Rick's Rant: The Moral Problem of ED Crowding

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

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Ian L. -

Which are so of the better Emergency Departments and how was their staffing and room quality ?

W. Richard B. -

You're asking a pretty specific question. I can tell you that my opinion is based on tons of conversations over the years with EPs at our courses. Can I tell you the name of specific EDs that are exemplary and what their staffing and bed capacity is -- no -- I never got that detail and honestly, my goal is to stimulate those who work in nasty EDs to understand who can make the better -- the CEO and the Chief of Staff. I have been listening to stories about ED crowding for decades -- it never changes -- the norm now is that many (most) EDs are just too busy -- but there are fixes that can make your ED much better and that making EDs better is not only good for patients, it is good for doctors and nurses and techs and everybody who works day-to-day in these departments.

Frederick S. -

Dr. Bukata,

What do you feel the role is, and plausibility, of educating the public of what constitutes the necessity of an ED visit? For example, in your discussion you mentioned the pt that will "still get a $1200 bill for sore throat". As physicians, we obviously know the majority of sore throats do not require an ED evaluation, or even often a physician at all, but often, and from some of the literature I have read, many patients have a "if I am sick I need to see a doctor" mentality.

Obviously we do not want to dissuade patients from seeking medical care, but in my limited experience I feel the overcrowding I see in the ED where I work is mostly due to the volume of pts coming in to the department, and not an issue with inefficiency or lack of resources. We often have 30-40 "boarders" in our department, and the same numbers in the waiting with literally no physical space to see patients.

We have a unique advantage of our CEO also being an EM trained physician, who still does clinical shifts in our ED. Pt flow and wait times are certainly on his mind, and our hospital has taken steps to do the best possible for our patients, but with the example given above, I am not sure what could remedy the volume of pts coming into the ED (without discussing the need for more primary care docs, which goes down the rabbit hole of less physicians going into primary care due to cost of medical school and student loan debt, which I fee plays a crucial role in overcrowding as well

What do you feel can be done to address situations discussed above? Thank you for your "rants", I enjoy listening to them very much and certainly appreciate your willingness to discuss issues with us.

W. Richard B. -

Thanks so much for your thoughtful comments. Regarding educating the public, seems that would be a long-term investment. Perhaps high schools could have a semester of health-oriented subjects. But if it were to occur, and if it were to work, the ROI would be way down the road -- but I definitely think it would be worth it. Regarding a shorter term fix, how about the ability to do a quick EMTALA exam (MD or APC) and then refer to a fast track operated by a physician with some APCs -- or just some APCs with the ability to consult a physician. They could handle the large number of minor cases -- but you would need a physician who was confident in his/her judgment and not be a test orderer (f there are any left). A mid-track could see the next level of cases (asthma exacerbation) and final the track would be for the patients likely to need admission. Regarding the admits being held in the ED, the hospital needs to have a program that manages LOS, facilitates discharges by noon (usually by having hospitalists) and the CEOs bonus needs to be tied to key ED metrics related to holding of admitted patients. Ideally, thee hospital would not be a teaching hospital where myriad consults are called -- in community EM consults in the ED are rare. The EPs make the call and talk with an admitting doctor -- period. So, a fast track, a midtrack and a potentially admitted track with APCs working with physicians, scribes, lots of techs and a reasonable number of nurses and a program that considers the eventual disposition of a patient when admitted and which has incentives to generate short LOS and discharges between 10am to 2pm. Obviously, to support this plan you need a hospital that has a volume of patients to support this organizational scheme and leadership at the top that is highly incentivized to make the ED exemplary. And thanks so much for writing.

peter e. -

Dr Bukata
thank you for this "rant". The timing of this could not have been better, as I had just had a long discussion with a colleague about this very topic and its impact on our wellness, morale, throughput and quality. As Emergentologists, we continue to do what we do best- forge ahead, don't complain, take the floggings, do the best we can, and hope for change. As front line docs, we often feel helpless to enact change on a systemic level. Even when I was medical director for the department, I quickly learned that our goals was not the same as those of the hospital, and no amount of data or impassioned pleas was going to change that. We are seeing more patients per year, while boarding more hospitalized patients and doing that abdominal exam in the hallway has become our norm. It is demoralizing and frustrating, to say the least.
You hit the nail on the head when you said that the ONLY way to get real change is to convince the hospital CEOs to own the problem. And the ONLY way for that to happen is when $$ is tied to solving the solution (as carrot and/or stick). So CMS or the Joint Commission needs to own this problem. An individual doc while be unlikely to convince them of this. However, having ACEP, AAEM or other groups of ED MDs pushing for this might be more effective. Do you know if this is something that is being approached by them? A strong position statement from them, with thousands of signatures, might have more weight than individual calls.
Thanks for writing this and allowing the discussion on this.

Peter Emblad, MD FACEP FAAEM
San Francisco, CA

W. Richard B. -

It's easy to grasp your frustration -- and thousands of your colleagues are equally frustrated. At nonprofit hospitals, although technically the Board of Directors runs the hospital, in fact, the CEO runs the hospital. The CEO controls the info that the BOD gets so it would be very unusual for a BOD to tell the CEO to fix the ED unless there were lots of patient complaints. In the for-profit setting the administration does what it wants. So, I agree with you -- somebody who pays lots of the bills (CMS) or controls the hospital's ability to see Medicare patients (the JC) are the only two institutions that can precipitate the changes needed in the ED. It took decades for CMS to be interested in the door to provider time and door to discharge times -- but what about door to admission times and hold times. The Brits and Aussies developed the 4-hour rule -- in or out in four hours. And sure, it was by no means perfect and there were likely ways to game the system -- but at least the government acknowledged the problem and made an effort to fix it -- there is NO effort on the part of CMS or the JC to address this ubiquitous problem -- holding admitted patients. So I agree -- our trade organization, ACEP, and its BOD need to spend money to aggressively lobby these organizations to set some reasonable standards -- and you can bet that the American Hospital Association will oppose ACEP's efforts. There are 40,000 ACEP members. Aside from fixing the "surprise" medical billing issue -- which appears around the corner (where Envision and TeamHealth have spent $28+ million to influence the outcome in favor of emergency physicians vs commercial payors [NY Times, 9/13/19]), ACEP needs to push CMS and the JC big time. They are our only hope. Otherwise, I see business as usual for the foreseeable future -- and emergency clinicians having prematurely short careers.

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