Innovation in Emergency Services

Podcast Transcript

William Morris, MD:
Hello, welcome to Health Amplified, a Cleveland Clinic podcast about innovating, venturing, and amplifying the powers of healthcare change through strategic business and product development, ecosystem collaboration, and transformational leadership. I'm your host, Dr. Will Morris, and with me as always is Dr. Akhil Saklecha, managing director of Cleveland Clinic Ventures. Today, we have a very special super episode for the podcast with you. We're meeting with five emergency medicine experts from Cleveland Clinic, and they're going to be discussing novel approaches to emergency room care, but it's not just about the acute care that they're rendering in the emergency department, it's about novel uses of technology, virtual visits, new payment paradigms to manage patients at home rather than having them come into the acute access hospital. And certainly, we'll be talking and addressing the COVID-19 and the impact on our caregivers, but also the emergency departments across the nation. Let's dive on in.

We have Dr. Bryan Graham, who is a staff emergency medicine physician, but also the local expert on billing and reimbursement, and with him is Chris O'Rourke. Chris is the administrator of Emergency Service Institute at Cleveland Clinic. Dr. Graham and Chris, welcome.

Bryan Graham, DO:
Thanks for having us on. Looking forward to the conversation.

William Morris, MD:
Well, I will kick things off as a hospitalist. I know Akhil, as a fellow emergency room physician, will have probably more pointed questions, but as a hospitalist, certainly COVID has really opened the doors for telehealth. We see this for post-discharge patients or even avoidance for readmission. I'm curious how COVID has opened the door, the proverbial door, for telemedicine in emergency services, and more importantly, do you see that door closing?

Bryan Graham, DO:
Yeah, I think that you hit the nail on the head. COVID, of all the things that came out of it, one of the positives was that we now have had a real acceleration into the virtual arena, especially around acute care. I mean, all the geographic and access restrictions went away with a lot of the waivers, and then, additionally, there was payment parity that surrounded it. And I think if you go back looking at acute care delivery, the ED sometimes is really this cost center, the most expensive place to actually go to be seen for something that's unscheduled.

And I think you can actually debate whether or not that's true, but the reality is, is there's been a push to really look at alternative ways to deliver that care. And we've seen programs that have actually focused on bringing physicians and PAs out to the home. There's been various different virtual models that have really focused on getting into the [inaudible 00:02:56] care space or supporting rural health systems, but they're all really limited by the lack of reimbursement around it. So, it was difficult to get buy-in beyond some type of shared savings model. And then, out of COVID, because there was just a need to reach people and do so efficiently, we now have this opportunity to do just that, and from there, we within ESI saw a real opportunity to really take advantage of it and enhance the care of the patients in our community, reach patients who are difficult to reach, whether they're in rural areas.

And then, also, to your point on all the other things within the health system, so reducing readmissions, post-discharge care, there's also an opportunity to really... The second someone at home recognizes there's a problem, intervene before they walk into the hospital. So, with that, we solve so that there's benefit in having the experts in that, the people who are really, truly experts in acute undifferentiated care, which is the emergency medicine physician. It's what we do. We see everything from, "I stubbed my toe," to the full cardiac arrest, and that allows us, really, to be the ideal individual to see that patient up front virtually to be able to make that same assessment. There's nothing that's outside of our scope.

And so, from there, we decided that what we needed to do to really pursue that was, essentially, built a virtual ED that had this 24/7, 365 board-certified emergency medicine coverage to do just that. For whatever would otherwise come to the ED, if there was an opportunity to intervene on site or enhance that care on site, so not just even prevent the ED visit, but let's say they're located somewhere where there's a transport time of 20 minutes with the EMS and the patient's in cardiogenic shock, I mean, there's real benefit to having an ED provider help guide care for those 20 minutes to improve outcomes. Chris, I don't know if you had additional thoughts.

Chris O'Rourke:
Yeah. I think the pandemic, just on the provider end, has made our physicians, our nurses, our APPs a lot more comfortable using telehealth or virtual health. So, during the pandemic, we had a lot of measures with COVID to limit interactions, et cetera, with patients that were potentially positive, so I think our providers and our teams in the Eds got a lot more comfortable using that technology. And I think our patients, in turn, got a lot more comfortable. And then on the backend, once... I think Bryan hit how we leverage virtual health on the front end before they get to the ed, but we've been a lot more comfortable on the backend scheduling ED follow-up appointments with different specialists, connecting patients directly with SNFs, and discharging them right to the SNF, as opposed to admitting them to the hospital and having some of those virtual consults with those SNFs to make sure that that coordination of care was there. So, I think we're doing a lot of stuff proactively on the front end to keep them from ever hitting the ED or the hospital, but then on the backend, leveraging virtual health to make that a smooth transition to the next step in that patient's journey.

Akhil Saklecha, MD:
So, I have to say that I'm really pleased at having fellow ER personnel on this podcast. I think it's good to turn the tables a little bit on the internal medicine folk on the call.

William Morris, MD:
Well, it evens out the IQ, so that's [inaudible 00:06:18].

Akhil Saklecha, MD:
Yeah. I think we can talk about our average, and that's probably much better. But regardless, I think we're digressing, Will. But I did want to touch upon some of the comments that both of you made, and I think a lot of it was around how we within emergency medicine are now taking advantage of this, I think, tidal wave of opportunity to catalyze change. And so much of it is positive in so many ways. A lot of the restrictions that we had, Chris, you mentioned even the ability to coordinate care with SNFs directly out of the ER and get some of those patients there, versus having to keep them in a hospitalized setting to manage that time period. Some of it is within our ability and control, and some of it is also willingness from external groups like SNFs and nursing homes to partake in some of this new innovation. And so, when you look at the change that both of you were talking about, how did you find the external parties, willing or unwilling, their ability to change and adapt? Maybe some examples of that.

Chris O'Rourke:
Yeah.

Bryan Graham, DO:
Yeah. Go ahead [inaudible 00:07:48].

Chris O'Rourke:
I think one area that we really leveraged the CMS leading the way was in this ET3 model, which is the emergency triage treat and transport. So, to give you guys some context, historically, the payment model really focused on when a patient calls 9-1-1, the only way an EMS squad could be reimbursed for the most part was if they transported that patient to an actual physical ED. Now, we saw some opportunity there with potentially patients coming to the ED that really didn't need to be in the ED at that moment, but it really took one of the payers, obviously the largest payer, CMS, to take the lead on this. And what they've done with the CT3 model is revise the payment to allow these EMS squads to be paid additionally for two instances, one being if they transport patients to an alternative destination, such as a PCP's office, an urgent care, a detox center for example, or if they actually take care of these patients on scene with the help of a qualified healthcare partner, such as the Cleveland Clinic.

So, we've partnered with a couple of squads that are participants in this program, and we really leveraged a virtual consult while they're on scene to help assess the patient, triage them to an appropriate care setting, or take care of them on scene. But that was really, now we're taking that concept in some of the demonstrated value and being able to sit down with other payers who, once we have a use case in some data there, are very, very eager to jump on board. So, that's one example I think of.

Bryan Graham, DO:
Yeah, that's exactly right. I mean, for us, it all really started a couple of years ago with the introduction of that model and recognizing that there was significant value for us to enhance our EMS partnerships and potentially even create new ones. But that model... EMS is funny, right? They have to go out and they see somebody on scene, and they can't ask, "Are you Medicare? Are you Medicaid? Are you a commercial payer?" They just pick them up and bring them to us and we take care of them. Same thing, we don't do wallet biopsies or anything like that. So, in order to have success in this program, we had to have third-party payer buy-in because EMS needed to make sure that they could get reimbursed for leveraging us to deliver that care on scene. And if it wasn't a Medicare patient, they'd still get paid because usually their budget comes from the city, oftentimes they're underfunded, they're overworked. So, to say the baseline is you're taking somebody to the ED, getting paid, and now we're taking that away from you, there wasn't a lot of interest there.

So, we really started circulating this idea pre-COVID, and we actually got one particular payer within Ohio, they have a big market presence, to really buy into it. And from there, we entered into a unique contract with them where they actually provided some upfront funding to help with this program that allowed us to really, they saw just how we did that. This EMS ET3 model was the tip of the iceberg, but there was 10, 15 different other ways to reach those patients virtually and create this virtual ED that's just going to allow us to get into pockets of the state or the country where patients have nowhere else to go. And then, also, those real high utilizers that are an opportunity for both the health system and the payer.

William Morris, MD:
I think what you elucidated, I think, it's the fundamental hypothesis, and it's the right one, that for those listening really need to understand and grasp. There are some tremendous innovative care models, and I think as clinicians and administrators, we are all eager to do that, but it's about alignment of incentives. That also means payment parity in order to achieve these outcomes. I think you really elucidated that. Help me understand, to a Akhil's point, when you're approaching a payer, not CMS, what's your angle? Is it that we can reduce your membership expense, is it utilization? How were you able to assuage the concern that this wouldn't actually create actually more utilization on the backend?

Bryan Graham, DO:
Yeah. I mean, exactly, all of those things is what we focus on, and the primary one being that it is it's going to be inherently a cost savings measure. For any patient that would have called 9-1-1 and gone to the ED historically, they're going to incur both the seeing the physician fee, so the professional fee, but then also the facility fee associated with just utilizing the ED in and of itself. The ET3 model immediately takes that away because there's no facility fee associated with that virtual visit, so it's just the physician services that the insurance company is paying for. And oftentimes, because of all the resources that ED has to have and the technology and we need to be staffed to be able to handle anything at any time, those facility costs can occasionally be three or four times as high as the professional fee. And so, that alone, this model allows for immediate cost savings there.

We were lucky that CMS actually put together this great white paper that talked about the impact it can have. It focused on a few different pilot programs that really had this type of intervention, and they were able to actually reduce ED utilization through this and subsequent readmissions by 10% and 15%, respectively. So, that also really supports the model and the potential impact that it can have.

But I think the other point that we've really tried to get across is, when you expand this outside of just EMS, there's an impact to further reduce your readmissions. There's also an impact to really enhance the quality, and that gets back to this patient is 20 minutes from the closest ED and they are teetering on the edge of death, essentially. And you have a paramedic or EMT... Or we actually had one primary care facility that we were talking to, they're in the mountains of Virginia, they have no EMS access after 5:00 PM, and a portion of the primary care space is in LTACH, so they have ventilated patients. So, if it's 3:30 and someone's teetering, they'll call 9-1-1 preemptively just because they don't know what they're going to do in the middle of the night when it's just a nurse in-house. So, there's a real opportunity there, too, to just have that ED physician, get you through that rough part of the night, that rough stretch, and improve that patient's mortality and morbidity, but also reduce healthcare cost.

Akhil Saklecha, MD:
Yeah. I think this whole concept of a virtual ED, and bringing an ED into your own, whether it's a nonmedical facility, your home, a nursing home, I mean that extension of care is really a novel concept. Right? It gets back to the introductory comments we made, which is that without COVID happening, a lot of this would never have had that initiation and force of acceptance by everybody willing to try these types of novel delivery of care.

William Morris, MD:
I mean, my mind is now racing because it starts with this, this is the beginning, but it certainly opens up a whole host of new care models and new care continuum, whether it be remote patient monitoring, now proactive as opposed to reactive triage and monitoring services. So, thank you Dr. Graham and Chris, it's been absolutely tremendous to learn a little bit about what you all are up to, and I look forward to reinviting you back in a year or so and you'll tell us what you're off to next.

Today, we continue our dialogue to explore emergency services, and we have the Senior Vice Chairman of the Patient Experience Office of the Emergency Service Institute, as well as the Academic Chair of Emergency Medicine at Cleveland Clinic Lerner College of Medicine, Dr. Steve Meldon. Dr. Meldon, thanks so much for joining us today. It should be a fun conversation.

Stephen Meldon, MD:
Yeah. Thank you for having me.

William Morris, MD:
I thought we could do stuff differently today and actually have Akhil kick things off as a fellow emergency room physician. Dr. Saklecha.

Akhil Saklecha, MD:
Well, thank you. I got to say, though, Steve is one of my bosses, so I'll be careful of the questions that I throw him. I'll let you do the hard questions.

William Morris, MD:
Right.

Akhil Saklecha, MD:
But Steve, it would be great to explain a little bit about the different roles that you have first, just at a high level across our whole ESI, and what some of those roles mean to the organization.

Stephen Meldon, MD:
Yeah. So, really, is we grew rapidly. When I got here nine years ago, we had two sites and 30 doctors, I think, and now we have 150 doctors, 150 PAs, 15 EDs, and we needed to create a better organized structure for that. And that's really where it's some of the roles came on. So, Dr. Borden asked me to be the medical director of main campus shortly after I got here, and then assumed the Vice Chair and then Senior Vice Chair role, really, to help represent ESI on an enterprise level.

We met early on about patient experience, and I was selected. I joke that's one of those ones where everybody stepped back and it looked like I stepped forward and became a Patient Experience Officer. I had a lot of training in that through a employment. It really worked with that, so had a good handle on it. And we've done really well with that, some novel things, which I think we'll talk about. And then, last, we're not an academic department. Until recently, we were part of the Department of Medicine at Lerner College of Medicine here in the Cleveland Clinic, and we applied for department status and got that. And I'm the inaugural chair for that academic department.

Akhil Saklecha, MD:
And so, when you look at all the different hats you wear and prioritizing your time, where are you spending it? Where is the bulk of your time? Because typically, you'll spend time on where the focus is. Where do you look at that, and how do you spend your time there?

Stephen Meldon, MD:
It was pretty evenly split between departmental duties, main campus, so [inaudible 00:18:40] the center director for main campus, and also then at the enterprise level. So, that drives a lot of it. The patient experience, I think we've gotten fairly buttoned up, which we'll talk about, so that doesn't take a lot of time. And then certainly running the geriatric EDs, putting those together, and then looking at, really, some research projects around that really take up a lot of them.

Akhil Saklecha, MD:
On the geriatric/ER side, so I'm going to ask maybe more of a skeptics question there because I know firsthand what it's like, but is this just a marketing ploy or is there actually something there behind the geriatric ERs?

Stephen Meldon, MD:
Yeah, there's definitely something behind it. So, let's talk about that. So, what's driving the geriatric ED concept? And it really is the recognition of need. Right? This is a unique population with geriatric syndromes and unique needs and increasing exponentially. Right? If you look at the demographics, over a 40 year period, from 2010 to 2050, this population will increase from 40 million to 80 million. So, we know that they're unique populations, right? So, who else presents with cognitive impairment, delirium, poly-pharmacy, fall risk? Very unique population. And we also recognize that the standard ED model, which is based on what's your chief complaint, address that, and move the patient along quickly, doesn't really fit well with the geriatric patient. They have cognitive needs, they might have social needs, they have functional impairments that really doesn't exist in a 20 year old or a 40 year old. So, that's long been recognized probably for the last several decades, and through that, the American College of Emergency Physicians said, "Why don't we create an accreditation program and really put some structure around improving care for older ED patients?"

William Morris, MD:
Steve, you actually said this recently to me, and it's absolutely stuck in my head, is what an opportunity, in four hours, we can five days worth of workup, treatment, and evaluation. And I imagine, you have that elderly patient coming in, they might have an acute issue, a fall, a UTI, but you look at them and they have poly-pharmacy or et cetera. Now, how do you teach that to 150 physicians to say, "Hey, there's a paradigm shift. Don't just be focused on that chief complaint, but look at the entire whole patient"?

Stephen Meldon, MD:
That's a great question. Right? Because part of the whole accreditation process, it's based on improving care. How do we do that? We do it through enhanced staffing, enhanced education, and then, also, policies and protocols to address these needs. So, for example, I put out a little lessons learned. I just put out something on delirium. Right? Hey, here's delirium, it's an acute process, here's the outcomes, here's its presentation. Right? Here's how you address it. But we have to do more than that. As you know, we really need more of a process, not just education. So, what's our process? We started screening for delirium using a simple two-stage screen, and we're screening all older people over 65. So, now, we're actually recognizing it, because we know it's under-recognized. Right? It's under-recognized in the ED, it's under-recognized on the floor, especially the hypoactive delirium. So, it's a combination of that education and process that I think really is going to move the needle and improve care.

William Morris, MD:
I'd imagine delirium and, as you said, we have an aging population, poly-pharmacy and just the fractured nature of health care, how do you feel like you're training at the point, but then you need to do that transition of care? How are you educating those that you interact with to ensure a seamless transition of care?

Stephen Meldon, MD:
Well, that's a big thing. Right? Transitions of care, we know are important. So, one thing we really focus in ESI is transitions of care. For example, we developed our ED to SNF program. That's all about transitions of care. I think the big thing, Will, is a couple things. One, it's a team approach. Right? So, transitions of care, I need case management helping me with that. Right? I can do the medical part, I can't do other parts like find an appropriate facility to take a patient if they don't need to be admitted. The other thing that we're doing that's very unique to the Cleveland Clinic is we have partnered with the Center for Geriatric Medicine. I think we may be the only geriatric ED in the country that actually has a geriatrician embedded in the ED. Usually, you're using nurses or advanced practice nurses or case management to screen patients, but we actually have a geriatrician here.

We've also done an interesting thing, so our delirium screening... And then when we have that, we'll actually put in a console for geriatric medicine. That's great here at main campus where I have my geriatric care unit and CDU, and we can put the patients there. But if I put that request in, it actually flows to the inpatient side. So, if I have find some recognized needs, whether it's poly-pharmacy, whether it's, "Hey, this person has had three falls, they're at risk for another fall," we can actually get those patients seen even if they get admitted. So, we're really trying to cover both sides. Right? The ED is the nexus for the outpatient and inpatient world, so how do we hit both of those? We have referral patterns set up for the Center for Geriatric Medicine, their successful aging program, so, we've got hats off to Dr. Hashmi who is doing that and then, obviously Dr. [Saxena 00:24:22] who's my partner here at the geriatric EDs.

Akhil Saklecha, MD:
There's so much to do there. You've talked about education, you've talked about the team importance there and having the enhanced team, you've talked about looking at a bunch of different geriatric issues, transition of care. Are these all processes, or are you using any technology there to augment and make things better, faster, cheaper, and scale it with all the efforts?

Stephen Meldon, MD:
No, that's a great question, too. And that's another unique thing that I think we found, is we know that there are a number of screens you can do in geriatric ED patients. We have helped develop one years ago. But they're manual, they ask questions about function, they ask questions about how many medications you're on, et cetera. What we did that was very unique was we took those issues, cognitive impairment, delirium, age greater than 80, poly-pharmacy, fall history, ED recidivism or visits within six months, and we bundled those into Epic to create, really, a best practice alert that this is a high-risk geriatric patient. So, our alert system actually pulls out of Epic and creates a banner that says, "Hey, this is a high risk geriatric patient. They're 83, they've been here twice with a fall," and that really alerts the providers to say, "Huh, what can we do for transitions of care, for workup, to really help this patient?" So, that's a unique thing as opposed to like a manual screen where a nurse is trying to screen for these high risk geriatric patients.

William Morris, MD:
I mean, this sounds great, but what are the metrics? How do I measure the outcome because, ideally, we want to prevent falls, we want to prevent readmission, we want to keep those patients healthy and safe at home? What are your thoughts on how we trap those metrics, and then how do we leverage those with at-risk contracts, et cetera?

Stephen Meldon, MD:
Yeah. So, that's great, too, because what we decided was doing that manually was probably impossible. Right? 25% of our ED patients are geriatric. That's a lot of visits. So, we actually have a dashboard that we've developed where we look at what's the delirium rate? Right? Here's how many people we screen for delirium. Here's the positive rate. We look at falls through that. So, we look at a lot of things through a dashboard, and then we can start to get a nice glimpse to say, "I think we need to address this with some type of education or another process or another screen or something," once you get that high level view. So, I think the dashboard is really unique.

And I think if you're going to be a geriatric ED level one, which is the highest level, you really need that because we're tracking a lot of things. I'm tracking Foley catheter use, we're tracking restraints, which we don't want to do. Right? Delirium. So, all of that goes into our dashboard. Still working on it. It's a work in progress, like all dashboards. Right? As we get more fast I'll with it. But I think it's been a big, big help for us managing this. And then, knowing that, we can start to look at our processes, whether it's the admission rates or transfer rates, direct to SNF programs, and we can really get, I think, a better handle on that.

Akhil Saklecha, MD:
If I just maybe double click on what you just said, it seems to me that the metrics that you're doing, and while you're tweaking them, they can make a meaningful difference, I think, on the population size of what we're doing, but also individually. Are there any anecdotes or stories that you're aware of on an individual basis where you think the implementation of the geriatric ER made a difference?

Stephen Meldon, MD:
That's great. And actually, we like to share those stories with our staff because I think stories resonate, and I think you're absolutely right on. I mean, yes, we're making a difference on a population base. We've seen that when we look at admission rates out of the GCU. They're significantly lower than just if you're placed in the CDU and did not see the geriatrician. But the individual ones, for example, maybe getting appropriate home health services that keeps the patient out of the hospital. Because really, what's the goal? It's healthy, successful aging. Right? And how can we do that? Avoid unnecessary admissions. Right? We've done a lot of things where we've adjusted medications.

The most recent case I can think of, we had an older patient on two beta blockers because this [inaudible 00:29:13] American medicine causes things like that, and they come in with syncope. What a shock. Right? So, we really changed the medications, put that then in the EMR because that's important to carry that forward so we have a system to do that to do a true medication reconciliation, and get that person back home and really decrease the risk of subsequent falls. Right? So, there's a good example of Dr. Saxena looking through this and going, "Wait a second, this doesn't make any sense." And that's the kind of things I think we need to do.

William Morris, MD:
So, I mean, that's a great example. It's the positive reinforcement of doing the right thing, but that sometimes doesn't always drive behavior, and I'm curious on the stick side. We see HEDIS measures and quality measures that were required in the ambulatory space, do you imagine some of these scores and work being something that actually you would advocate for policy change for public reporting on delirium screening, poly-pharmacy management? What are your thoughts on just not only building a great program, but also driving requirements, public reporting, legislation, if you will, or payment parity around these things to really affect change?

Stephen Meldon, MD:
So, this is the hard question part, right? No, that's a great question. I don't think we're there yet, and here's why. These programs are really still in the infancy. This geriatric accreditation program really started just a couple of years ago. I think as you build out those capabilities, I think then you start to address, "Hey, where else can we do this?" So, for example, I think we already do some of this, right? We look at CAUTIs, catheter-associated urinary tract infections. What's that done? It's driven the decrease in Foley catheter use. We used to throw Foley catheters in everyone. Why? For convenience. That's the wrong answer. Right?

So, I think, yes, it does follow, I think you first recognize it, you get everybody together on the same page saying, "This is an issue," and then I think that this will follow, for example. We know that if we do the right thing for the patient, we're going to have better outcomes, less cost. It's almost kind of organic, isn't it? And you guys know that. And so, I think we're focused on what's the right thing for the patient? Guess what? Admission to the hospital might be the right thing for the patient. Right? But it might not be. So, how do we drive that through teamwork, through case management? And then we will be successful, just like with the ED and SNF program, we were successful in preventing unnecessary hospital admissions just for SNF placement.

William Morris, MD:
Well, it's absolutely a pleasure, Steve. It's clear there's a third C, which is compassion. I mean, your compassion to question the status quo, to address obviously this tsunami of geriatric patients coming, the confusion of navigating the medical system, but all with an eye towards the patient. It's clear, caring and communication is key, but the compassion of you and your colleagues are absolutely are exemplary. So, we thank you, A, for your time today, but more importantly, your service and continued innovation. We would love to also be a partner with you as you see gaps and white spaces that perhaps need to be enabled through other technology or other services. This, to me, is not the end of the chapter, it's the beginning.

Stephen Meldon, MD:
Right.

William Morris, MD:
Joined with us is Dr. Jason Milk, who is the Center Director of the East region, and Jim Mark. Dr. Mark is the center director of our West region. Dr. Milk and Mark, thank you so much for joining myself and Dr. Saklecha.

Jason Milk, MD:
Thank you.

James Mark, MD:
Yeah, thanks for having us.

William Morris, MD:
So, I think that would be great for us to lead off, is my understanding is 80 to 90% of emergency service patient volumes actually occur in the region. Give the audience a little perspective on thoughts on best practice innovation, how do you leverage where the majority of care is rendered, those best practices, and how do you actually feed it back both centrally but also to disseminate it across a group practice?

James Mark, MD:
So, we've split up ESI, or the way things have been managed in ESI, over the last two or three years, and we used to be a lot more main centric, so to speak, a lot more of the leadership. And now, Jason and I are each set up in the region. And as you said, 80, 90% of the patients are seen out there, that's where the majority of the providers are. And so, we really work a lot with our regional teams. I would say that we get a lot of our ideas, a lot of our information from there. We're really big within ESI on standardization, trying to make it the same at every site.

So, we're pulling all of those ideas, we bring them back together, try to create a standard approach to any of those ideas. And we can give you examples. I think we're going to talk about COVID coming up here, how we did that with that. And then we set it up and rolled it out both in that main campus and then to all the regional sites. So, it's just getting more of a voice, more of a recognition of a lot of the really bright providers that are out in the region and have a lot of ideas to share.

Jason Milk, MD:
We think the structure with which he assigned has designed itself at this point in time lends it to be a little more regional centric. Both Jim and I spent a lot of time coordinating together to hear the voice of the region. Again, the majority of the patients seen are there. It's very intentional that we meet with our directors at least twice a month to make sure that we understand the needs that are there. And if there's an issue at Avon, I guarantee it's not dissimilar at Euclid. And putting those things together, I think a lot of our regional colleagues feel like the voice is heard. Again, I think there's a lot of times that trickles back towards main campus, and then we need to adapt it across the region. But the voice and the structure is certainly present for them to get their vision out there.

Akhil Saklecha, MD:
So, it's actually a good segue into maybe a specific topic, and Jim mentioned COVID, and I think this whole play of understanding how a central system works, how the spoke system works, especially as information and patients have to roll back and forth. If we go back about a year ago when we were starting to prepare and realize that things are going to come in a painful way towards our patients and system, how did the ESI react both in the regions and centrally?

Jason Milk, MD:
So, I think initially, when COVID occurred, ironically, we were in a system-wide meeting with ED leadership at the time, and we pulled ourselves out and began just structuring what our response would need to be at that given moment with the information that we had, and I think, at that time, I think most of us were really unprepared or unaware of the scope and the magnitude of where this was going to go. I think the smartest thing that we did was create a cadence of meetings that were daily, and it was really for a message in dissemination of information. From those meetings, we began to put out daily reports to all of our teams, both as a way to receive information, but as a way to put information out. And it almost became akin to like an old newspaper. Right?

So, we had a heading, we had what was important, we had all the things that were necessary to know for the day, and then we huddled around that information at all of our shops every day. And we even had other institutes asking to get our information because it seemed like we were passing information along at such a speed that we really had our finger on the pulse on what was most current and what was most necessary to understand at the time. So, I think, initially, it was really about getting the right information together, getting the right pieces into play, and then really aligning that in a way that we could communicate it to our teams so they felt safe and they felt understood when they were on shift.

William Morris, MD:
And can you give an example of communication and awareness, especially as things evolve, best practices that emerged and local innovation? And then give maybe [inaudible 00:38:43] example of how that was disseminated, distributed, and deployed, so to speak.

James Mark, MD:
Sure. So, early on in COVID, there's a million things out there. Right? Like it was hydroxychloroquine was going to be something that might work or any number of things. Right? And there was so much out there that maybe would work or what's the best masking or how are we going to handle steroids or what meds should we be given? There's just a lot of questions. Right? And so, I think one of the things we did, Jason andI set up a team of docs for the region and for ESI, actually. We had folks on it from a couple of the different hospital sites and then in the region and main campus, got those group of five or six docs together, and we started digging into what was out there, what literature was there, what information was out there, and started getting a list of best practices for COVID. Right?

And then we would add that to... As Jason said, we were communicating daily. Right? We would start putting that out. And then we started putting out a treatment protocol or plan. We came up with a separate protocol, and it actually led to a lot of nice interaction with the other institutes, because then we started reaching out to the Respiratory Institute and it started talking to the ICU docs. And okay, when they come to you, how do you want to see this handled and to the hospitalist and internal medicine teams? Right? And we started building our plan as part of a continuation, or there's as part of a continuation, of our plan, and it made for a nice, seamless thing. And it really made the region feel like... Everyone out there, I think, felt like, "Okay, we really know where we're supposed to be." Everyone was getting a story from London or from somewhere else, "Here's what we should be doing." Right? And so, it distilled a lot of those things and kept it consistent.

But the other neat thing that happened was we started realizing how many bright and engaged people were out there in the region wanting to get involved with that and help. And from that, we had people doing research projects, and we had one guy, had an engineering buddy, and he started working on designing ventilators. We put out a video about PPE and the risk of spread and demystified a lot of the fear and pani that was out there. So, getting a group like that together and then working through it really led to a lot of nice things for us.

Akhil Saklecha, MD:
If we look at where we are now, after all of that work, we start thinking we're coming out of the tunnel, and then we hear more bad news going on, whether it's internationally or other parts of the state, our numbers in Ohio are still... The latest I saw is that our hospitalizations are still running above the 21 day average, so we're not quite out of the woods yet. But yet, people are talking about post-pandemic preparation or how things are going. How do you see where we are now, things that we've learned, and then how do we implement those things to move forward?

Jason Milk, MD:
And you're absolutely right. Most of us are talking about things as like the pandemic's over, but I think as we evolve over time, I think we're realizing that we need to be focusing not only on the current state, but as we look forward into the future, how it's still with us. And we shouldn't become complacent. And a lot of our messaging over the last several months has really been about creating a safe environment, not only for our patients, but for our visitors and also for our staff. Most of our ED still have areas where we cohabitate COVID patients. We have certain rooms that are designed better to have patients in certain areas. We certainly segregate our waiting populations from those that are potentially COVID positive from patients who are maybe not.

And I think as we look forward in the future, we say, "How does this apply to influenza? Why wouldn't we be doing it for that? What other things are there that we should have on our radar, for which we should forever provide some semblance of differentiation for waiting spaces?" And I think as we move forward in the future, this pandemic probably will forever change the way ERs are eventually designed.

Akhil Saklecha, MD:
It's a good point. I think back to some pediatricians offices where they have a waiting room for kids that are sick and those that are well. Right? Keep them apart. You're right, We may have to rethink how things are engineered, both in physical layout and processes. Another question I have is the ER, increasingly is becoming a place of public health, not just for acute care things, but we're seeing patients that oftentimes have no health care ever, and this is the time you're seeing them. And so, some of the discussions I've heard are how can the Emergency Department play a stronger role in things that are traditionally considered primary care? For instance, screening or vaccinations. If someone comes in for an ankle sprain, can we give them a COVID vaccine if they haven't had one yet? Right? I guess how has ESI and the regions thought about things around becoming more active proponents and engaging further on public health initiatives?

James Mark, MD:
I mean, those are interesting ideas, and you're probably right. Right? I think there's some of that that's definitely going to happen where we consolidate some of their care when they come in, as you say, for one thing and we treat them for two or three others. We see that a little bit. We see that starting to happen with programs such as our... If someone comes in for a drug overdose, heroin overdose, something like that, and we're getting them involved and set up with the right agencies who are either coming in or virtually coming in and meeting with the patients and setting them up and we're getting them directly to where they need to go, in the past, we'd weight them, we'd get them to clear clinically, and then you discharge them maybe with referrals. Where, now, we're doing those whole, maybe the whole week, first week of stuff before they even get out of the ER.

And so, I think it's probably more of those types of programs. The key, as you know, is keeping throughput in mind and not letting those types of things derail the process of the ER for what we also, what we specialize in. Right? The sick patients and the patients that we need to keep moving through. It's interesting. I agree. I think that there's going to be some blending of the two.

Jason Milk, MD:
I think as we move forward, I think you're going to see some of those programs pop up. I think the ED is probably hesitant about becoming a source for primary care, so the more we build, the more we may get the things that we don't necessarily think should be coming to the ED. I think probably where we're headed now in the near term is probably more structure around making sure we get them a follow-up appointment in the primary medicine world, because technically we're not trained to do all of those things. Certainly, we could look at smaller buckets like vaccinations or some of those little avenues that are more convenience of care, but as Jim alluded, we are stepping into the opioid arena, we are now for STDs recommended getting HIV screenings.

So, while we have them captured, we want to act on some of this, but we really want to utilize the structure of healthcare as it currently exists, but really try to break down the walls of access for those patients. And if we can do that, then we're at least getting them in the right direction. I think there's more of an emphasis on that today than there's ever been.

William Morris, MD:
Well, I wish to thank you both. I think it's an exciting journey. Yes, the year has been tremendously difficult. I want to acknowledge not only your physician staff, but the amazing nursing staff, physical therapists, the respiratory therapists who are all out in the region, probably thread bare and worn out. But I really appreciate your reflections, but more importantly, your appreciation of the evolution of care and being literally the cutting edge, so to speak, of care. So, Dr. Milk and Dr. Mark, thank you so much for joining us for this podcast. This is Will Morris, with my partner., Akhil Saklecha. Thank you.

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