Wednesday, May 27, 2009

ER Crowding...A Moral Dilemma

Moral Consequences of ED Crowding

A family in the area recently called me and told me of their long 10 hour wait in the ER at OSF-SFMC in Peoria.

See my letter written to OSF's Keith Steffen regarding my concerns of dangerous overcrowding in the OSF Emergency Department.

In the May, 2009 issue of Annals of Emergency Medicine there is a two part article regarding crowding in the Emergency Departments in the United States.

Below are key points from these articles and my comments regarding OSF’s Emergency Room:

1. According to Hospital Based Emergency Care: At the Breaking Point, a 2006 report of the Insitute of Medicine (IOM), there is a national crisis of ED crowding.

2. ED overcrowding occurs primarily when sick patients, evaluated by the emergency physician and admitted to the hospital, have no place to go and remain in the ED. It is mainly a symptom of an overcrowded hospital, not the result of “inappropriate” ED use (like patients with sprained ankles, etc.)

This was the exact position I found myself and my patients in on September 26, 2001.

3. Current research on ED crowding strongly suggests that discouraging the use of the ED for non-emergency issues (sprained ankles) will not solve the problem. Rather, output issues, especially the inability to transfer emergency patients to inpatient beds and the resultant “boarding” of admitted patients in the ED for long periods, are most commonly associated with ED crowding.

4. There are moral consequences to ED crowding and serious ethical concerns.

5. ED crowding has a variety of undesirable consequences, including increased patient waiting times, decreased ability to protect patient privacy and confidentiality (if they are lying on a gurney in a busy hallway), impaired evaluation and treatment, and difficulties in delivering person-centered care. ED crowding frequently interferes with the ability of emergency physicians to honor these fundamental principles.

6. When a circumstance such as ED crowding makes it increasingly difficult or even impossible for health care professionals to respect basic moral norms, it is essential to address that circumstance to reduce the likelihood of conflict between these moral norms and to enable professionals to satisfy all of the reasonable moral expectations of their patients.

7. The Joint Commision reported that 55 events associated with delays in care, 29 occurred in EDs. Crowding was noted to contribute to 31% of sentinel events in the ED. Two recent studies found a significant association between ED crowding and increased inpatient mortality. Crowding increased the risk of harmful medical errors in a variety of ways. In a crowded ED, errors may occur as a result of hurried treatment decisions with limited information, of delayed or poorly organized transfer of information from one clinician to another, or of failure to reexamine a patient or to reevaluate a previous physician’s provisional diagnosis or treatment plan.

8. Multiple studies associate ED crowding with delays in access to definitive therapy for emergency conditions, thereby increasing the risk of poorer outcomes. Numerous emergency conditions, including myocardial infarction, stroke, trauma, meningitis, and pneumonia, have been shown to have time-sensitive outcomes.

9. By delaying patient access to assessment and treatment, crowding also forces patient to endure existing harms, including pain and anxiety, for prolonged periods. In all of these ways, crowding impedes clinicians efforts to carry out their duties of beneficence.

10. Patient choice of care is in fact limited by personal and system resources, but enabling patients to choose care that is effective and convenient remains a legitimate moral goal. ED crowding interferes with the satisfaction of that goal when it triggers ambulance diversion and long waiting times for ED care and for hospital admission. Ambulance diversion to other hospitals often thwarts patient strong preference to receive care in the hospital in which their physicians and medical records are located. Diversion also increases transportation time for each patient. Longer transportation times may increase ambulance response time to subsequent patients, there by delaying those patients’ access to out-of-hospital and ED care for their emergency medical conditions.

11. This is what I think is happening at OSF in Peoria:

There are financial barriers that diminish the response of hospital administrators to solve the problem of ED crowding. The IOM report offers the following reason: “No major changes in health care can take place without strong financial incentives, and today hospitals have almost no incentives to address the myriad problems associated with inefficient patient flow or ED crowding. Indeed….hospitals have a number of financial incentives to continue the practices that lead to these problems.”

What are these alleged financial incentives? The IOM report identifies the following 4:

1. Hospitals maximize income by operating at high capacity, making full use of their employees and facilities. The ED can enable its hospital to operate at or near full capacity by acting as an escape valve for excess demand, providing necessary care for seriously ill or injured patients until the hospital can accommodate them as inpatients.

2. Patients awaiting an inpatient bed in the ED compete for beds with patients admitted electively for surgery or other invasive procedures. Such elective admission patients are usually insured and the procedures they undergo are often well reimbursed, generating significant revenue for hospitals. Emergency admissions, in contrast, are more likely to be uninsured or underinsured, to have more severe illnesses, and to have lower rates of reimbursement. Hospitals thus have a financial incentive to prefer elective over emergency admissions. Failure to honor requests for elective admissions, or frequent cancellation of scheduled admissions, may in fact alienate surgeons and other procedural specialists whose patients generate substantial income for the hospital.

3. Hospitals with EDs are required by federal Emergency Medical Treatment and Active Labor Act (EMTALA) regulations to provide a screening examination and necessary emergency care for all patients, regardless of ability to pay. When the ED is crowded, however, access to emergency care is inevitable delayed, and some patients choose to leaves the ED without being seen. In the case of ED closure and ambulance diversion, access to care through the ED is temporarily denied. Thus, hospitals may have a financial incentive to permit ED crowding and subsequent closure because those conditions can limit the hospital’s legal duty to assume the care of uninsured and underinsured patients.

4. Giving elective admissions priority over emergency admissions may enable hospitals to maximize revenues in another easy. If they are denied admission, elective patients may choose not be hospitalized, or to go to a different hospital, and the hospital will lose their patronage. In contrast, patient boarded in the ED are “captive”; they are already in the hospital and cannot easily go elsewhere. So, despite lower priority and longer wait for an inpatient bed, the boarding patients will receive continuing care in the ED and will also eventually be admitted. In this way, the hospital will secure 2 admissions instead of just 1.

If the wait got too long for the patient and their family, on occasion, I directly transported the patient to the inpatient bed myself. I doubt this was looked upon favorably by Dr. Rick Miller, who was in charge of the ED at OSF at the time. Rick did not want waves made that in any way challenged the administrative powers that controlled Dr. Miller and his assistant director, George Hevesy, M.D. Unfortunately for ED patients and staff, there was a dangerous parasitic relationship between the ED directors and OSF Administration.

According to May, 2009 Annals of Emergency Medicine:

Hospitals can implement “full capacity protocols” in periods of severe hospital and ED crowding. Under these protocols, patient boarding in hallways or other unsafe areas in the ED are moved to hallways in various inpatient units. Such protocols alleviate the burden on the ED of boarded patients by distributing those patient throughout the hospital. This strategy may also increase hospital-wide awareness of crowded conditions and thereby motivate physicians and staff to make beds available.

Several years after I was fired from OSF-SFMC, OSF created an observation unit to attempt to relieve ED crowding. Clinical decision units or observation units, for example, can monitor patients with symptoms such as chest pain, abdominal pain, or shortness of breath who may or may not ultimately need hospitalization. Admission pending units can provide continuing evaluation and treatment for admitted patients outside the ED when other inpatient units are full. Discharge units, sometimes referred to as discharge lounges, can accommodate patients who have been discharged by their physician and are merely awaiting discharge instructions or a ride home for the the hospital.

In the early ‘90’s I gave an Emergency Department Grand Rounds regarding creating an Observation Unit at OSF in order to decompress the ER. I asked Jim Moore to attend and explain the financial reasons regarding an observation unit. He agreed to be there. Mr. Moore was Administrator of OSF at the time and is now CEO of OSF Coroprotate. I also asked a general surgeon, and adult cardiologist to attend. All attended the ED Grand Rounds except Mr. Moore.

And as mentioned above, 10 more years went by until OSF implemented an Observation Unit.

In Summary:

1. To maximize efficiency hospitals must decide how to distribute resource among their current patients to do the best job of caring for all.

2. Although emergency physicians and other emergency care professionals confront the moral challenges of ED crowding firsthand, effective response must come from the institutional and system-wide level. Although emergency physicians do not have the power to change the health care system, they certainly can and should participate in addressing the problem of ED crowding.

3. When I wrote Keith Steffen in 2001, I was hoping for his guidance. Instead, he referred to me as a cancer in the emergency room at OSF and I was placed on “probation” the next day.

4. In April 2005, emergency physicians at Vancouver General Hospital, frustrated by their ongoing failure to persuade hospital administration “to address the crisis of admitted patients in our ED,” began giving selected patients a statement expressing their “non-confidence in the ability of the Vancouver Gerneral Hospital ED to provide safe, timely, and appropriate emergency medical care.” This action stimulated heated public, political, and professional debate in British Columbia. After emergency physicians at other Vancouver area hospitals publicly expressed similar concerns about patient safety, the provincial Ministry of Health funded a $7 million campaign to address the problem. Despite this campaign, however, the ED at Vancouver General Hospital remained gridlocked with admitted patients in 2006.

5. The Vancouver no-confidence statement certainly called attention to the problem and it evoked an official governmental response. The Vancouver emergency physician’s proposed strategy for alleviating ED crowding, namely, the use of time limits on ED stays to trigger protocols that distribute admitted ED patients throughout hospital hallways, is also intended to raise the visibility of the crowding problem by spreading the burden to areas other than the ED. This strategy is obviously not an ideal solution, because patients are likely to feel almost as exposed and uncomfortable in a hallway of an inpatient unit as in a hallway of the ED.

6. If hospital EDs in the United States have a moral and legal mandate to provide quality emergency care to all who need it, it is important that emergency physicians and nurses make governmental and institutional leaders aware of the significant problem of ED crowding and that they participate in efforts to address this problem.

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