ER Overcrowding: View from the Outside

I guess they just got their journals, but this week both DB’s Medical Rants and Notes from Dr. RW have decided to denounce the Institute of Medicines’ recommendations to help ease ED overcrowding, specifically the IOM’s recommendation (poorly worded, IMHO) to “…achieve this goal by adopting operations-management techniques and related strategies to enhance efficiency and improve patient flow.”  Kevin, MD calls this an “asinine tactic”.

Essentially, they don’t think this is a workable solution to easing ED overcrowding.  Dr. RW doesn’t actually give a solution, but DB does:

The solutions are all economic. We need better access for health care outside of ERs. We can only get that if we fund primary care better and subspecialties less well. We need to recognize the importance and difficulty of delivering excellent primary care.

The lack of adequate reimbursement for primary care (relative to subspecialties) leads to serious externalities on our system. But then, do we really have a system?

Uh, huh.  No, we don’t have a system, we can agree there. 

A few things.  First, people who are being admitted to the hospital cannot be cared for in the internists’ office.  If they could, we’d gladly send them there.  I know how the argument goes: if we could just get more people funded for primary care, they wouldn’t get sick as often, and admissions would go down.  Sounds great, but I sincerely doubt it works that way with an aging population.  Most of the ill patients I admit have seen internists, are taking their 3-20 medicines, and still need to come into the hospital.  Add in the monkey-with-a-gun and fear of missing anything, and patients will be admitted.

Second, what’s so magic about the ED?  Only the ED and OB have rubber walls and are infinitely flexible, to try our best to care for every patient ho needs our help.  Except, see, our walls really aren’t made of magic rubber, we can’t just snap our fingers and make more rooms, beds, monitors or nurses appear.  Every patient who should be admitted to the hospital but isn’t is a) not getting the specialized nursing care available on the ward where they belong and b) is taking up a bed in the ED we need to see then next 1-12 patients.  The linked commenters in the first paragraph give a ‘suck-it-up ED’ subtext that rankles.  We’re doing that.

To make things worse, our county drank the potion and decided none of the ED’s would go on diversion for medical cases unless an internal disaster was invoked (and it’s not easy: it involves waking the VP’s, etc).  What that means from an operational standpoint is a never-ceasing tide of patients, and now permanently occupied hallway beds, and since we don’t have that many rooms, we have a lot of hallway beds.  Sick people in hallway beds, because we don’t have enough room, or rooms.

Lastly, I know that ‘hallway protocols’ to put admitted patients into ward hallway beds work.  We started it at our joint last year (about the time we stopped ambulance diversion), and we found some amazing things (predicted by the consultants from places that had done it before us): tell a ward they’re getting a hall patient, and magically a bed opens up on their ward, someone already dismissed but the bed status hadn’t changed.  When there really are no rooms on the ward, each ward gets exactly one hallway patient.  You only need to move hallway patients to about 10 wards and it has a tremendous positive impact on our flow in the ED, and from the feedback the extra workload isn’t that great on the nurses upstairs.  (There are very strict criteria for hallway patients: no ICU, not too sick, etc).

So, fellows, while it’s just a temporizing measure, the IOM recommendation works, for now.  I expect the numbers of patients requiring admission to go up, not down.  We all await your workable solution to today’s problem.