Un-Maligning the ER

One last post on the ER….for awhile.

As I mentioned in an earlier post, the ER is the portal of entry to our hospitals now, for better and for worse.

On the plus side, this means that most patients being admitted to general medical and surgical services (the big exception here is elective surgery–patients having elective operations don’t need to be triaged) have a workup at least started and are triaged appropriately to their destination.

A good ER evaluation should answer the following questions:

1. What’s the nature of the illness?

Are we dealing with the heart, the brain, or an abdominal organ?  Is the cause an infection, a blockage, or a blood clot?

2. Based on #1, where will the patient best be situated?

Will the patient need intensive care, or will the “regular” floor be sufficient to attend to the issues at hand?  Should the patient be admitted to a surgical team or a medical (non-surgical) team?

Depending on the hospital, does the patient get admitted to a teaching service (where residents perform the care under the supervision of attending [fully trained] doctors) or a non-teaching service?  Should the patient be on a specialty service (e.g. cardiology, GI, or oncology), with a hospitalist (a trained internist who mostly sees only hospitalized patients) or a generalist (an internist or family physician who sees hospitalized patients as part of the spectrum of services they provide).

Even with these two straightforward questions, the decision-making can become fairly complex, given all of the available options.

And in teaching hospitals, an extra layer of complexity is added as doctors from different services sometimes fight not to admit the patient to their roster of patients.

Contesting an admission might occur with good intentions, but one thing is for certain: it delays getting the patient out of the ER and up to a hospital ward, which compounds the problem of ER backup and overcrowding.

Monday morning quarterbacking occurs in hospitals on a daily basis.  ”If this patient had been admitted to the Intensive Care Unit (ICU) in the first place, a lot of these mishaps could have been avoided,” is a frequent refrain heard the morning after a very sick patient has been admitted.

In teaching hospitals, admitting and triage decisions take longer, since the resident doctors, both in the ER and the ones working on the hospital floors are learning the skills of triage.  There’s a subtle (and not-s0-subtle) dance that goes on to choose the service and the location.  Most of the time it’s very straightforward.  The few times that it’s not can lead to major worry on the part of everyone.

Patients admitted to general medical services from the ER usually come in two varieties:

1.  Completely undifferentiated illness, with a first time presentation.  For example: new onset shortness of breath.  There are myriad possibilities, and a deft ER will help sort our which are most likely.

2. An acute exacerbation (heightening) of a chronic medical condition.  Of the two presentations, this is the far more common.  In an aging population with a preponderance of chronic illness (diabetes, hypertension, survivable cancers, strokes, and cardiac conditions), patients can have a perturbation of their bodily balance (e.g. a salty food binge) that can result in acute on top of chronic illness.

We’ve moved away from the direct admission.

This occurs when a doctor evaluates a patient in the office, and determines that there’s a variety #2 going on–an acute flare of a chronic condition.

Such a patient does not likely need an extensive workup to determine the nature of the illness, since it’s long ago been defined. The patient requires a titration of medication in a supervised fashion (many of these medicines alter the body chemistry, and can upset the heart or kidneys) to alter the physiology back toward balance, and then the patient can be discharged.

Yet since we’ve become so reliant on the ER to triage everyone, we’ve fallen into a predictable pattern of sending all patients destined for admission to the ER.

“Let the ER sort it out,” is the oft-thought, rarely-spoken mantra of a busy office physician.

Is it any wonder the ER is so crowded when on top of having people use the ER as a medical home, we have doctors shunting patients through the ER as a portal of entry?

The hospital’s admitting office does not want to receive and then admit patients who might be “unstable.” At the hospital at which I work, if a patient even has an IV placed (customary for a patient admitted to a general medical service) they are deemed too “unstable” to wait in the admitting area.

Something has to give.

It would be nice for patients if they could be admitted to their hospital bed as quickly as possible. The patient is relatively powerless to decide how they get into the hospital.

There’s a real opportunity for the place that figures out how to transition people who are sick from the outside world to the inside-hospital world in a more seamless fashion.

In a world of medical consumerism, that’d be something to boast about.