The New ED: Keep Patients Out (but Happy)
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Cases of attempted suicide in the ED have been growing to such an extent, the Joint Commission last year advised hospital staffs to be on the lookout for patients who may be at risk for attempting suicide, even though they don’t obviously have behavioral health issues. And that’s another reason why increasing the number of dedicated psychiatric units is so important, most ED officials said.
“This is a situation that keeps getting worse,” says ACEP President Sandra Schneider, MD, an emergency room physician at 722-licensed-bed Strong Memorial Hospital in Rochester, NY.
“It’s not unusual to hear of patients who stay a week or more in the ED while in emergent need of mental healthcare. Most of the time they get some sedation so they don’t act out and disturb other patients, but there’s a feeling among some individuals that these patients aren’t sick—their blood pressure is okay—when really, they’re among some of our sickest and most vulnerable patients.”
Some ED planning specialists see a bigger calling for physicians who are also palliative care providers, whose role might be to explain to patients and family members, in more realistic terms, what was done for them in the ED and what they might expect going forward.
One physician who has embraced this role is Denise Waugh, MD, at Scott & White Hospital, a 636-licensed bed level 1 trauma center and 150-licensed-bed acute care hospital in Temple, TX.
“To the emergency room physician, the assumption has always been that if you came to the ED, you’d want everything possible done. But that may not be so,” says Waugh, a pain management and palliative care specialist.
“Emergency room doctors are the hardest working of any, but they often express a patient’s status in terms of what has just happened: Your grandmother is much better. We gave her [drugs] to bring blood pressure up. And she has a tube to help her breathe, so she’s being transferred to the ICU,” Waugh says.
“But what the family members hear is that you’re curing their grandmother,” Waugh continues. “A palliative care physician might explain that grandmother is still very critically ill. She’s not able to maintain her own breathing or blood pressure to maintain a blood supply to her brain. And that while the hope is she will be able to breathe for herself in a day or so, if she makes no progress, we need to talk about who your grandmother is and what she wants.
“I truly believe that they aren’t coming to the ED because they want to be intubated or because they expect we will restore the health they had 20 years ago,” Waugh says. “This is not about denying services, but helping the patient understand the box they’re in, and that every book has a first chapter and last one, and it’s our team’s goal to make sure that the last chapter is as comfortable as possible.”
Conn of MGH agrees with that concept. “We think we can identify people who would benefit from palliative care right up front while they’re in the emergency department and manage them more efficiently,” he says, adding that Patricia O’Malley, MD, the previous director of pediatric ED at MGH, has undergone training and “changed her career path” to help with palliative consults, and others are considering the role as well.
“We haven’t formulated any concrete paths yet, but I think in the future we will need to do so,” Conn says.
Companies that manage large numbers of hospital emergency teams are scrutinizing department metrics, comparing and contrasting to see what strategies seem to work, such as TeamHealth’s “Top Decile” project, says Barbara Blevins, COO for hospital-based services at TeamHealth.
The Knoxville-based company hired Lean-certified nurses and assigned them to each division to set “aggressive goals” for their 300-plus ED clients. “Then we looked for the top 10%, the ones that were able to quickly reduce times for such measures as length of stay, door to doc, left prior to medical screening exam, and patient satisfaction,” she says. “Then we looked for the common steps, the actions, that those places had that allowed them to have those great metrics.”
One common theme, she says, is that “across the board, the ED nurse director and the TeamHealth ED facility medical director had excellent leadership, they spoke with one voice, they had common goals, and most had a charge nurse on every shift.”
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