December 17, 2019

Writing in the New York Times, Gina Siddiqui, a resident physician in emergency medicine, recalls a busy overnight ED shift to make the case that EDs need to rethink how they deliver care to keep up with growing and evolving demand for their services.

6 steps to ED transformation

Up vs. out

"My choices as a doctor in the [ED] are up or out," Siddiqui writes. The very sick are stabilized in the ED until they can go "up"—upstairs to the hospital where they can receive their surgeries or other inpatient care. Everyone else goes "out," Siddiqui writes, explaining, "I stitch up the simple cuts, reassure those with benign viruses, prescribe Tylenol and send home."

"Up or out is what the [ED] was designed for," Siddiqui contends. That's "what it's good at," she adds.

But for nearly two decades, demand for the ED has surged, "growing at twice the rate projected by United States population growth," Siddiqui writes. This means "doctors [are] pressed to turn stretchers the way waiters hurriedly turn tables," Siddiqui writes. The result is a "frantic pace [that] leaves little time for deliberating over the diagnosis or for counseling patients," according to Siddiqui.

During a recent overnight shift, Siddiqui witnessed how this dynamic can harm patients.

A shift that began 'simply enough' ends with a death

Siddiqui's shift begins "simply enough" at 10 p.m., with a 22-year-old man who was drunk and hit a tree with his car. The man's X-rays are clean and he's "sober enough to walk," so he's discharged, Siddiqui writes.

The pace keeps up throughout the night. At around 4:00 AM, Siddiqui is called treat a 23-year-old woman, Mariah, brought into the ED "gasping loudly through the oxygen mask that paramedics put over her face, screaming, crying, and thrashing all at once."

Siddiqui learns that Mariah has bipolar disorder and severe asthma that's landed her in the ED "many times." Two months prior, Mariah had been to the ED with breathing issues, but once stabilized, she left abruptly, going home without an inhaler or steroid regimen to treat her asthma. 

Siddiqui also learns Mariah doesn't see a primary care doctor. "In effect we have been her primary doctors, although we didn't know it and didn't do much primary care," Siddiqui writes.

As her vitals decline, the doctors sedate Mariah and put her on a ventilator and another round of medications.

"Through the breathing tube and the IVs, we give everything we have already given, again: albuterol, epinephrine, magnesium, helium, antibiotics, lidocaine," Siddiqui writes. "Nothing is working; her lungs remain stiff and in spasm. Her heart slows, then stops. We start chest compressions and push more medications. We probe her heart and lungs with the ultrasound, trying to find something we can reverse. Nothing." At 5:47 AM, they call time of death.

As Siddiqui fills out the death certificate paperwork, she writes that Mariah's cause of death was cardiac arrest caused by respiratory failure due to severe asthma exacerbation. Then, when writing the final underlying cause, Siddiqui is "ashamed" because the underlying cause of death she must write is "no medications at home to control her asthma."

"Our failure was not today but a few weeks ago, when she was last in the [ED] and we didn't find a way to get her asthma inhalers to her at home," Siddiqui writes.

The limits of the ED and how things can be done differently

Nearly one in 10 patients discharged from the ED returns within three days, Siddiqui writes. "What I leave unaddressed—persistent pain, nagging uncertainty about a diagnosis, a social dilemma—tends to stay that way, begetting yet another visit. An [ED]'s success is measured by how fast it sees these patients, not by whether it breaks these cycles."

Many patients will survive their diseases by being sent to other areas of the hospital by the ED, but others, such as Mariah, "make their needs clear in the [ED], but we are too busy to meet them, and by the time they come back, it's often too late."

Some EDs have tried different strategies to address these problems, Siddiqui writes. For example, between 2012 and 2014, the federal government financed a pilot at the University of Colorado in which disadvantaged patients who frequented the ED were matched up with social workers, health coaches, and other providers who would visit them at home and stay in touch with them for months, Siddiqui writes. The pilot found revisits to the hospital dropped 30% among the test group compared with the control group.

Similarly, at Yale New Haven Hospital, where Siddiqui works, a pilot program was implemented in which the hospital offered at-home follow-up care for elderly patients who came to the ED after a fall. During the follow-up, the Yale team screened for risk factors that could lead to another fall, Siddiqui writes. Within a month, patients in the program called 9-11 roughly half as often as similar patients who weren't in the program.

But, Siddiqui these types of programs "are not considered the ED's core business, so they often rely on grants—and they end if funding dries up." In other cases, EDs may hire more social workers and care managers but without additional changes these employees can quickly become buried under paperwork and high patient loads and very rarely get outside to see patients at home.

What set the University of Colorado's and Yale's programs apart was reframing the EDs resources, Siddiqui writes. "They recognized that the [ED] staff could identify problems that were destined to arise after discharge—and empowered those employees to help" (Siddiqui, New York Times, 12/16).

6 steps to ED transformation

Every population health manager has reducing avoidable emergency department (ED) utilization among their top priorities. However, ED optimization is often a missed opportunity to right-size ED utilization, which has benefits under both fee-for-service and fee-for-value payment models.

This in-depth case study details how the University of Colorado Hospital in Aurora, Colorado successfully redesigned emergency department services.

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