Solutions to Problems That Shouldn’t Exist

YPS President’s Message

by David D. Vega, MD FAAEM

Emergency physicians are masters of adaptation. The variety of challenges we face on a shift-by-shift basis is a driving force for many in choosing emergency medicine as a specialty. Throw us an unusual, complicated case filled with diagnostic challenges, and we’ll be talking about it for days and weeks to come. Put us under the pressure of multiple ambulances bringing sick patients at the same time, and we’ll do what needs to be done to take care of our patients. Those of us who are newer emergency physicians, in particular, seem to enjoy the times when we have to adapt to unusual circumstances to get the job done. We can come up with solutions for almost anything you throw at us. If we can’t get it figured out, then we can certainly get the patient to someone who might be able to.

Nowhere is our adaptability better demonstrated than in our ability to care for patients in the far less than ideal conditions found in the majority of emergency departments (ED) across the country. Utilization of the ED for healthcare continually increases, as do unfunded regulations and mandates from governing bodies, which has helped to create a crisis state where waiting rooms are packed and admitted patients are held in the ED for hours or even days, severely limiting the space and resources available to care for patients. We adapt by just doing the best we can with what we are given.

Unfortunately, though, we are reaching the brink of our ability to adapt to the problem of overcrowding. More and more adverse events are occurring in waiting rooms where patients are spending increasing amounts of time. Patient care suffers as we are forced to see patients in the hallways. To compound matters, our experienced emergency nursing colleagues are leaving the ED for areas of the hospital with better working environments.

These problems have not suddenly appeared, but have gradually developed over the course of the past few decades. The literature includes references to overcrowding from the early 1990s (DP Andrulis et al, Emergency departments and crowding in teaching hospitals. Ann Emerg Med 1991 Sep;20(9):980-6). The slow, insidious nature of these problems, along with our admirable ability and willingness to continually adapt to any situation, has kept our efforts at correcting the real problems meager until recently. Fortunately, EM organizations and governing bodies are now beginning to recognize the critical importance of correcting these problems, instead of just adapting to them. 

In addition, more and more evidence in the literature is demonstrating that the problems that have been previously attributed to emergency department inefficiency and other internal problems actually are more attributable to patient management at other levels in the healthcare system (S Schneider et al, Rochester, New York: a decade of emergency department overcrowding. Acad Emerg Med 2001 Nov;8(11):1022-3). The mismatch of hospital-wide demand and resources, for example, has led to increased boarding of admitted patients in the ED.* This common practice of boarding patients is increasingly being recognized as detrimental to patient care and safety, professional well-being and staff turnover, and also has been shown to have a significant financial impact through lost patient care opportunities (T Falvo et al, The Opportunity Loss of Boarding Admitted Patients in the Emergency Department. Acad Emerg Med 2007 Apr.;14(4):332-337).

Since these problems are not based solely in the emergency department, our efforts at finding solutions should include multi-disciplinary teams looking at entire hospital systems. Focusing efforts solely on the emergency department, such as expanding facility size, is insufficient (JH Han et al, The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med 2007 Apr; 14(4):338-43), while efforts involving outside departments have been shown to be successful (KJ McConnell  et al, Effect of increased ICU capacity on emergency department length of stay and ambulance diversion. Ann Emerg Med 2005 May;45(5):471-8). We must always remember that we are experiencing symptoms of an ill healthcare system and that the problems are not isolated to the emergency department.

The application of information and system engineering technologies shows great promise in providing effective methods of analyzing extremely complex, hospital-wide systems of healthcare. As emergency departments continue to integrate information technology with patient care, we have the opportunity to show concrete numbers that demonstrate the detrimental effects of problems like overcrowding and boarding. These numbers can then be more easily understood by hospital administrators and our colleagues outside of emergency medicine.

I cannot think of a specialty which is faced with more fundamental challenges to basic patient care than emergency medicine. We continue to adapt to the increasing demands which are placed upon us and make the system work somehow. But we must not be complacent with just managing to survive, as we are reaching the brink of our ability to adapt. Each of us must find ways to get involved in making changes to the healthcare system.

As the Young Physicians Section continues to develop, we will continue to focus on providing members with knowledge that will allow each one of us to contribute to the solutions to these problems at the local, regional and national levels. As the newest generation of emergency physicians, we must act individually and collectively to facilitate changes to the current system. Each one of us must dedicate time to learning the issues involved with ED overcrowding and understanding the processes involved. We must be continual advocates for the improvement of these conditions in which providers are forced to deliver less than ideal care. We must get involved with taskforces, sections and groups that are working towards creating change. 

The Young Physicians Section has opportunities for interested members to become involved with projects involving these non-clinical aspects of emergency medicine. If you are interested, please send an e-mail to info@ypsaaem.org. Also, talk to your colleagues who are not members of AAEM and encourage them to join both AAEM and the Young Physicians Section. YPS membership is open to members of AAEM who are in their first seven years of practice after residency. 

*AAEM’s position statement on the boarding of admitted patients is available online at http://www.aaem.org/positionstatements/