In the typical emergency room, demand far outpaces the care that workers can provide. Can the E.R. be fixed?
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Well, maybe. Back in the day (1965) when I rotated through the emergency room (called emergency department) the same question arose. Since that time many solutions have been attempted, with varying success.
My choices as a doctor in the emergency room are up or out. Up, for the very sick. I stabilize things that are broken, infected or infarcted, until those patients can be whisked upstairs for their definitive surgeries or stents in the hospital. Out, for everyone else. I stitch up the simple cuts, reassure those with benign viruses, prescribe Tylenol and send home.
Up or out is what the E.R. was designed for. Up or out is what it’s good at. Emergency rooms are meant to have open capacity in case of a major emergency, be it a train crash, a natural disaster or a school shooting, and we are constantly clearing any beds we can in pursuit of this goal.
The problem is, traffic through the emergency room has been growing at twice the rate projected by United States population growth and has been for almost 20 straight years, despite the passage of the Affordable Care Act, and through both economic booms and recessions. Americans visit the E.R. more than 140 million times a year — 43 visits for every 100 Americans — which is more than they visit every other type of doctor’s office in the hospital combined.
The demand is such that new E.R.s are already too small by the time they are built. Emergency rooms respond like overbooked restaurants during a chaotic dinner rush, with doctors pressed to turn stretchers the way waiters hurriedly turn tables. The frantic pace leaves little time for deliberating over the diagnosis or for counseling patients. Up, out.
The underlying problem is a shortage of physicians. Patients after discharge from a hospital may not be able to see a followup physician for two or three weeks, allowing a relapse into what originally brought them to an emergency department.
Private exams on stretchers in hallways, patients languishing without attention for hours, nurses stretched to the breaking point; all of it has become business as usual. I think about this on nights like tonight, when I start my shift inheriting 16 patients in the waiting room. I think about what I will learn that these people need, and about what I will fail to provide.
Should the emergency room treat only emergencies? More than 80 percent of our patients arrive without sirens blazing, by walking in or after parking their cars with the valet out front. A rash that won’t stop itching, a lower back that won’t stop aching, a child who won’t stop vomiting. If their problems aren’t in our manual of emergency conditions, we say they are misusing the E.R. and try to dispense of them as quickly as we can. But here they are, having waited six hours to see me, asking for help. What to do for them?
I click a few perfunctory buttons in their charts. I say there’s nothing life-threatening going on as I hand them boilerplate discharge paperwork to sign. Someone calls me to see my next patient. I send them back to their families, jobs and responsibilities equipped with little more than these unceremonious goodbyes.
Almost one in 10 — 8.2 percent — of these discharged E.R. patients return to an E.R. within three days. What I leave unaddressed — persistent pain, nagging uncertainty about a diagnosis, a social dilemma — tends to stay that way, begetting yet another visit. An E.R.’s success is measured by how fast it sees these patients, not by whether it breaks these cycles.
Although the E.R. was built to quickly get the sick “up” into the hospital, it has exposed, better than anywhere else, what patients lack while “out” in their otherwise private lives. Patients like Cynthia and Jean-Luc will survive devastating diseases under our care “up” in the hospital, but we send them “out” unable to sustain their precarious conditions without us. Patients like Mariah make their needs clear in the E.R., but we are too busy to meet them, and by the time they come back it’s often too late.
Such matters now fall into the category Social Determinants of Health. This category may be the overriding cause of their disease(s). Homelessness, poverty, lack of social services, acute climactic events
These factors often contribute to 8.2% of the return visits to the emergency department of most hospitals.
Financial limitations, lack of social workers limit the services in the emergency department. Insurers, medicare will not reimburse for these services in the emergency department
From 2012 to 2014 the federal government, recognizing that neither up nor out was solving the problem for a growing group of patients, financed an experiment at the University of Colorado. The typical E.R. has surgeons on-call to treat patients with broken bones; following that model, the E.R. in Colorado set up a team on-call for patients with broken homes.
Disadvantaged patients who kept returning to the E.R. were matched to social workers, health coaches and doctors who visited them where they lived and kept in touch for several months. By staying involved after the E.R. visits and not letting details fall through the cracks, the team reduced these patients’ need to revisit the hospital by 30 percent compared with the need of those in a control group.
The E.R. at Yale, where I work, addressed a different group in need. Elderly patients who came to the E.R. after a fall were offered a follow-up at home. There, they were screened for risk factors that might lead to another fall, such as loose rugs, medications that increased their risk of balance problems, or lack of necessary equipment or support at home. Over the next month, those who received such visits called 911 about half as often as similar patients who did not participate in the program.
Programs like these are not considered the E.R.’s core business, so they often rely on grants — and they end if funding dries up. Of the slim resources that E.R.s do set aside to address patients’ barriers outside the hospital, most are put toward hiring social workers and care managers. But these employees, stymied by mountains of paperwork and unrealistic patient loads, never get outside the hospital to see their patients, either.
The programs at Colorado and Yale succeeded by framing the E.R.’s resources differently. They recognized that the E.R. staff could identify problems that were destined to arise after discharge — and empowered those employees to help. Both programs orchestrated follow-ups outside the E.R; those teams worked on the day-to-day problems at home that go unaddressed in hospitals and clinics and can cause catastrophesA Doctor’s Diary: The Overnight Shift in the E.R. - The New York Times:
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