This week on Perspectives, we're counting down our most popular posts of 2013. Improving patient flow — in the emergency room and throughout the hospital — was certainly on many of our minds this year. So it's no surprise that this piece by veteran hospital administrator Michael L. Harrington racked up over 4,800 clicks. Reposted for your enjoyment … Perspectives' #3 post of 2013.
Over the years of working in healthcare and having direct encounters with large and small emergency departments (EDs), I have heard the relationship between the ED and inpatient service described in lots of ways, sometimes even with expletives. However, I think the phrase "the inpatient sneezes and the ED gets pneumonia" best paints the picture of this relationship.
I'm sure each of us may have a different phrase or description, but what is important is the existing relationship and the work that is needed to improve patient flow between these departments. Paying attention to this concept of flow is a much better focus than saying we have to fix the ED, because in fact it can be factors outside of the ED that can influence its function the most.
The labored breathing and fatigue suffered by the ED these days are not problems endogenous to the ED itself — they are caused by exogenous factors. The clogged passages are caused by large increases in community demand for ED services. Similarly, even small changes in inpatient strategy back up into the ED and cause congestion. While the ED does need to heal from within to handle these challenges, it is important that we recognize and neutralize the actual sources of the infection.
While hospital admission rates from the community have declined over ten years, admissions from the ED have made up for the loss of direct admissions from community physicians. The ED is now the source of almost half of all admissions to the inpatient floors. In some hospitals, the ED accounts for over seventy percent of admissions! This means that the ED is examining, testing and triaging many more patients than they have in the past.
There are three factors outside of the ED that help to explain why this is occurring. First, the cultural differences between inpatient service and the ED are like the differences between a mule in harness and a race horse. Each serves its purpose well, but trying to get them to work together can be troublesome. The inpatient service is about bed placement and treatment. The ED is about triage, stabilization and rushing to move to the next patient in the queue. While the inpatient units have occupancy limits, the ED door is always open. The flow of patients into the ED is often unpredictable. All of this causes suffering in the ED — suffering in the form of inpatient holds, delays for diagnostics and time wasted on the phone. These factors make it difficult for the ED to turn over the beds. To alleviate this suffering, the two separate cultures need to join into a new culture of flow between departments as embodied by the concept of the Acute Care Continuum. How can this be done? Places to start would be sharing metrics between the inpatient and ED services and structuring systems to facilitate system patient flow. For example, patients can be discharged from inpatient units earlier in the day to make room for admissions from the ED at peak times.
Another factor contributing to the ED's pneumonia is the lack of mental health services. Any ED, no matter its size, has to hold patients with psychiatric diagnoses until they can be placed in appropriate mental health services. I have a colleague who leads a 21-bed ED that must provide beds to hold three to four mental health patients at any given time because of lack of access to mental health care. This effectively reduces the capacity of the department. A solution to this problem will come about only through the combined efforts of the police, healthcare, mental health and education leaders.
The third factor causing congestion in the ED is its use as a safety net by physicians and community clinicians. These doctors send their patients for evaluation or observation to the ED because they are under pressure to care for more people and do it for less money — with the threat of liability hanging over their heads. They transfer the patients and this threat to the ED staff, who in turn cannot afford to waive any testing which could be relevant to outcome. Unless tort reform changes the nature of physician liability, the use of the ED as a safety net will only increase with the rising number of independent mid-level providers in the community.
We need to respect our physicians, nurses and technicians across the country who provide everyday care in our EDs by focusing on the exogenous pathogens that clog the airways of our EDs. We need to make changes like unifying the inpatient and ED cultures, creating needed mental health care centers and reforming tort law. This is the medicine that will allow our EDs to breathe easily.