Tuesday, November 21, 2006

Here we go again on ER crowding. It’s not us against them.

A while back I wrote a series of posts criticizing the Institute of Medicine’s proposals to remedy ER crowding, and their incredible statement that hospitals can fix the problem, and eliminate diversion and patient boarding just by being more efficient. I thought I made it clear that I was only criticizing the IOM, but then Grunt Doc weighed in with this:

Second, what's so magic about the ED? Only the ED and OB have rubber walls and are infinitely flexible, to try our best to care for every patient ho needs our help. Except, see, our walls really aren't made of magic rubber, we can't just snap our fingers and make more rooms, beds, monitors or nurses appear. Every patient who should be admitted to the hospital but isn't is a) not getting the specialized nursing care available on the ward where they belong and b) is taking up a bed in the ED we need to see then next 1-12 patients. The linked commenters in the first paragraph give a 'suck-it-up ED' subtext that rankles.

That wasn’t what was intended, so I clarified here. Grunt Doc graciously relented (in my comments). But the finger pointing by some of the ED types in his comments suggested an “us against them” attitude. My clarification post made these points:

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. Concerning whether patients who needed boarding should be boarded in the ER or on the wards I said: 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.

Well, I figured I’d made that pretty clear until commenter Ryan (evidently an ED provider) weighed in with this straw man: My question to you is why are my halls better then your halls? And then: I ask again why floor nurses are different from the ED nurses.

Look, it’s not a matter of my nurses vs. your nurses, or my hallways vs. yours. I never said it was! Why do ED types seem to want to frame it in adversarial terms? Hospitalists are “on board” with this issue. We’re on the same side. Really. One of the thought leaders at the Southern regional hospitalist meeting in New Orleans a week or two ago said that the Society of Hospital Medicine is committed to helping improve ER throughput. (I wasn’t there but I browsed the syllabus one of my colleagues brought back. Sorry I missed you DB. We’ll hook up one of these days).


Allen said...

Actually, we were afraid of physician push-back to hallway beds upstairs. It turned out not to be an issue at all, from the physician side (and that's the story we got from the hospital reps we got the idea from). The docs might initially say "I don't want my patient in the hall", but when presented with the reality that their patient will either get an ED hall or an upstairs hall they grudgingly agree, and then let it go.

The real barrier to this (and any other transformative action is hospital bureaucracy and turf. The ones who push back on hallway boarding are the nurses; it's a different practice, it's more work, etc. Our hospital spent a lot of time in meetings, and made it work very smoothly. It helps; it's not the solution (and there is no the solution, it'll be a mixture of changes necessary) to help out the ED overcrowding.

I think the problem between the two 'sides' here is that the ED's are being swamped, the IOM made at least some helpful if halfway recommendations, and these were immediately poor-mouthed by people not in the ED as (I paraphrase) 'not a useful recommendation'. That's what got our collective dander up; we're getting over-run, and docs aren't supporting the recommendations, innocous though they are.

We're not enemies on this issue, at all, but we are sensitive when we percieve we're not being supported in our effort to decompress the ED and give more timely care.


Notes from Dr. RW said...

Grunt Doc,
I try not to talk too much about conditions at my own place, but would just mention that I have no axe to grind, no personal interest whatsoever about where patients are boarded, and absolutely no role in deciding. No personal interests, no conflicts. Same with nurses---they get pulled where they're needed most, from ER to ward and vice versa. The IOM's recommendation---no boarding, no diversion, no nothing, all a hospital has to do is be efficient----was what got my dander up. To me that was less than helpful and patently absurd.

At my place, if a patient needs boarding I would much prefer it *not* be in the ED.

Kim said...

I don't "do" hallway nursing. Not because of me but because of what it means for the patients!
I saw my critically ill father transferred to an ER and heard Who the hell is that? Put him in the hallway, we don't have room.

Ever since then I have an absolute aversion to putting any patient in an ER.

But...I'm lucky. We have an actual "extra" room in our ER that can hold up to four patients, on gurneys. It's extra because it is away from the nurses station and is not part of the regular department. It does however have oxygen and suction.

My hospital is small but we are starting to run into the bed issue.
So, if we overflow, we call in an extra ER nurse to be the "overflow" nurse. One "overflow" nurse can take four medical surgical patients and still stay in the mandated ratios of my state. We even have a portable monitor in case one is a tele patient.

In an extreme emergency, the pre-staging area for the cardiac cath area attaches to this room and has three more beds.

My point is, while we are holding patients in the ER, they aren't twiddling their thumbs upstairs. The minute we start holding patients, the in-house patients are being triaged and those who can be are being discharged. The whole facility mobilizes.

As long as those of us in the ER know that we are not being "dumped on" and that every resource is being used to mediate the situation we're happy to do our part.

And the stubbed toes, the "I vomited once", the scraped knees and the twisted ankles just have to wait.

They won't be happy and our patient satisfaction scores will fall and then we'll be told how we have to be more considerate and work faster.

Sometimes those of us in the ER feel like we are stuck between the public that we can't turn away and an impacted facility that can't mobilize fast enough to accomodate the admits.

We would prefer it otherwise, but it's the nature of the job.

But...there are options to the hallway bedding and I'm lucky my facility had the room and the layout in the ER to at least minimize it as much as possible.

NOT because it is more work for me (the nurses) but because it is an awful message to the patients and their family.

I've been on both sides of the hallway. I'll do anything to keep a patient within four walls and not out for the entire world to view.

Kim said...

Ooops - I meant aversion to putting a patient in an ER HALLWAY! LOL!

I don't mind a patient in an ER! LOL