EDs must learn from past to solve nagging problems
Many problems identified years ago still exist
Experts in emergency medicine often have correctly identified key challenges over the past 20 years; unfortunately, they have not been as adept at addressing them, say observers. However, the lessons learned at least point the way to future improvement, they add.
"We've learned that indentured servitude will not work; you can't force people to provide care," says Robert Bitterman, MD, FACEP, president of Bitterman Health Law Consulting Group, Harbor Springs, MI, referring to the Emergency Medical Treatment and Labor Act (EMTALA) and the ongoing problem of finding specialists to take call. "With unfunded mandates, you end up with patients dying, or not getting care on a timely basis, or not having access to care," he says.
What Bitterman hopes will happen is a "swinging of the pendulum." For example, "It could be as simple as providing some form of liability protection," he says, noting that the state of Florida has put a hard cap on liability for EMTALA-related patients.
"People look at EDs as public facilities, and if they are looked at that way, they should be treated that way," he says. "If you can't sue police, firemen, or other public officials, you shouldn't be able to sue an emergency physician." Bitterman says he understands the need for funding to compensate for patients without insurance, "but you can't threaten the livelihood of the physician."
There has been a failure to recognize that people did not want to wait out front in the ED, says James J. Augustine, MD, FACEP, director of clinical operations at Emergency Medicine Physicians, an emergency physician partnership group in Canton, OH. "In the last three years, the emergency system has suffered tremendously because of widely disseminated information about people left to die in the waiting room," he says. "It is absolutely essential to cut out that lengthy front-end process so we do not have people performing triage functions facing criminal actions."
The best way to accomplish that step is to develop physician leadership of the greeting process, he says. "Physician in triage and other programs with a variety of names are critical elements to get patients into the system rapidly, address acute medical needs, and to move them more quickly through the ED so beds are available for the next groups of patients," notes Augustine.
Overuse of telemetry?
Augustine also cites "failure to recognizing that preventing death from care at age 50 results in many more people 60, 70, and 80 years old coming to the ED with medical events that result in them needing telemetry beds." That lack of planning or ability to identify outcomes "has created more difficulty in running EDs and to others misinterpreting outcomes, leading some to say we overuse telemetry," he says.
His solution? "We should prepare by building EDs that can provides the services for this changing population," he says. "That includes an intake area that sees them rapidly and allows the physician to begin directing their care very early on." This change also might require more people "to simply help move them around the department," adds Augustine.
In addition, "We should build EDs with beds and other accommodations that are comfortable for people who are older and more frail, and in many cases not able to rest as comfortably on cots with 1-inch mattresses," he says. So, Augustine explains, in choosing bed design, ED managers should consider thicker and more comfortable mattresses and rail systems that will allow an older patient greater ability to move and to care for themselves.
Experts in emergency medicine often have correctly identified key challenges over the past 20 years; unfortunately, they have not been as adept at addressing them, say observers. However, the lessons learned at least point the way to future improvement, they add.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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