Incident 2: Emergency Department Repeat Admissions — A Question of Resource Use

Matt Losinski finished reading an article that provided grim details of a study of the overuse of emergency services in hospitals in central Texas. He smiled that sardonic half smile that meant there was a strong possibility that County General Hospital (CGH) might have the same problem. As chief executive office (CEO), Losinski always saw the problems of other hospitals as potential problems at CGH, a 300–bed, acute care hospital in a mixed urban and suburban service area in the south central United States. CGH was established as a county–owned hospital; however, 10 years ago the county wanted to get out of the hospital business and the assets were donated to a not–for–profit hospital system. The new owner has continued a strong public service orientation, even though CGH no longer receives the tax subsidy it did when it was county owned; it must look to itself for fiscal health.

The study data showed that nine residents of a central Texas community had been seen in emergency departments (EDs) a total of 2,678 times over 6 years. One resident had been seen in an ED 100 times each year for the past 4 years. Given that an ED visit can cost $1,000 or more, the nine residents had consumed $2.7 million in resources. These high users of ED services were middle age, spoke English, and were split between male and female. To Losinski, the problem seemed like a manifestation of Wilfredo Pareto’s classic 80/20 rule.

Losinski forwarded the article on a priority basis to Mary Scott, his chief financial officer (CFO), and asked her to see him after she read it. Scott stopped by Losinski’s office late the next day and began the conversation by asking him why he thought the article was a priority. Scott reminded Losinski that Medicaid paid 75% of costs for eligible ED users and that the cross subsidy from privately insured and self–pay ED admissions covered most of the unpaid additional costs. Losinski had a good working relationship with Scott, but he was a bit annoyed by her rather indifferent response.

Losinksi wanted details on use of the ED at CGH. He asked the administrative resident, Aniysha Patel, to gather data to identify use rates for persons repeatedly admitted to the ED. The findings that Patel gave to Losinski two weeks later were not as extreme as those reported from central Texas; however, they did show that a few persons were repeatedly admitted to the ED and accounted for hundreds of visits in the past year. The clinical details were not immediately available, but a superficial review of the admitting diagnoses suggested that most admissions involved persons with minor, nonspecific medical problems—persons commonly known as the “worried well.” Although Scott was correct that Medicaid covered the majority of costs, the fact remained that over $200,000 each year was not reimbursed to CGH. Were that money available, it could go directly to the bottom line and could be used for enhancements to health initiatives for the community. In addition, repeated admissions to the ED contributed to crowding, treatment delays, and general dissatisfaction for other patients.

Losinski presented the data to his executive committee, which includes all vice presidents, the director of development, and the elected president of the medical staff. The responses ran the gamut from “So what?” to “Wow, this is worse than I imagined.” Losinski was bemused by the disparity of views. He had thought there would have been an almost immediate consensus that this was a problem needing a solution. The financial margins for CGH were already very thin, and the future for higher reimbursement was not bright. A concern echoed by several at the meeting was the requirement of the federal Emergency Medical Treatment and Active Labor Act (EMTALA) that all persons who present at an ED that receives federal reimbursement for services must be treated and stabilized.

Losinski asked his senior management team for recommendations to address the problem of ED overuse.

Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

Competency 1: Apply information literacy and library research skills to obtain scholarly information in the field of health care.
Apply academic peer-reviewed journal articles relevant to an ethical problem or issue as evidence to support an analysis of the case.
Competency 3: Apply ethical principles and academic standards to the study of health care.
Summarize the facts in a case study and use the three components of an ethical decision-making model to analyze an ethical problem or issue and the factors that contributed to it.
Discuss the effectiveness of the communication approaches present in a case study.
Discuss the effectiveness of the approach used by a professional to deal with problems or issues involving ethical practice in a case study.
Apply ethical principles to a possible solution to an ethical problem or issue described in a case study.
Competency 4: Write for a specific audience, in appropriate tone and style, in accordance with Capella’s writing standards.
Write clearly and logically, with correct use of spelling, grammar, punctuation, and mechanics.
Write following APA style for in-text citations, quotes, and references.
Instructions
Note: The requirements outlined below correspond to the grading criteria in the scoring guide. At a minimum, be sure to address each point. In addition, you are encouraged to review the performance-level descriptions for each criterion to see how your work will be assessed.

For this assessment, develop a solution to a specific ethical dilemma faced by a health care professional. In your assessment:

Access the Ethical Case Studies media piece to review the case studies you will be using for this assessment.
Select the case most closely related to your area of interest and use it to complete the assessment.
Note: The case study may not supply all of the information you need. In such cases, you should consider a variety of possibilities and infer potential conclusions. However, please be sure to identify any assumptions or speculations you make.
Include the selected case study in your reference list, using proper APA style and format. Refer to the Evidence and APA section of the Writing Center for guidance.
Summarize the facts in a case study and use the three components of an ethical decision-making model to analyze an ethical problem or issue and the factors that contributed to it.
Identify which case study you selected and briefly summarize the facts surrounding it. Identify the problem or issue that presents an ethical dilemma or challenge and describe that dilemma or challenge.
Identify who is involved or affected by the ethical problem or issue.
Access the Ethical Decision-Making Model media piece and use the three components of the ethical decision-making model (moral awareness, moral judgment, and ethical behavior) to analyze the ethical issues.
Apply the three components outlined in the Ethical Decision-Making Model media.
Analyze the factors that contributed to the ethical problem or issue identified in the case study.
Describe the factors that contributed to the problem or issue and explain how they contributed.
Apply academic peer-reviewed journal articles relevant to an ethical problem or issue as evidence to support an analysis of the case.
In addition to the readings provided, use the Capella library to locate at least one academic peer-reviewed journal article relevant to the problem or issue that you can use to support your analysis of the situation. The How Do I Find Peer-Reviewed Articles? library guide will help you locate appropriate references.
Cite and apply key principles from the journal article as evidence to support your critical thinking and analysis of the ethical problem or issue.
Review the Think Critically About Source Quality resource.
Assess the credibility of the information source.
Assess the relevance of the information source.
Discuss the effectiveness of the communication approaches present in a case study.
Describe how the health care professional in the case study communicated with others.
Assess instances where the professional communicated effectively or ineffectively.
Explain which communication approaches should be used and which ones should be avoided.
Describe the consequences of using effective and non-effective communication approaches.
Discuss the effectiveness of the approach used by a professional to deal with problems or issues involving ethical practice in a case study.
Describe the actions taken in response to the ethical dilemma or issue presented in the case study.
Summarize how well the professional managed professional responsibilities and priorities to resolve the problem or issue in the case.
Discuss the key lessons this case provides for health care professionals.
Apply ethical principles to a possible solution to an ethical problem or issue described in a case study.
Describe the proposed solution.
Discuss how the approach makes this professional more effective or less effective in building relationships across disciplines within his or her organization.
Discuss how likely it is the proposed solution will foster professional collaboration.