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Emergency Room Tension


Emergency Room Tension

Our hospital’s emergency department (ED) seems to be busier than ever. As hospitalists, we are getting a lot of pressure to get patients out of the ED and upstairs as quickly as possible. Often times, we are too busy and not ready to accept these admissions, but they send them anyway. This has created tension between the ED doctors and the hospitalists. Do you have any suggestions on how to remedy this problem?

Lisa Evans, Oklahoma City, Okla.

Dr. Hospitalist responds:

What you are seeing in your hospital’s ED is being played out over and over in numerous EDs throughout the country. A recent Center for Disease Control (CDC) survey of 362 hospital EDs notes there were 119 million visits made to EDs in the United States in 2006, up 32% from 90 million in 1996. This, despite the fact the number of EDs dropped almost 5%, from 4,019 to 3,833. Population growth does not adequately account for this surge in ED visits. The number of visits per 100 people grew from 34.2 to 40.5. Many blame the uninsured for overcrowding the EDs, but that is not entirely supported by this study’s data. The number of uninsured accounted for 17% of visits in 1996 and 18% in 2006. The study authors suggest patients’ inability to get a timely appointment at doctors’ offices is the main reason for the increase in ED visits.

Not surprisingly, the increase in visits has resulted in increased ED wait times. The average wait time to see a doctor in U.S. EDs rose nearly 47%, from 38 minutes in 1997 to 56 minutes in 2006. This is the amount of time patients wait before they see a doctor. The amount of time patients spend in the ED after that often stretches for many more hours. There were other expected findings. Winter and summer had the highest number of ED visits. The early evening, around 7 p.m., was the busiest time for visits.

What does this mean for healthcare policy makers? This is a serious public health issue that demands immediate attention. While not all patients who seek care in EDs have life-threatening conditions, delays in care often means delays for everyone, including those with serious conditions, such as myocardial infarctions and strokes.

What does this mean for hospitalists? I don’t expect the increased ED volume to abate any time soon. Emergency doctors are under pressure, and they will continue to vent their ED by discharging and referring patients for admission as quickly as possible. If they don’t, they will face continued criticism for increased wait times and witness poor outcomes because patients wait too long for care. Nowadays, the amount of time an ED is on diversion is often used as a surrogate marker for ED quality. Some locales no longer allow their EDs to go on diversion. In these communities, the growing volume in the hospital ED waiting room simply spills out of the ED into hospital hallways. The growing number of unmonitored patients is a concern for everyone.

Under such circumstances, you will find it difficult for hospitalists to find a sympathetic ear. Hospital administration and patients, let alone the ED staff, don’t understand why hospitalists can’t come down and admit a patient with a heart attack. They don’t want to hear that the hospitalists have many more patients upstairs. They ask why the hospitalists did not discharge patients sooner in the day. The hospitalist discharge time begins to be blamed as the reason for the backup in the ED. Sound familiar?

Your program runs the risk of developing a negative perception, not only from the ED, but also from the hospital leadership, if your hospitalists are not able to admit patients in a timely manner. I suggest you do your best to turn this problem into an opportunity. The hospital leadership is motivated to resolve this problem.

  • Ask to discuss additional support to increase staffing.
  • Consider realigning your staffing model to increase resources at the busiest times of the day. Most hospital EDs are busiest in the late afternoons and early evenings.
  • Create a hospitalist admissions team whose sole job is admitting patients. Work with outpatient providers to encourage direct admissions from clinic, thereby bypassing the ED altogether.
  • Consider utilizing non-physician providers to assist in patient care, which will allow your physicians to focus on admissions from the ED.
  • Track hospitalist response time for admissions. Share this information with your hospitalists and create incentives to improve performance.
  • Focus efforts to improve communication between hospitalists and the ED staff. Set up routine meetings to address transitions of care.

You can minimize the risk of tension between the hospitalists and the ED staff if both parties have a mutual understanding of each other’s problems and work together to address the differences.

Medicare Expands List of ‘No-Pay’ Conditions

You mentioned in a previous article that Medicare was considering expansion of its no-pay hospital-acquired conditions. Did they decide to add all of the items?

Robert W. Lukens, Braintree, Mass.

Dr. Hospitalist responds:

As you noted, in April 2008 Medicare proposed to expand the list of non-payment hospital-acquired conditions. Medicare initially announced in 2007 it would stop paying to treat certain hospital-acquired complications it believed preventable with good care. After a review of public comments, Medicare has decided to add the following conditions to the list:

1. Deep venous thrombosis (DVT)/ pulmonary embolism (PE);

2. Inpatient glycemic control, including the following:

  • Diabetic ketoacidosis;
  • Diabetic coma;
  • Hypoglycemic coma; and
  • Nonketotic hyperosmolar coma.

3. Surgical site infections after the following surgeries:

  • Total knee replacement;
  • Laparoscopic gastroenterostomy;
  • Laparoscopic gastric bypass; and
  • Ligation/stripping of varicose veins.

Of the three new proposals, the DVT/PE measure is the most controversial. Evidence suggests DVT/PE are not completely preventable. Hospitals will rely on hospitalists to develop systems to minimize this complication. TH

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