5.1 VOLUME! VOLUME! VOLUME!
Fully developed ECs are delivering well in excess of 30,000 bed days per year. Some are heading towards or have beaten the 40,000 mark.
The casemix is high value with Cardiology and Orthopaedics prominent features.
The strong Medical mix (>50%) whilst not high revenue keeps the occupancy up especially over weekends and prevents troughs e.g. during surgeon conferences. The medical mix helps attract general physicians who are now rare but absolutely essential to run a safe and decent surgical facility. Surgeons need and want a large variety of physicians to assist with perioperative care and complications.
If run well, the word of mouth effect of attracting patients is extremely strong.
VMOs are attracted to a good facility with a good reputation. The packaging service we provide makes their practice much more enjoyable and less stressful. Their need to attend the hospital at night actually reduces in most instances. They start to congregate around the centre and start asking for rooms. At St Vincent’s Toowoomba, multiple suites at the hospital were filled by high quality specialists BEFORE we opened the private EC. The specialists were aware of the potential of the centre and moved in ready for opening.
We have to say that some nursing and support staff do not enjoy the disruption that an EC brings. The unpredictable nature of the emergency workload has a high tendency to disrupt schedules and organisational structures. It is also culture changing because there is no routine and significant variation from day to day.
Historically, many doctors and nurses, having trained in good quality public units initially won’t make the shift into private emergency medicine because of fears of inconsistent work and perceptions of a “non-interesting” casemix. However, in time, the credibility of the unit is established and they will be attracted to work in it. This further enhances the credibility of the unit, attracting more visiting specialist support.
This also helps expand the casemix. In several sites large numbers of VMO’s have completely ceased their public hospital commitments because of the volume and work variety provided by a complex hospital with a good emergency centre.
The financial strain is very high in the early period and the hospital must be able to carry it. We aim to get to a critical volume as soon as possible.
When the centre breaks through what we call critical mass several effects are created
- Constant Volume
- Fluctuation reductions
- Top up in key areas ICU /Theatre
- Feeder to Radiology /Pathology (if you own them or have an incentive contract)
All these add up to a “marginal business conversion effect”
Since the costs pressure has been applied by the health funds, the margins made during busy times are now much less. While they used to cover the losses during quiet times, this is now much less likely to occur. An EC has a smoothing effect so that during quiet times wards can be kept open (20 to 30 acute admissions on the weekend is common).
Losses of running an emergency centre, can be more than compensated by the conversion of $10 to $20 million of extra business coming through the EC doors.
Some hospitals have made less money since opening an EC because of lack of control of ward costs.
We have a table of possible volumes consistent with a medium style launch.
Table 1a. Actual figures from Two EC department during the first 4 years.
The approximate casemix of this activity is shown in Table 2.
Table 2. Casemix
Impact on hospital services
This shows the seasonal swing common to all EC’s.
The impact of the emergency centre’s increased admissions during winter will need further careful evaluation and planning once a decision to proceed with an EC is made. Bed pressure and access block become fundamental bread-and-butter issues for the EC, its patients, stress levels of its doctors and nurses, as well as for those specialists who will face difficulty admitting their own patients during these times. The hospitals will be required to confront hard choices in resolving some of these conflicting demands.
Impact by day
Distribution of emergency centre admissions also varies by day.
Weekends are a time of significant activity within an emergency department and admission numbers are higher than during the week. This is a very valuable aspect of the EC profile as these admissions will have a higher marginal conversion rate than at any other time. A hospital’s costs have been largely covered by its elective workload, therefore the additional costs of handling emergency admissions including on the weekend are less.
On the other hand, emergency centre weekend activity will not completely smooth out the weekend drop off in activity even if it significantly ameliorates it.