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Posted by Ishani Ganguli November 1, 2012 07:00 AM
The crowded emergency department (ED): It has become a symbol for our fragmented, inefficient health care system and for one presidential candidate, an acceptable alternative to expanding health insurance under Obamacare.
In the wake of Hurricane Sandy, the visual has become more familiar than we'd like - the young and the old slumped forward on rigid plastic chairs in the waiting room, occupied stretchers lined up in tandem in the hallway. Some of these patients are sick enough to warrant a hospital admission but languish in the ED for hours to days until beds are available for them upstairs. This last group of patients - so-called ED boarders - has become a new focus of efforts to mitigate ED overcrowding. One way to address the issue? Assign a doctor whose only job is to take care of them.
In the past one to two decades, the rapid rise in the number of people seeking emergency care has far outpaced the dwindling supply of Emergency Department beds. The growing numbers of the uninsured seeking guaranteed care and the diminishing reimbursements for this treatment are partly to blame for the resultant overcrowding, but recent research has pointed to the lack of open inpatient beds as the biggest single culprit. (Because of the way hospitals are paid, they must run close to full occupancy if they want to make a profit.)
The result has serious implications for the patients who wait for those beds: researchers have linked ED boarding to longer hospitalizations and higher rates of death. While emergency medicine doctors are great at managing acute medical issues and doing procedures on the fly, they aren't trained, nor do they have the time, to provide the type of care that patients need once they are hours into their hospital stint.
A few years ago, in response to this concern, MGH educators created an ED Boarder Rotation in which internal medicine residents take over the job with the supervision of a dedicated attending. After a certain number of hours waiting for a hospital bed, a patient's care doesn't move physically so much as philosophically: from the emergency medicine priority of triage and avoiding catastrophe to the internal medicine one of providing longer term care. How many hours exactly? It's a tricky question that involves balancing the benefits of inpatient-level care (and regulatory pressure) with the risks of playing telephone with unnecessary hand-offs between residents.
On my four weeks of the rotation, I spent a good portion of my time at home scanning the ED census on my iPad to predict when I might be called in to see boarder patients. When I did go in, there could be more than a dozen of them at once. Some boarders I'd be able to send home. Most, I'd have to pass off to the next ED Boarder resident or, if a bed became available, to the team upstairs. It was clear, in this process, that this effort was simply a patch sewn onto a tear in our health care system. But I also liked to think that I was helping those patients get better care in some small way.
Having the inpatient teams care for boarding patients "has had some modest effect on [decreasing] hospital length of stay," says Paul Biddinger, Director of Operations for Emergency Medicine at MGH. He tells me he's also noticed fewer safety concerns reported by clinicians because patients had prolonged waits for their diagnostic testing or had delays in receiving their usual home medications.
Our ED boarder system is unique among most teaching hospitals around the country: at hospitals affiliated with New York University, Columbia, University of Michigan, Baylor, and University of Chicago, for example, as soon as ED doctors decide that a patient needs to be hospitalized, he or she is assigned to a certain medical team that then assumes care of the patient while still in the ED. While this approach prevents extra hand-offs, it also adds the wrinkle of caring for patients from afar.
There are challenges with the MGH program: the electronic health records in the ED and on the medicine unit aren't connected, so some of our efforts in the ED need to be duplicated by our colleagues upstairs. There are also the huge swings in the number of boarders (certainly not unique to MGH) and the difficulty in assuming care for many of them at once.
"Right now our staffing models for residency assume a 'stable trickle in' of patients and we know that is just not the case and it's much more variable," Vinny Arora, Associate Director of Internal Medicine Residency at the University of Chicago, wrote to me in an Email. Eugene Litvak and his colleagues have looked into why, finding that the biggest predictors of ED wait times are the number of patients being hospitalized for elective surgeries (leaving fewer beds for patients coming from the ED), the number of ED admissions (well, ok), and hospital occupancy. The first factor, at least, is both predictable and fixable (with surgical smoothing, for example). The same attention to ebb and flow might be applied to staffing the ED Boarder rotation more efficiently.
The rotation is just one of several measures to make patient care safer in the ED and it's not perfect. But if I've learned one thing in caring for ED boarders, it's that patients are most vulnerable when stuck in the fraying seams of our health care system and any efforts to ease their stays are well worthwhile.
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