The patient care process begins with registration and, with the advent of the information age, registration has taken on even greater importance than ever. (Figure 6)
The registration personnel are often quite adept at helping to detect ‘who is sick.’ The staffing model utilizes 0.4 – 0.5 registration hours per patient visit. This compares to the 1.7 – 2.1 productive nursing hours per patient visit (hppv).1 Therefore, compared to the nursing equivalent, good registration personnel require 25 – 33% of the time to perform their part of the patient care continuum.
The managed care interface has been exponentially difficult for some patients and providers to navigate successfully. The major manifestations of this are in the difficulty in accessing physicians as well as long appointment waits and testing delays.
The patients have adapted to this scenario by utilizing the emergency department. “If you have to go to the ER, you don’t need an appointment, can get your testing done, can even receive medication there as well and even return transportation.” Some patients will make this decision, suggesting that this one-stop convenience outweighs the detriment of the co-pay for those that have insurance, and has minimal impact for those that don’t.
Often times the ED staff can assist with scheduling the desired testing as outpatient procedures, thus avoiding admission or further unnecessary delay. The first appointment for “next-day testing” is often helpful, assuming this slot is reserved for ED patients.
It is problematic when retrospective certification requirements are instituted after patients present for care. These “pre-certification” requirements are often work-intensive administrative impediments that are established to ration the provision of select care. This arduous administrative burden often shifts to the often-overworked ED staff; the procedures are often associated with psychiatric issues or drug and alcohol use care, both of which are routinely rationed by the healthcare insurance providers. Since this information is best provided by the primary care physician or clinic, the difficulty often leads to a transition of this task to the emergency department staff.
Figure 6. Emergency Department Patient Processing Plan
To help speed patient disposition, a multidisciplinary approach to this dilemma can be helpful. Registration personnel can often contact case management or social service departments for “pre-certification” assistance early in the process of select cases. Likewise, the use of a psychiatric liaison could help to facilitate placement for mental healthcare.
Most facilities have some manner of registration impediment or “paperwork” bottleneck. Therefore, conversion to an integrated electronic registration system is essential to proper functioning. A bedside registration program should be initiated from the inception or when the ED is 50 – 75% occupied depending on the facility (Figure 7).
A novel approach analogous to the “Call-Ahead Seating” process can be attempted to help alleviate this difficulty. Here, the patients would register themselves at a secure web-based hospital registration site. There are two benefits offered by this novel registration process, where the patient receives an appointment time for select routine care issues. This alleviates ED overcrowding issue, while still offering a customer service solution to the “minor emergency” problem.
It is inherently obvious, however, that an integrated patient registration process is instrumental to the department’s success.
Figure 7. Bedside Registration Protocol
1. “Benchmarking in Emergency Services.” ACEP Management Course Manual 1994: 7
3. Emergency Consultants Inc.© Vukmir, R., O’Rourke, I. QualChart Information Systems Patient Management Program. Traverse City, MI. Revision 4.04; 2005 – 2006.