ACEP Chief Rails Against ED Diversions, Scheduling

It's a fact that hospitals and policy makers should not ignore.

This alarming statistic about ED overcrowding – and others equally grim – came from a large population study published this week in the Journal of the American Medical Association. The research paper gives Sandra Schneider, MD, president of the American College of Emergency Physicians and an ED doc at Strong Memorial Hospital in Rochester, N.Y. a chance to make some additional points about how the system must change to save lives.

For starters, hospital executives and consumer groups need to realize that it's not just heart attack patients who are more likely to die when EDs are on diversion, she says. It's patients with any critical illness – pneumonia, stroke, injuries or wounds from violence, "or any other condition where it's important to get treatment early." The circumstance of diversion has implications for patients who were already admitted to the hospital that sends ambulances elsewhere, because chances are staff is already too strapped to provide them with optimal care, she says.

Additional studies should document the casualties of those other medical conditions as well, she suggested.

When I asked her to comment on the JAMA study this week, Schneider seemed to not want to get off the phone. "I'm passionate about this because I'm the one who has to watch patients die," she says. "There's absolutely no question in my mind, and the mind of every emergency physician out there, that holding inpatients in the emergency room and backing things up … leads to ambulance diversion. It's just bad. It causes death; it causes delays in care; it causes increased discomfort."

Yet it happens all the time in U.S. hospitals where "ambulances are lined up waiting in a queue, waiting to get someone checked into that ED, sometimes as long as two or three hours, and that's because there's a hospital patient in that ED bed."

Schneider lashes out against the U.S. healthcare system that she says allows this to go on, and even make the problem worse. For starters, she says, nursing homes often don't accept patients from hospitals on the weekend.

Also, many hospitals could organize elective surgeries more efficiently, on a seven day-a-week schedule rather than a five-day one, to avoid backing up EDs in the early week peak and provoking many ambulance diversions.

"For many, many reasons, elective surgery patients are often brought into the hospital on Sunday, Monday, and Tuesday and undergo operations on Monday, Tuesday and Wednesday. One reason is because the services they need, such as occupational, physical, respiratory therapy – all that stuff they need to recover from their surgeries – operate only five days a week," Schneider said.

It's those elective cases, she says, that take up hospital beds, leading to:

• ED flow impediments
• ED patient boarding during peak times
• Patients becoming exasperated and stressed
• More avoidable deaths

"Very few services these days are just open Monday through Friday. I can go to the bank, the dry cleaners, and the post office on Saturday. But hospitals aren't fully open on Saturdays," she explained. "This flow through the hospital is really essential to keep the emergency department open, so patients don't die, and in this particular case, don't die from heart attacks."

Her late aunt's situation illustrates the problem.

"She went to a hospital in Pittsburgh with very bad pneumonia, and after she got into a bed she got sicker and needed to go on a respirator in the ICU. I called in to see how she was doing and they told me she was transferred from a floor bed to the emergency room instead of the ICU.

"The reason that happened is because they had a 'call-off' of a nurse in the ICU, (a nurse who did not show up for work.) Every one of the nurses in the ICU already had two patients, and no one nurse can take care of three patients. They had an unwritten rule," said Schneider.

Schneider spoke with the ED nurse, identifying herself as the patient's niece, but also as an ED physician from another hospital.

She said, "He told me, 'Oh, you'll understand. I already have three ICU patients, and I have three patients already admitted to the hospital, and I'm also taking care of four emergency patients. I'll do the best I can by your aunt.' "

Schneider's aunt survived that incident and lived another year. But the ACEP president says she was outraged. "This isn't seen as wrong. No nurse should take care of more than two patients, but it's okay for the emergency department nurse to take care of 10 patients? You can imagine if one of those patients needed a lot of care, the other nine wouldn't be able to get very much," she said.

That, she says, is the problem that this JAMA paper is talking about. It may not just be life and death care, but care to address patient pain. "If you had a patient whose blood pressure was falling, and another needed pain medication, which would you address?" she asked.

The cycle is a vicious one.

When EDs keep elderly patients for long periods after they've been admitted until a bed opens up, it contributes to delirium. "The patients can get confused and disoriented," she said. "And then everybody says, 'Oh my God, they have to go to a nursing home.' "

There's evidence, Schneider says, that these elderly patients are three-to-four times more likely to have to go to a nursing home rather than home after discharge than if they had taken directly to a bed.

"It doesn't matter how sick they are; that's just the difference between what happens on crowded ED days versus not-crowded days." Schneider says the U.S. could learn from England, Canada, and Australia, all of whom have put time limits on how much time people can spend in the ED.

The idea of time limits took hold in England after an elderly woman spent two days in the ED waiting for a bed, Schneider explains. "It was so horrifying to the British public that there was an outcry to impose time limits," she added.

"What was amazing to us in the U.S. is that almost every one of us knows patients who have spent two days; that's nothing," she said. An ACEP study soon to be published will show patients spending four and five days waiting in the ED for a bed, and one in Massachusetts that is looking at patients with mental illness spending as many as eight days waiting for an inpatient bed."

I thought the interview was about wrapped up. But Schneider asked to make another point. ACEP did a survey of ED directors in New York State several years ago. Asked if they personally knew of a patient that had been harmed because of ED boarding and overcrowding, 70% answered yes. Then they were asked if they had personally cared for a patient who died as a direct result of boarding and overcrowding...

"And 30% of these ED directors across the state of New York answered, yes.

"I think that's stunning," Schneider said.