Health + Hospitals has made great progress in reducing wait times and improving the patient flow through our EDs.

  • Nurse staffing: In the past two years, we have taken some great steps to address these nurse staffing challenges. During this same period, we’ve hired over 600 new nurses, and in December, Health + Hospitals reached a 4-year contract agreement with the New York State Nurses Association (NYSNA), which represents more than 8,500 nurses across Health + Hospitals to pay fair wages, ensure safe staffing, and improve recruitment and retention of our nurses. Health + Hospitals has also agreed to collaboratively address nurse-to-patient staffing ratios with NYSNA and will follow an approved staffing model.Physician recruitment: In 2018, we launched the system’s first official physician recruitment campaign – DOCS4NYC – to help fill 75 new and open primary care physician positions and expand access to community-based primary care across the five boroughs. We have also focused on retention of our physicians through programs like Doctors Across New York. In 2019, Health + Hospitals received 16 grants for loan forgiveness for doctors (~$2M in total) for 16 doctors in exchange for their continued commitment to serve the system (for 3 years).
  • Improved Workflows: We are providing access to other appropriate levels of care to reduce the need for ED visits through expansion of primary and specialty care, and having them self-select our ExpressCare clinics. We are also implementing targeted interventions for conditions where we see high rates of potentially preventable ED visits by expanding care to the home.
  • Improving ED Throughput: When patients do show up in our EDs, we have developed processes to quickly move them through our EDs and get them to the right type of care that they need, whether it’s utilizing providers in triage to get the definitive evaluation and treatment initiated right away or utilizing direct-to-bed where no patients wait in the waiting room. We are also working on improving efficiency by reducing our lab and radiology turnaround time, and moving our inpatient discharge times to earlier in the day to open up hospital beds to meet ED admission demands.
  • Left Without Being Seen: Patients come to our EDs to see a doctor. During particularly busy times in the ED, patients without an imminently dangerous condition often have to wait to see a definitive provider after they are triaged by a nurse. In order to minimize situations where a patient leaves before seeing a provider, we continue to implement operational flow strategies based on published evidence and best practices of similarly sized EDs. Some EDs use a provider-in-triage model which sits a physician or Advanced Practice Provider (APP) at the front end that makes sure a provider evaluates every patient to expedite their care. This is complementary to a split-flow model which directs patients to different areas of the ED to match their needs and facilitate the work up. Other EDs use a direct-to-bed model where patients are placed in any available space and use bedside registration to minimize waits. We are making these improvements at NYC Health + Hospitals/Queens, Lincoln, Kings, Woodhull, Harlem and Bellevue.
  • ExpressCare: This new care setting will provide an alternative for patients seeking fast, reliable and non-emergent care, as well as connecting patients to a primary care provider if they don’t already have one. We do community outreach to encourage patients with non-life-threatening conditions to avoid the ED and directly walk in to the clinic. We currently have ExpressCare clinics at six sites, NYC Health + Hospitals/Lincoln, Elmhurst, Queens, Woodhull, Metropolitan, and Harlem and we expect to have clinics at NYC Health + Hospitals/Jacobi and Kings County later this year.
  • Increased Access to Primary and Specialty Care: We launched NYC Care in the Bronx in August, and have enrolled over 13,000 Bronxites in the program. Last month, we rolled out the program in Brooklyn and Staten Island, and will be in all five boroughs in New York City by the end of 2020. One of the primary goals of NYC Care is to decrease reliance on emergency rooms, and increase access to primary and specialty care for hundreds of thousands uninsured New Yorkers, half of whom are ineligible for health insurance or cannot afford it. Our eConsult system, which allows primary care physicians to send an electronic referral directly to specialty clinics has already produced 200,000 consults and shortened specialty care wait times.

Other Health + Hospitals Initiatives

Other initiatives we have embarked on include decreasing our potentially preventable ED visits and hospital utilization. For example, over the first four years of the Delivery System Reform Incentive Payment Program (DSRIP), we reduced avoidable admissions by 20%, which is on par with the State’s overall trend under DSRIP. We are also doing targeted interventions for conditions where we see high rates of potentially preventable ED visits by expanding care to the home. For example, we are connecting patients with asthma to community-based organizations’ community health workers who work with the care team to engage patients in an asthma action plan and go into the home to address environmental triggers. We’ve seen a 20% reduction in potentially preventable admissions for pediatric patients with asthma in the performing provider system’s population since the program started and are expanding to adults this year. Recognizing that transitions from the ED or an acute setting are hard for many patients, resulting in them often coming back to our hospitals unnecessarily, OneCity Health has also invested in programs to make transitions back into the community or other care settings easier. In addition, our Office of Population Health and Community Care teams have been working on screening for social determinants of health (housing, food, legal, immigration, etc.) and linking patients to appropriate resources. These unmet social needs bring patients to our ED’s as the safety net for not only the healthcare system but our social systems as well.

Investments in Health + Hospitals Emergency Departments

Thanks in large part to the financial support of the City Council, other local and state elected officials, and other resources, Health + Hospitals has invested in new equipment and embarked on major renovations of several of its emergency departments to ensure that our patients continue to receive state-of-art-care that they deserve. This investment is also a part of the systems’ broader multi-year redesign to build a competitive, sustainable organization that will continue to offer high-quality and accessible health care to the people of New York City.

Lincoln: Earlier this month, Lincoln announced it received FY20 capital funding from the City Council to transform two X-ray rooms in the ED. The space will be renovated into a brand new, state-of-the-art digital radiology suite. The new equipment’s enhanced features will be fully digital to improve image quality.

Elmhurst: In the fall, NYC Health + Hospitals/Elmhurst announced its plans to expand its emergency department. The $43 million expansion project will include the redesign of 28,900 square feet of space; and an added floor above the emergency department will be built to accommodate the hospital’s Adult and Child Emergency Psychiatry and Partial Hospitalization programs. The space will incorporate a state-of-the-art Stroke Center, featuring an advanced medical imaging unit that will allow the hospital to expedite life-saving care for stroke patients.

Bellevue: Last summer, Bellevue Hospital Center announced the installation of a new state-of-the-art computer tomography (CT) scanner in the emergency department that will reduce wait times, produce faster testing and better image quality, quicker diagnoses and treatment for patients, particularly critical patients in the ED.

Woodhull: In the spring of 2019, Woodhull Medical Center received $5 million in FY19 capital funds from the Council’s Brooklyn Delegation to expand its emergency department to improve access to services, alleviate overcrowding, reduce wait times, and improve the patient experience.

Thank you for the opportunity to testify. I look forward to your questions.

1 https://www.beckershospitalreview.com/rankings-and-ratings/hospitals-with-the-most-er-visits-2019.html