AAEM NEWS
COVID Lays Bare an Emergency Medicine Crisis Terrence M. Mulligan, DO MPH FAAEM
Many people who are involved in emergency medicine got into it for the right reasons: wanting to help people, wanting to be able to take care of anyone, anything, anytime, being able to offer assistance when nobody else has been able to in the health care system. However, the emergency department has turned into something else. It has been turned into an overflow pressure valve on a mismanaged hospital system, like on a bathtub. If the hospital is getting full or if it’s too expensive to staff a hospital the way it should be, hospitals turn the emergency department into an extra catchment area. Hospitals should be run at 85% capacity with a lot of room for overage and surges, with a system for calling in extra staff and capabilities when necessary. Instead, hospitals often choose to run on very thin margin: 95% capacity, shutting down wards and wings of the hospital on a weekly or monthly basis because of the cost of staffing. Emergency departments then swell and become overcrowded. One of the characteristics of the emergency department is an open front door. You cannot close the front door and we do not want to close the front door. We want to be open 24/7/365 for anyone, anything, anytime. The problem is, the back door of the ER is often closed, at least partially. Therefore, when people come in, they’re seen by emergency physicians and the emergency professionals and we do our emergency care and we make a decision of whether the patient needs to be admitted or whether they are able to be discharged. We intend to provide definitive care or appropriate care with definitive care to follow such as at referral clinics, et cetera. However, when we make the decision to admit, we often cannot because the hospital is mismanaged or full because of mismanagement. We can’t make proper decisions of proper follow-up. Sending patients to other primary care doctors, specialists, social workers, behavioral health resources, or drug and substance abuse referral agencies is often dysfunctional because those agencies are not staffed well. After their initial acute, episodic treatment, patients come right back to us because of improper admission capability or improper follow up. We really are Jacks-Of-All-Trades, and we are being taken advantage of.
We want to be open 24/7/365 for anyone, anything, anytime.
This is the situation I think that this pandemic has shined a giant spotlight on: the emergency department is taking care of much more than just sick people. The department takes care of hospital problems, staffing problems, hospital management problems, insurance problems, economic problems, social problems, and we’re really the catch all of the health care system. A lot of this contributes to the emergency system being run in the red for too long.
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COMMON SENSE NOVEMBER/DECEMBER 2020
Every now and then, a crisis such as this once in a hundred year viral pandemic comes on. However, the crisis of emergency medicine is not a one in a hundred-year crisis — it is ongoing. This pandemic is just pulling the curtain aside to show the real state of the emergency system: it is running on fumes. People are running to take care of too many patients. I often think of the video of Lucille Ball and Ethel Mertz from the I Love Lucy show, where they are standing at the conveyor belt trying to wrap up chocolate. I think that is a good analogy of us in the emergency department. We do incredible work. We see patient after patient. Fifty one percent of all hospital care in the U.S.A. is delivered in the emergency department, and one third of all the patients who come in the emergency department are sick enough to be admitted. Additionally, between 60-80% of all hospital income comes from emergency department admissions. Therefore, within the hospital, the emergency department is the economic engine, the admissions engine, and the patient safety engine. When we do things right in the emergency department, it makes the whole hospital run better.
This pademic is like a stress test for the whole health care system.
When we run the emergency department well, we diagnose and stabilize patients as much as we can. That makes a hospital run better. We streamline systems hospital by hospital, it makes all the hospitals run better. In turn, the situation on the floor of the hospital becomes a slow simmering boil instead of a rolling boil flowing over the top of the pan. Emergency physicians provide tremendous value to our patients’ safety, and to hospitals’ stability. Despite this, emergency physicians do not own or control the value we create. Our created value has been usurped and taken away from emergency physicians, then dispersed to contact management groups, hospital management groups, insurance companies, and other administrative groups. Each of these parties is taking the value created by emergency physicians, profiting off of it, and sometimes mis-managing it. We are then asked to work harder: to pick up the slack and take care of more and more. Imagine a hospital with an emergency department on the first floor. The patients come in the front door of the hospital: the ER. They don’t go into the hospital correctly and they don’t
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