How to Stop a “Twindemic” from Overcrowding Your Emergency Department

Is it the flu, COVID-19 or a combination of both that’s contributing to the looming threat of busier than usual hospitals? Here’s how to use data to prevent an overcrowded emergency department.

People already refer to it by many hair-raising nicknames. “Double Threat,” “Double Whammy,” “Double Trouble,” “Duel Infections” and “Twindemic” are a few that come to mind.

The “it” in question is the convergence of the COVID-19 pandemic and this year’s flu season. Where they might converge is in your hospital emergency department (ED).

The official Oct. 1 start to flu season is here and the time to immunize your emergency department from the Twindemic is now, and the most readily available vaccine is data.

Let’s look at some numbers, then do a little scenario planning. I’ll also suggest how you can use data and analytics to successfully manage your ED capacity and patient throughput to help prevent patients with COVID-19, the flu or both from overwhelming your hospital.

COVID-19 and flu by the numbers

The Centers for Disease Control and Prevention estimated that as many as 56 million people in the U.S. got the flu last season, which ran from Oct. 1, 2019, through April 4, 2020. That, according to the CDC, resulted in:

• 26 million medical visits to doctors and other providers
• As many as 740,000 inpatient hospitalizations

Meanwhile, the CDC reported more than 6.3 million confirmed cases of COVID-19 in the U.S. between Jan. 21 and Sept. 10, 2020. Also:

• Nearly 2 million people went to the ED with COVID-19-like symptoms between Sept. 29, 2019, and June 27, 2020, according to 3,608 hospitals that reported data as of July 2 to the CDC.
• Hospitals were treating about 40,000 people for COVID-19 as of Sept. 9, according to the latest data from the U.S. Department of Health & Human Services (HHS).

Yet, hospitals’ overall emergency department volume is dropping because of COVID-19, people are avoiding going to the ED out of fear of contracting the deadly virus. That’s the takeaway from a study published Aug. 2 in JAMA Internal Medicine. Researchers looked at changes in ED visits from Jan. 1 through April 30 at 24 EDs operated by five different health systems in five different states. They found that:

• ED visits dropped 41.5% to 63.5% in that time, depending on the state.
• But admissions from EDs increased 22% to 149%, depending on the state.

What could go wrong in your emergency department?

No one knows exactly what’s going to happen in your ED when COVID-19 and the flu virus begin affecting the country together. The fact they have similar symptoms will only exacerbate the situation.

Let’s look at some potential scenarios:

• Your ED is overrun with patients who think they have COVID-19 but really have the flu
• Your ED is overrun with patients who think they have the flu but really have COVID-19
• Your ED is overrun with some patients who have the flu and others who have COVID-19
• Your ED is overrun with patients who have both the flu and COVID-19
• None of the four scenarios above affect your ED, because patients aren’t coming in for other needs and you have plenty of capacity

Your challenge will be preparing for any of the above scenarios, because any of them could affect your historic emergency capacity and patient throughput numbers, not to mention the strain on your operating costs.

Data may be the best “vaccine”

We all know that the best strategy against the flu is prevention. We should get flu shots, cover our noses and mouths when we sneeze and cough, and we should wash our hands. The best strategy against COVID-19 is more or less the same: Until there’s a vaccine, we should wear masks, maintain social distancing and wash our hands.

It should come as no surprise that when it comes to keeping flu and COVID-19 patients from affecting your hospital’s emergency department throughput the best strategy is also prevention. That prevention starts with data and analytics.

There are a lot of metrics that track ED throughput. Medisolv’s Rapid analytics software includes 17 of key time point indicators. The five most important metrics that all hospital EDs should track are:

• Arrival Time to Triage (how long it takes to triage a patient after they arrive at your ED)
• Triage to ED In-Room (how long it takes to put a patient in an ED bed after triage)
• ED In-Room to Seen (how long it takes before a clinician sees a patient in their ED bed)
• Seen to Decision (how long it takes to decide to discharge or admit a patient after a clinician sees them in their ED bed)
• Decision to Depart or Admit (how long it takes to discharge or admit a patient after a clinician makes that decision)

Look at your data over the past year (especially during the last flu season) to see where your bottlenecks are in moving your emergency patients in, out or up. The three most common bottlenecks are: Triage to ED In-Room, because your ED beds are full; Seen to Decision, because you’re waiting on test results or to make a diagnosis; and moving patient to the floor after the Decision to Admit, because all your inpatient beds are full.

Drilling down for answers and solutions

Armed with answers from that data, you can start drilling down to figure out what’s causing delays. Is it a particular inpatient unit that never has any beds open? Is it a specific admitting physician? Are you always waiting on a particular diagnostic test?

Conversely, which inpatient units always have a bed available for your ED patient? You can share whatever they’re doing right as best practices with other units. It’s the same with the admitting physicians. What best practices can high performers share with other admitting physicians?

The convergence of COVID-19 and the flu in your emergency department will put stress on all of those throughput metrics, and the time to start looking at your data to make preventive changes in your structures and processes is now, before both COVID-19 and the flu are knocking at your emergency department’s door.

For example, what if you’re going to need more inpatient or ICU beds because you’re expecting to admit more COVID-19 patients if there’s a second wave of the pandemic? That will inflate your Decision to Admit time unless you start rethinking your admission processes now.

If you’re not doing discharges 24/7 now, you should. You may also want to deploy hospitalists to handle all inpatient discharges, rather than waiting on other physicians. Or you may want to have all your discharge paperwork done a day before an expected discharge, so when it does happen, there aren’t any avoidable delays. Be certain to utilize your hospital information system (HIS) to communicate discharges and potential discharges throughout the hospital.

For more ideas on how to improve your ED throughput, read these other blog posts:

• Strategies for Improving ED Throughput 
• The Problem Facing Emergency Departments: Improving ED Throughput 

Whatever strategies and tactics you plan on using to immunize your emergency department against the Twindemic, it all starts with data. It’s the best preventive medicine.    

Medisolv would like to thank Danika Davis, Director of Emergency Services at Granville Medical Center and Melissa Doehrmann, CNO at MercyOne Newton Medical Center whose insights helped shape this blog article.