December 4, 2006
Student Scene
Resuscitating the Emergency Department
Photo by Graham Ramsay Erica Seigeur |
Safety in health care has been a buzzword ever since the Institute of Medicine (IOM) published To Err Is Human, which chronicled some of the challenges of developing a safe and effective health care system. In the popular press, and in common parlance, the problem of safety within the health care system, whether referring to medication errors or sponges left in patients during surgery, has remained a salient issue. For those focused on emergency departments across the country, safety has become a rallying point.
According to several recently released studies on emergency care and services by the IOM, emergency departments have been closing across the country: over the last 10 years, 60 EDs have closed. Major cities appear to be greatly affected. In Los Angeles, for example, eight EDs have closed in the last three years, and there has been a 20 percent reduction since 1980. At the same time, hospital emergency departments are taking on responsibilities far beyond their mandates such as caring for a predominantly uninsured population.
An Emergency Care Emergency
David Blumenthal, the Samuel O. Thier professor of medicine and professor of health care policy at Harvard Medical School, has been studying the safety of EDs and says that the increase in volume of patients being seen in emergency departments is the result of many factors: the closure of EDs across the country, the general increase in the U.S. population, the aging of the population, the shortage of primary care physicians, and declining insurance levels among employed populations. According to Blumenthal, the most important contributor to safety issues is overcrowding. “A close second,” he said, “are flaws in the design of care processes that do not take into account human-factors principles.”
Recent headline-making stories of patients waiting upwards of 24 hours in hospital EDs to be admitted have focused attention on the impact of overcrowding on patient care. The IOM takes issue with the practice of “boarding,” a term used to describe how hospitals keep patients on stretchers or chairs in hallways and other locations until a bed becomes available. In many cases, patients wait for hours in this kind of holding pattern until the hospital frees up beds through discharging inpatients.
Hospital emergency departments are taking on responsibilities far beyond their mandates such as caring for a predominantly uninsured population. |
The IOM describes this practice as “antithetical to quality medical care” and recommends that diversion (rerouting ambulances away from an ED when capacity is reached) and boarding only occur in situations with mass casualties, such as might be anticipated in natural disasters or terrorist attacks. Diversion is a common occurrence, with up to 40 percent of EDs reporting this on a daily basis. While Blumenthal agrees that boarding is an “invitation to safety problems, and should not occur in a well-designed health care system except in rare periods of overwhelming demand,” he believes that the IOM recommendation is unrealistic under current circumstances.
The Technology Solution
One approach to addressing the quality of patient care more broadly across
all aspects of the health care system has been to develop and implement information
technology tools. Blumenthal believes these same tools, which can be used to
provide decision support, prevent loss of patient records and duplication of
testing, alert physicians to potential drug–drug interactions and patient
allergies, for example, are applicable to EDs. “Health information technology,” he
said, “is a cornerstone of optimal health care design in the 21st century.”
But such systems are costly. “For institutions that are financially solvent,
like MGH, resources for IT should come from the institution itself,” said
Blumenthal. “For others, there needs to be public support through grants,
loans, or additional reimbursement for services rendered.”
There are more
than 100 million visits to EDs each year, and the number is growing even as
the number of EDs is declining. These factors have important implications for
patient safety and the quality of health care that ED patients can expect.
For those who have ever worked in an ED or been an emergency patient, the critical
nature of the care provided and the difficult circumstances surrounding care
delivery are clear.
—Erica Seiguer is an MD–PhD student studying economics in Harvard’s
Doctoral Program in Health Policy.
Related Websites
IOM Hospital-based Emergency Care: At the Breaking Point: http://fermat.nap.edu/books/0309101735/html/.html
National Association of EMS Physicians:
http://www.naemsp.org
Copyright 2006 by the President and Fellows of Harvard College