The Emergency Crossroad

Emergency medicine in the United States is in deep and chronic crisis. There has been no shortage of articles, reports and conversations to support the thesis that emergency departments have, for many years, been overwhelmed by people unwilling or unable to seek medical care from primary physicians or even urgent care centers. The emergency department has become the default destination for patients experiencing all manner of ailments, even for those who do regularly see a PCP. A major contributing factor for this is due to liability concerns; call any doctor’s office, pharmacy, clinic or insurance helpline and their phone message will almost certainly have a statement directing the caller to dial 911 or go to the nearest emergency room if they feel they are experiencing a life-threatening medical emergency. While certainly reasonable, this puts the caller in a position to decide whether their complaint constitutes a “life-threatening medical emergency” or not. This often means people experiencing any chest discomfort or unusual sensations make their way to the local ED, sometimes on their own and sometimes via an ambulance. Some of those patients, after an extensive work up and hours of waiting, will be hospitalized. Many more will be discharged without a clear diagnosis.

All this adds expense and stress to a healthcare apparatus already buckling under the weight of shrinking insurance reimbursements, consolidation and the inevitable downsizing that comes with it, chronic nursing and support staff shortages, unfounded government mandates and the struggle to deliver medical care while wading through a veritable quagmire of bureaucratic and administrative requirements. Charting, not tests or procedures, has become the lifeblood of healthcare. Hospitals employ EMR experts to guide physicians as they document their work in an effort to maximize revenue and minimize the threat of legal action. Chart reviewers comb through records to find any missed opportunity to bill for critical care time and department heads spend at least as much time worrying about the business aspect of medicine as they do the medical aspects. All this takes place against a backdrop of increasingly sick and complex patients as well as a pandemic that refuses to go away.

While the financial demands of healthcare are a constant thorn in the side of practitioners, there are a host of additional issues that intersect in our emergency departments that are less failures of the healthcare industry and more failures of the larger society. Our emergency departments have become de facto warehouses for individuals ignored or neglected by the community. In jurisdictions where involuntary commitment (IVC) is easy, children barely old enough to be in school are brought in by police at the behest of family and caregivers who can’t or won’t handle their behavioral or psychological issues. Some of these children will languish for days or weeks in a frightening and alien setting completely inappropriate for their special needs. It’s even worse for older children who are often residents of group homes or adrift in the foster care system; many have extensive psychiatric and/or behavioral issues that make it difficult if not impossible to find them appropriate care. Some of these young people will spend months confined to a small corner of the emergency department, watched by cops, largely removed from social structures and unable to expel their energy in a constructive way. They are expected, not unlike inmates, to never raise their voices or express their anger at being held captive; any sufficiently violent outburst is usually resolved by pharmacological intervention.

It is disheartening and infuriating to follow the documentation from physicians, psychiatrists, social workers and nurses, all trying to make a difference and reach a positive outcome but hampered every step of the way by resistant living facilities, full behavioral hospitals and a general lack of options for kids too old to be children but not old enough to be released under their own recognizance once given medical and psychiatric clearance. It is unsettling to see the same names on the track board shift after shift as the encounter timer passes into the hundreds and then thousands of hours. This is not entirely the fault of individual hospitals as, once again, the emergency department has become the sole hope for parents struggling to address the unmet mental health needs of youth in a world that has deprioritized mental health care so much that it has become like the proverbial white whale, a phantom that we chase but rarely find. There seems to be little to no financial incentive to build facilities and train staff to treat adolescents who have no way to pay for their treatment and hospitalization.

Adults and the elderly also can find themselves in this limbo of not being “sick” in the medically acceptable way but still being unable to care for themselves. As a result, hospital social workers have become as ubiquitous in the ED as radiology technicians or respiratory therapists. Theirs is the Herculean task of trying to secure placement for the aged and the disabled who, by accident or design, have checked in for issues not always of the medical variety. Social workers have to try and negotiate the competing interests of patient, family, payors and prospective facilities to achieve the mortal equivalent of aligning the planets. This is not what the emergency room should be, but it is what the emergency room has become: a liminal space between independence and dependence, wellness and illness.

There is also the matter of physical space, or the lack thereof. Hospitals can only accommodate so many hospitalized patients as they’re limited by how many licensed beds they can offer and staff. The ongoing COVID-19 pandemic has left many organizations heavily reliant upon expensive contract nurses to fill gaps left by burnt out and fed-up staff nurses. This has put extraordinary pressure on many smaller systems (and some larger ones) and the ramifications have been acutely felt in emergency departments. Unable to offer the kind of wages or freedom advertised by contract companies, hospitals have seen understaffed inpatient units and congested EDs holding dozens of admitted patients with nowhere to go. This puts unbearable strain on ED nurses who find themselves having to function as med-surg and progressive care nurses while also having to perform their usual duties for the unending stream of new emergency patients arriving. The situation fluctuates between untenable and dangerous depending on the workload and it crushes spirit and morale in a way no amount of admin sponsored pizza can alleviate. Additionally, we do not enjoy the political luxury of being able to build new hospitals in a matter of days or conscript thousands of people to staff them, so we are stuck, unable to magically produce new bed towers and unable to staff them even we could.

None of these problems, of course, will or can be solved simply by passing some comprehensive new legislation or even by dismantling the for-revenue healthcare industry we have allowed to dominate so much of our lives. Efforts to reform the status quo have been well-meaning but have never taken aim at quite the right targets. One of the most significant provisions of the Affordable Care Act (AKA Obamacare) was the creation of health insurance marketplaces and the controversial individual mandate. These were enacted (to various degrees) at the federal and state levels to ensure underinsured and uninsured Americans had the opportunity to get coverage, ostensibly to help cover expenses and try and give people access to otherwise inaccessible care. The result, however, was a patchwork of programs and options, most of which were still managed and sold by the same insurance companies accused of driving up costs to start with. The increase in insured individuals, however, did little to decrease costs as providers still had to account for increased administrative costs, delays in payment and the constant fight to get reimbursed by companies whose primary goal is to maximize their own profits. Other laws and requirements enacted by Congress and promulgated by regulatory bodies (eg The Joint Commission and CMS) have only added to the headache of trying to practice medicine and receive care in an efficient and predictable way.

Unfortunately, the only way to combat the multiple threats facing America’s healthcare landscape is to also fight on multiple fronts. This will involve both macro and micro changes, some of which are enumerated below:

  1. Misinformation and advertising masquerading as medical information must be brought to heel.
  2. People must have access to resources other than emergency rooms to address unexpected or sudden concerns. This could include things like dedicated pediatric mental health clinics that would help avoid the use of IVC paperwork and police involvement.
  3. Private equity and other Wall Street machinations should be kept out of healthcare.
  4. Physicians and other patient-side staff should have greater freedom to practice based upon evidence and experience rather than protocols and algorithms.
  5. Ensure physicians are doing the job and hold them accountable when they make careless or irresponsible prescribing decisions in the name of expediency.
  6. If we insist on operating in a money driven healthcare system, make state and federal funds available to ensure systems (particularly non-profits) are able to compete and meet the demands of the communities they serve.
  7. Work to change the expectations and attitudes of of people coming into our hospitals – patient and family hostility and abuse are serious contributors to the well documented exodus from the nursing profession.
  8. Work to improve the relationship between direct-care staff and hospital administration. Executives and managers need to be seen in the trenches and not just sending their impersonal memorandums of encouragement.
  9. Interdepartmental cooperation must be made a focus. Too often ED nurses seem to be at war with inpatient colleagues and the pharmacy department gets criticized for “losing” medication that should have traveled with the patient to their various rooms.
  10. Direct-care staff must feel that their concerns are being heard, considered and addressed by the management. Nurses know better than anyone the dangers of 6:1 patient ratios and emergency RNs working as ICU nurses and while most are willing to do what’s needed, they also want to know that real attention is given so that it doesn’t become necessary.

Many of the above points can be accomplished without major legislative action and even those that do could avoid the political minefield that always accompanies any notion of single-payer healthcare. Making the changes needed to reform healthcare in the United States will be a multi-generational quest, not an election year talking point. The kind of work that needs to be done cannot be completed during a single Congress or presidential administration. It will require changes, not just to the way healthcare looks and functions but to the way we think about health and the social structures that overlap. Only then can we hope to achieve the real potential that our country’s medical professionals want to realize.

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