The Effectiveness of Holistic Care Unit by Using Rate of Patients Revisiting Emergency Department within 3 Days in Taiwan

Author(s) Meng-Chieh Wu1, Li-Sheng Chang2, Hsin-Kai Huang3, Tzu-Chieh Weng 4, Chun-Cheng Zhang 5, Kao-Chang Lin6.
Affiliation(s) 1Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan, 2Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan, 3Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan, 4Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan, 5Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan, 6Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan.
Country - ies of focus Taiwan
Relevant to the conference tracks Clinical Practice and Hospitals
Summary Owing to the convenience of health insurance, the numbers of community hospitals has declined in past 20 years in Taiwan. Many patients directly visited medical centers for aid and waited for admission through the gate of emergency department. Overcrowding situations affecting the quality of care at Emergency Departments is an important issue in the Taiwan medical system. The overloading pressure induced the shortage of emergency physicians and nurses. A new department, holistic care unit, was established in Chi-Mei Medical Center in Taiwan in August 2012, to bridge ER and wards in order to provide the continuum of patients care and safety. To our knowledge, it is the first approach in Taiwan.
Background The word 'holistic health' was defined in PubMed database as follows: “Health as viewed from the perspective that humans and other organisms function as complete, integrated unit rather than as aggregate of separate parts”. The definition of a holistic view was that all aspects of people's psychological, physical and social needs be taken into account and seen as a whole. The term is sometimes confused with alternative medicine. Owing to the convenience of health insurance, the numbers of community hospitals has declined in past 20 years in Taiwan. Many patients directly visited medical centers for assistance and waited for admission at emergency departments (ER). In the ER the waiting time was prolonged and more difficult for patients to have beds available. It also influenced the effectiveness of medical treatment. A new department, holistic care unit (HCU), was established in Chi-Mei Medical Center in Taiwan since August 2012, to bridge the gap between ER and wards in order to provide the continuum of patients care and safety.
Objectives Overcrowding situations affect the quality of care at Emergency Departments and is an important issue in  the Taiwan medical system. Many health care workers, including physicians and nurses, are under a lot of working pressure. Many health care workers have retired from emergency department and critical medicine. The shortage of physicians in emergency medicine has significantly decreased the quality of health care. Accordingly, holistic care units were established to improve the quality of medical care. To realize the effectiveness of Holistic Care Units, we evaluated the waiting time for hospitalization and revisits to the Emergency department within 3 days after discharge.
Methodology This Holistic Care Unit was set up close to the Emergency Department to reduce the workload of emergency physicians who were responsible for patients waiting for admission. This newly created unit was composed of seven experienced medical attending staff who would to take care of patients in 8 hours rotations in collaboration with emergency physicians, radiologists, nurses, social workers and cases manager who constituted the team. This team had similar three domains of responsibility: education and training programs, living together in same place, and sharing the medical devices and resources. Each morning there were meetings focused around subspecialties to discuss the constellations with the exception of difficult or surgical cases which ere referred. The case manager followed the condition of post-discharge patients from Holistic Care Unit in order to assure smooth and regular compliance in the transition home without the need for readmittance into the wards. The case manager tracked patients of Holistic Care Unit from January 2013. We used the waiting time period and the rate of revisits to the Emergency Department within 3 days in a proper statistics evaluation of the effectiveness of Holistic Care Unit in our hospital.
Results From February to July 2012 and August to January 2013, before and after the establish of Holistic Care Unit, the rate of waiting period for more than 24 hours for admission at ER declined from 8.55% to 5.4% and from 2.71% to 1.27% for more than 48 hours. The overcrowding conditions at Emergency Departments were largely improved after the establishment of the Holistic Care Unit. The numbers of patients treated at the Emergency Department was 86712 persons from January 2013 to August 2013. The rate of patients revisiting emergency department within 3 days was 3.6% from January 2013 to August 2013. The rate included the patients of Holistic Care Unit. The rate of revisiting Emergency Department within 3 days was 6.1 % among the patients who were discharged from the Holistic Care Unit. The rate of revisiting the Emergency Department within 3 days was 3.2% after eliminating the patients who were discharged against medical advice (DAMA).
Conclusion Overcrowding situations affect the quality of care at Emergency Department and is an important issue in Taiwan medical system. The overloading pressure and the fear of liability has created a shortage of emergency physicians and nurses. A new department, Holistic Care Unit, was established to improve the overcrowding situation and our preliminary results indicate that it has worked effectively. The rate of revisiting emergency department within 3 days is lower if physicians from the Holistic Care Unit suggested early discharge from hospital. However, the overcrowding situation still influences the quality of care. If patients were discharged against medical advice of physicians from the Holistic Care Unit, the rate of revisits to the Emergency Department within 3 days is higher. The major reason for discharges against medical advice is the unavailability of beds and long waiting times for wards. More attention needs to be paid to the long waiting time to admit patients. To our knowledge, this project was the first approach in Taiwan to establish a new department nearby Emergency Department to intervene in the earlier take over patients who waited for admission for advanced and continued care. Beyond above benefits, the mutual interaction bridging Holistic Care Unit and Emergency Department will also cultivate an interdisciplinary teamwork that can achieve the same goals of patients care, education, quality and safety outcomes.

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