Many experts and articles exists as to the reason why Emergency Departments deal with overcrowding issues. Many cite the abundance of uninsured flocking to ER’s as their only means to access medical care, some look at the homeless. By far, the most accepted reason is “boarding” patients. Boarding is the holding of admitted patients in the ER due to the hospital not having beds available on the floors. This not only takes up a bed that could be used for another patient presenting to the Emergency Department, it also utilizes ER resources as now the ER staff still has to care for said patient. And what many don’t realize is that care differs, it is more in depth, and more time consuming. So in effect, it can take away time needed to spend on other patients. Rarely does a hospital send floor staff, who are much more used to this type of care, to the ER for care of admitted patients. In the end, the Emergency Department nurses and ancillary staff get overloaded. Furthermore and in response to boarding, many studies have been done to show that if you immediately bring back patients (no matter how simple or serious the complaint) and register them, triage them, and have them seen by the Physician or Mid-Level Practitioner (MLP), you effectively keep that bed open. It works and while operator dependent, I’ve seen it minimize the time it takes for an ER to get overloaded. Not to mention it’s safer to have a patient in serious condition back in the ER, even if on a hallways stretcher than in your waiting room. Regardless, it’s only a matter of time before that ER does get overloaded. Why???
Now, I would never say that boarding is not an issue. It most certainly is. However, likely to the chagrin of my mentor, colleague, and favorite person to debate Alfred Sacchetti, MD, to zone in on just boarding is short sighted and wrong. Wrong in so far as all of the reasons are right. As anyone who knows me, I take issue with any solution to a problem that focuses on one aspect or issue and this is no exception. Most, if not all problems are multi-factoral. So when I say it’s wrong, I mean that concentrating on only boarding to the exclusion of all else is wrong. To fully address this issue, systems must be in place to address all of the factors noted above (and I’m sure others that I haven’t even addressed).
Uninsured / Underinsured / Limited Access To Care
One of the first ways Emergency Departments tried to address the number of patients who come to the ER for simple and/or chronic medical complaints (i.e. common colds, ear infections, sprains, non-emergent cases of hypertension, etc) was to create the “Fast Track”, basically a small section of the ER that sees only simple cases. In short, they rarely work. First, staffing quickly becomes an issue. While they start off well, eventually and quite soon, they become understaffed. Mostly this is due to staff getting pulled to address patient’s and issues in the main part of the ER. Regardless of the reason, whether you take a nurse away, a registrar away, or a tech away, you remove an important piece that keeps the fast track working. Consequently, it gets backed up.
Many ask me, “what about clinics?”. A valid question. In an ideal world, these patients would be utilizing the clinics. However, I have come to find that many clinics do not operate as clinics. Instead of making scheduling conducive to last minute illnesses, many clinics operate by scheduling every time slot each day. I used to think my patients were all being less than honest with me when they told me the clinic would not see them for their illness for 2 weeks until I actually called on one to make the appointment for the patient. Well, in 2 weeks, the patient is either going to be better or dead. Clinics play a role in the issue. If they are indeed a clinic, they should really be a walk in service. Even still, if they want to schedule some patients, there are ways to be available to both appointments and walk ins. For example, they can keep every 4th appointment open for a walk in or schedule only certain times of the day, say morning only and accept walk ins the remainder of the day.
And let me be clear, I’m not putting this all on the clinics or Emergency Departments. There are many patients who willingly do not use medical services properly. Those who never go to the clinic and use the ER when it’s convenient for them to get a refill on a prescription. Patients have a responsibility too. As I have said, it’s multi-factoral. There are always going to be times when the ER may be one’s only option for a simple or chronic condition. That is acceptable. And to chronically, repeatedly, use an ER for medication refills and chronic issues is an inappropriate use of medical services by the patient which they need to be held accountable for.
The intent of this article is not to insinuate that the homeless never get ill or need hospitalization. Nor is it to go into detail about that care. The homeless most certainly do get ill and get the appropriate care when that is the case. That said, there is a still a large contingent of homeless who misuse the ER as a place to sleep for the night. Rarely do they come in saying as much. When they do present to the ER, they come with a complaint of chest pains, shortness of breath, or a psychological complaint such as being suicidal. Some say these patients are “playing the system”. That may very well be true or not. I’m not writing this to debate that point. Regardless, the end result is the same, they have presented with a complaint which under the EMTALA laws requires a medical screening to determine if an emergency exists. To that end, these patients again take up a bed in the ER and wind up getting tests which in many cases are not needed. Tests that increase operating costs.
When I see these patient’s, I try to ascertain if they really are having chest pain, etc. Some are honest and tell me they just need a place to stay for the night. I have no problem getting that person a blanket and letting them stay as opposed to doing tests that may not be necessary. Ideally, I would love to have a way to get them to a shelter for the night. Problem being, by the time they arrive to the ER, the shelters are closed. Again, while part of the responsibility does fall on the patient, in my opinion the way shelters are run are also flawed in themselves.
Urgent Care Clinics
Urgent Care Clinics are a medical model designed to lessen the stress on Emergency Departments by seeing the “fast track” type of patient’s listed above. While somewhat new to our region, they have been around quite some time in the South where they have done well. As they are somewhat new to our area, I would prefer to hold my opinion until they have had time to establish themselves to see if they indeed have an impact or not.
In an ideal world, we would influence patients to properly use the health care system with minimal change to our structure. However, given the scale of the situation, I think this is unrealistic. What we can do is change our structure to guide patients to the appropriate care. Again, this must be a multi-factoral initiative.
When I say Pre-Hosptial Care, I am not talking about Emergency Medical Services (though that could be integrated). I am referring to initiatives to identify those who utilize ER’s repeatedly for chronic issues or have repeated admissions due to frequent exacerbations of chronic illnesses and get them the care they need before they need the ER/Hospital. This has been done with a good deal of success by Dr. Jeffrey Brenner in Camden, NJ who has utilized hospital metrics and data to identify such patients and get them the appropriate medical care (either in office or in their home) for their chronic medical conditions thereby reducing their ER visits and hospitalizations. While the ER and Hospital are great at treating patient’s for acute illnesses, they are not set up to properly ensure long term care and access to care once a patient discharged.
I believe that in the future, Hospitals should look to design/redesign their Emergency Departments and Clinics into an integrated system to better care for acute/life threatening conditions, chronic illnesses, and the homeless patients that arrive at our door. This redesign is not just about procedure but also about location. The design hospitals should follow would have an ER, a clinic, and a homeless shelter side by side. As a patient arrives to the combined unit, they are triaged, and can be directed base on their complaint to either the ER (chest pains, complicated injuries, etc), the clinic (medication refills, common cold symptoms, etc.), or the shelter (homeless needing a place to stay who do not have a medical complaint). As triage is truly an ongoing process, not just an initial assessment, the design leaves open the ability for a patient to move from one area to the other. For example, a patient who is triaged to the clinic for a medication refill can quickly be taken to the ER if they suddenly develop chest pains.
In this design, each department still needs to maintain their normal day to day operations with slight augmentation of procedures. Emergency Departments and their directors still need to address boarding of patients with hospital administration to keep it to a minimum. They may also need to reduce or eliminate their fast track areas. In addition to moving their location, clinics will need to change operations to allow for more walk in patients. In most if not all cases they will gain closer proximity to outpatient radiology and laboratory for their patients. And the shelter would have to adjust to accepting people at later hours.
My recommendations are of opinion and observation. I don’t expect the medical establishment to take my views as evidenced based conclusions and start a complete overhaul of Emergency Departments across the country. And there is logic in my opinion and observation. There is evidence that merely changing one aspect of a problem rarely solves or greatly improves that problem. Actual study, both clinically and economically, is needed. And those studies need to be done. This is all completely achievable. The only road blocks are physicians, staff, and administrators unwilling to explore the possibility of change.