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VA technique cuts emergency wait times

Wes Venteicher
| Monday, Oct. 2, 2017, 9:00 p.m.
Dr. Ali Sonel, who oversees the clinical management of VA Pittsburgh Healthcare System, stands for a portrait in the ER at the VA in Oakland, Friday, Sept. 27, 2017.
Andrew Russell | Tribune-Review
Dr. Ali Sonel, who oversees the clinical management of VA Pittsburgh Healthcare System, stands for a portrait in the ER at the VA in Oakland, Friday, Sept. 27, 2017.

Veterans Health Administration hospitals around the country are adopting a Pittsburgh-developed technique for reducing emergency room waits and making sure vets can quickly see a specialist after an ER visit.

Twenty-six sites are now using VA Pittsburgh's Rapid Access Clinic model, and every site in the system with an emergency department could adopt it over the next year, says Dr. Susan Kirsh, a VA national director for clinical practice management.

The model targets patients who in the past might have waited hours to see a specialist only to undergo a simple procedure, such as getting a cast, before leaving with instructions to make a followup appointment, says Dr. Ali Sonel, VA Pittsburgh's chief of staff.

Waits for specialists can grow long if the doctors are busy with surgeries or treating more serious injuries, and some patients with relatively minor maladies would leave the ER without treatment, Sonel says.

Front-line ER doctors now identify patients with a list of common conditions — such as a fracture, blood in urine, a tendon rupture or swollen joints — and treat them without calling in the specialist. Emergency department staff then schedule followup appointments for the patients before they leave.

Sonel says the idea for the clinic emerged from discussions in late 2013 about how to reduce wait times. A national scandal erupted in 2014 over long waits for veterans in some states to get appointments with VA doctors, with some veterans dying while waiting.

“The thing that we were trying to solve at the time was not keeping the patient in the (emergency department) any longer than they had to be there,” he says.

The clinic, launched at the beginning of 2015, has reduced the number of patients who leave the emergency department without being seen to 1 percent, down from 5 percent, Sonel says. The national target is 4 percent, he says.

“We save the specialist time and save time for the patient,” he says.

The clinic has not reduced the overall time it takes to get treated and leave the emergency department, but has reduced wait times for individual patients with certain conditions, a VA spokesman says in an email.

“More and more organizations are looking at doing this sort of thing, but it's much easier said than done,” says Kenyokee Crowell, senior vice president of clinical access for Allegheny Health Network.

Crowell says the network has adopted a process similar to the VA's for emergency room patients who need to see a cardiologist. The network discharges some patients with low-acuity chest pain with an appointment to see a cardiologist within 72 hours, Crowell says.

She says AHN aims to have the model in place across its hospitals by the end of the year, and is evaluating other health conditions that could be handled in the same way.

“We do have plans to continue building upon that, and hopefully to move toward a model like the VA has,” she says.

UPMC hospitals use several strategies to reduce wait times, spokesman Rick Pietzak says in an email.

At UPMC Presbyterian, consulting specialists schedule followup appointments before the patients leave the emergency department for certain conditions, Pietzak says. Other specialties reach out to patient proactively to schedule followup appointments or tests, he said.

The VA Pittsburgh model requires more coordination between the emergency department and specialist offices to make sure the specialists keep enough slots open, Sonel says, and relies on emergency room doctors to identify which patients still need to see a specialist in the emergency department and which don't.

“It seemed in some ways simple, and in some ways it was really quite innovative,” Kirsh says of the Pittsburgh model. “It's just chipping away at this, taking one piece at a time, each one iteratively improves the system as a whole.”

Wes Venteicher is a Tribune-Review staff writer. Reach him at 412-380-5676, or via Twitter @wesventeicher.

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