In response to my post on ER overcrowding DB notes that the Institute of Medicine (IOM) is unrealistic on many issues and points out the relationship of ER overcrowding to under compensation of general ambulatory care. Increasing utilization of the ER as a “clinic” by patients without access to primary physicians overtaxes emergency care. Worse, some ER patients require hospital admission largely due to the shortage of clinic doctors and inordinate wait times which preclude expeditious out patient work ups.
Today Grunt Doc offered a dissenting view and said (referring to DB, Kevin and myself): “The linked commenters in the first paragraph give a 'suck-it-up ED' subtext that rankles. We're doing that.” I guess I pushed the wrong button here, but no such subtext was intended. I was being critical of the IOM, not emergency departments. I have no doubt they’re doing the best they can.
He made this comment over at DB’s blog: “I think there’s a lot of arrogance in absolving the hospital of any responsibility to ease ED overcrowding. Overcrowding isn’t a result of ED inefficiencies, it’s a lack of hospital ownership of the patients admitted to the hospital through their own ED.” Wait a minute---nobody’s blaming the ER here. This isn’t “us against them.” The emergency department is part of the hospital. Their problems are the hospital’s problems, and vice versa. If the ER is overtaxed the entire hospital feels the strain due to extensive overlap and sharing of resources.
What’s Grunt Doc’s solution? Hallway beds. Fine. It seems to work at his institution. I’m not exactly sure what the hallway protocol entails, but I suppose it means that if all regular beds are occupied (hospital “full”) you put the patients where ever there’s physical space, initiate care and hold them there until a regular bed opens up. To me that’s a form of boarding, but you do what you have to do. There’s nothing written in stone in my mind that such boarding has to take place in the ER unless the patient needs cardiac monitoring.
But hallway boarding has its problems too. If the hospital has reached the capacity of its licensed beds (presumably the case if its wards are really full) might those hallway admissions run afoul of the law? In many cases it’s about more than licensed beds and physical space----it’s about staffing. That’s a patient safety issue. There’s plenty of evidence that higher patient to nurse ratios are associated with increased mortality. In this study, for example, 30 day mortality rose 7% for each patient added per nurse.
I’ll say it again. My whole point was directed at the IOM. They say hospitals wouldn’t have to divert or “board” if they’d just be more efficient. That is simplistic. Hospital administrators, physicians and case managers have been working their fannies off to make hospitals more efficient under draconian negative cost incentives (AKA DRGs) that have been in place for 23 years. That is not the answer to ER crowding.
Related criticisms of IOM:
The hyping of medical errors.
The promotion of pseudoscience.