Friday, June 29, 2007

ER Overcrowding at OSF

In September 2001 I wrote a letter to Keith Steffen regarding the ER at OSF. As documented in Keith’s Letter, the ER was not working well.

I was put on probation the next day by George Hevesy, the Director of the ED at OSF. Three months later I was fired from OSF by Mr. Steffen.

I believed then and believe now that not enough effort was directed to the main ER at OSF to help patients move efficiently through the system.

A recent study published in March 2007 in Annals of Emergency Medicine described the relative impact of input, throughput, and output factors on the average daily ED length of stay. Output factors examined included the number of elective surgical admissions, the number of ED admissions to the hospital, the number of critical care admissions, and hospital census. The only factors that were independently associated with increased ED length of stay were output factors. These included hospital occupancy, the number of ED admissions to the hospital, and the number of elective surgical admissions.

An editorial in Annals regarding this study indicated that “smooth functioning of the ED is highly dependent on the ability of a hospital to accept admitted patients. (This is considered “output”). Any disruption in the outflow of patients from the ED to the hospital drains resources and impairs the ED’s ability to car for new seriously ill or injured patients. Hospitals that have had the most success alleviating ED crowding are those that have recognized the hospital-wide nature of patient flow problems and designed initiatives to move admitted patient out of the ED more efficiently.”

My letter to Mr. Steffen six years ago was pleading for help for patients in the OSF ER that were not being admitted in a timely fashion. Were the number of “elective surgical admissions” at OSF, guaranteed to make money for OSF, keeping my ER patients boarded in the ER for long periods of time?

The Annals editorial continued:

“It is no longer just the key stake holders in the emergency care system who are calling for the end of inpatient boarding in the ED. The Institute of Medicine (IOM) has also recognized that boarding inpatients is the most important driver of ED crowding and has called on hospitals and the regulatory bodies that govern them to end the practice of boarding. The IOM committee didn’t leave shades of gray when it published the following recommendation:

“Hospitals should end the practices of boarding patients in the ED and ambulance diversion, except in the most extreme cases, such as a community mass casualty event. The Centers for Medicare and Medicaid Services should convene a working group that includes experts in emergency care, inpatient critical care, hospital operations management, nursing, and other relevant disciplines to develop boarding and diversion standard, as well as guidelines, measures, and incentives for implementation, monitoring, and enforcement of these standards.”

In January, 2007 Emergency Medicine News contains an article written by Dr. Peter Viccellio. Dr. Viccellio is a professor of emergency medicine and the vice chairman and clinical director of the department of emergency medicine at the State University of New York at Stony Brook.

His article was titled, “I’m as Mad as Hell, and I’m Not Going to Take This Anymore”.

Here are some interesting facts and thoughts from his article regarding the crisis of emergency departments across the United States:

1. There were 120 million people that visited emergency departments last year in the United States.

2. The patients’ needs and how long their needs take to be cared for should be enumerated in the ER. Their needs have been viewed as impossible or as a burden to be suffered alone. We (ER doctors and nurses) have been in the underbelly of the beast too long. Our view of our own world (emergency rooms) is too dysfunctional.

3. Dr. Viccellio states, “I am convinced at this point that the real under-pinning is not that we have too many patients. The real thing that drives this issue is that our hospitals as a culture are organized around the needs of the staff and not the patient. That is why we let them sit in the waiting room.”

4. The ED should be designed to save lives. It should be the front door of the medical center determined to do the same. The ED should provide a service to the individual and the community. This is an ED (and hospital) where everyone is a Very Important Person who deserves, if we can give them the chance, to continue their Very Important Life, and not to toss it away in the waiting room or ED hallway because we can only hope for an ED built on compromise and capitulation. Why demand any less?

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