Institute of Medicine to overwhelmed ED managers: 'You're not alone'
Many problems caused by flaws in system, landmark reports say
"Emergency health care in crisis."
"High demand overcomes inadequate system capacity."
"Overcrowding, boarding, diversions are major challenges."
ED managers who read these headlines in the three Institute of Medicine (IOM) reports on emergency care probably will feel as though they could have written them themselves.
What is different about these reports is that it's not the ED managers pointing out the problems in the system, but a major organization that carries substantial clout. And the report's emphasis on regionalization and system processes clearly demonstrate that problems such as ED overcrowding are not ED problems, but system problems. In the case of overcrowding, for example, that means it's a hospital problem.
"First of all, the IOM calls this a national crisis," says Mike Williams, MPA, HAS, president of The Abaris Group, a Walnut Creek, CA-based health care consulting firm specializing in emergency services. "I think this report is a major reinforcement to ED providers that the system is broken, and that the IOM feels your pain. But they reinforced that with the message that hospitals, for example, have not done everything they can do."
The findings of the IOM "absolutely rang true," Williams says. They report, for example, that hospitals went on diversion a half-million times in 2003, he says. "I think the report documents a very grim situation, painting a picture of a very unstable and de-compensating health care system as it relates to emergency care."
The IOM's Future of Emergency Medicine Committee wanted to address a lot of the fragmentation in the continuum of emergency care, explains Benjamin K. Chu, MD, MPH, regional president of southern California for the Kaiser Foundation Health Plan and Hospital in Pasadena and a member of the committee. "We want a much more coordinated system — one that is seamless and regionalized, so the patient gets to the right place at the right time — and a system that is accountable," he says.
People outside the ED, Chu contends, are blinded to the lives of those within the ED. "They don't push for maximum efficiency, and just figure things will be taken care of," he says. However, that belief is a fallacy, he maintains. "The one place you don't want fatal errors is in the ED, but when you're overcrowded and rushed like that, how can you avoid it?" he says.
Fellow committee member Arthur Kellerman, MD, MPH, professor and chairman of the department of emergency medicine at the Emory School of Medicine in Atlanta, says that the report describes in detailed and hard-hitting terms the ever-widening mismatch between the demands placed on the emergency care system and its resources. Also, the report highlights "the attendant, unmistakable signs of distress: diversion, an increased risk of errors, high levels of stress, burnout, and our failure to deliver on our promise to the American people that we will be there when they need us," he says. "It's really hard to respond to a flu pandemic or some other major disaster in that context."
With its focus on systemwide change, it is not surprising that most of the IOM's recommendations also were targeted to systems: hospitals, state and federal governments, and health care organizations.
Kellerman says he has three top recommendations:
- On the federal level, he wants the creation of a lead agency responsible for improving the delivery of emergency care. "Currently these responsibilities are widely scattered in many agencies," Kellerman says.
- Second, the states should take an active role in regionalizing delivery of pre-hospital care, including the designation of hospital capability to ensure the right patient goes to the right hospital at the right time, he says. Also states should manage the system "so you will not find ambulances wondering around," he says.
- Third, hospitals have to end the practice of boarding of admitted patients and end the widespread practice of ambulance diversion, Kellerman says.
The Joint Commission on Accreditation of Healthcare Organizations and the Centers for Medicare & Medicaid Services should work to develop positive incentives to hold hospital administrators accountable for that third goal, he says. "It's just stupid that we allow the most time-critical parts of the emergency system to gridlock because the larger system is unwilling to do what it needs to do," Kellerman says. "You have to have a system that pulls patients out of the ED into inpatient units."
Calling all ED managers
The fact that many of the recommended solutions are systems solutions does not mean they should not involve ED managers, Chu emphasizes. For example, when it comes to coordination, "an ED manager really needs to be involved in the overarching design of the system," he says. "You have to be at the table when we talk about trying to get EMS people to communicate with hospital people."
He says one of the coordination pieces that the report discusses is regionalizing and defining different "tiers" of EDs so each tier is adequately trained for the levels of services being offered and being delivered, according to evidence-based protocols. "Each manager has to pay attention to what services their ED is capable of delivering," says Chu. "If you are a Level I trauma center, you have to make your surgeons, radiologists, and neurologists are properly trained and adhere to evidence-based protocols."
In terms of accountability, the committee called for a panel to be convened by the Department of Health and Human Services to develop evidence-based indicators of emergency care system performance. "The ED manager will likely have to worry about making sure that the indicators that are chosen are reasonable and that they can adhere to them," Chu advises. Once EDs have the indicators, the manager will have to work to optimize them, he says. "It will be their job to track them and to embed the department in overall improvement processes as a way to achieve them," he adds.
Managers also must be aware of strategies that are already addressing these problems, adds Williams. "We always cry about boarding, but the first thing I ask a client is, 'Do you have a clinical decision unit?'" he offers.
Williams defines it as "a unit established around an observation medical model, state of the art, with protocol-driven care with the goal of moving all patients through the system in 14 hours." Less than one in 40 EDs has one, he says, "But it's clearly a well-publicized best practice."
Get the best-trained EMS
ED managers will be affected by the IOM's reports on EMS and pediatric emergency medicine as well, says Chu. "If you are a good ED manager, you will take a larger system view and make sure the EMSs associated with you are the best trained and are supervised by ED docs who really know what to do," he advises.
The pediatrics report recommends a family-centered approach, Chu says. "The committee observes that children do better when parents are involved," he says. A lot of hospital inpatient areas have begun letting parents stay overnight, but in a busy ED, it's not always easy to accomplish that, he acknowledges. "In a crowded ED, the manager might have to advocate for a separate area for children and families," Chu says.
Sources
For more information on the Institutes of Medicine reports, contact:
- Benjamin K. Chu, MD, MPH, Regional President, Southern California, Kaiser Foundation Health Plan and Hospital, Pasadena, CA. Phone: (626) 405-7983. E-mail: [email protected].
- Arthur Kellerman, MD, MPH, Professor and Chairman, Department of Emergency Medicine, Emory School of Medicine, Atlanta. Phone: (404) 778-2602. E-mail: [email protected].
- Michael J. Williams, MPH, HAS, President, The Abaris Group, 700 Ygnacio Valley Road, Suite 270, Walnut Creek, CA 94596. Phone: (925) 933-0911. Fax: (925) 946-0911. E-mail: [email protected].
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