Friday, April 18, 2008

ER boarding and mortality

A report last June in Critical Care Medicine concluded that ER boarding of patients for greater than six hours awaiting ICU transfer is associated with increased mortality and length of ICU stay. I was tipped off to the article by this rant from Emergency Medicine News. And quite a rant it was:

Although reasonable solutions to this problem have been suggested (e.g., putting admitted patients on the halls of the wards), most administrators have chosen not to contaminate the rest of the hospital with these excess patients but rather hold them in the ED where they make the department malfunction substantially. Their reasoning: It may offend the medical staff, patients' families, and hospital floor staff. The philosophy is to sacrifice the ED and its patients for the sake of the rest of the hospital. Until recently, the perceived consequence of this decision was to reinforce the general beliefs of the community that EDs are associated with long waits and a litany of other

It sounds like more of the “us against them” finger-pointing I’ve commented on before. Here’s more:

We need aggressive medical staff leadership driving lengths of stay; we need administrators willing to close the hospital to elective surgery when the ED has no place to put its patients; we need options to efficiently discharge admitted patients; we need hospitalists committed to providing efficient, evidence-based care; we need ICUs open only to those qualified to admit patients to these units (rather than every Tom, Dick, and Mary on the medical staff). And, yes, some of these initiatives will upset the medical staff, but hospital and medical staff leadership need to jointly step up to the plate and take on the challenge.

ER crowding is a problem every hospital should be concerned with, and I agree with some of the suggestions above. But let’s get back to something more basic. From the introduction of the Critical Care Medicine paper (emphasis mine):

Emergency department (ED) “boarding” of critically ill patients (holding admitted patients pending ICU bed availability) is common and increasing in frequency in the United States, resulting in a prolonged ED length of stay (LOS).

Therein, perhaps, lies the problem. The patients were being boarded but were they being actively treated? Once the admitting doctor accepts the patient, that patient is considered “handed off.” There is a prevailing mindset that the ER is not a place for ongoing care once a disposition is reached. That mindset was expressed in the discussion section of the paper:

Whereas the ICU is a clinical environment that, by definition, enables close attention to the critically ill and allows for expeditious recognition of physiologic change and sudden deterioration, the ED under most circumstances is neither designed nor staffed to provide extended longitudinal care for the critically ill patient.

So, acknowledging that ER crowding is a problem with no quick fix in sight, perhaps, while we work on solutions, we should also look at what happens to ER patients during the delay. What kind of care are they getting? The study does not answer that question.

For some patients there’s evidence that definitive ongoing care in the ER for six hours before admission to ICU is associated with good outcomes. I’m referring, of course, to septic patients who are candidates for early goal directed therapy (EGDT). In the original protocol validated by Rivers, et al, patients were kept in the ER for EGDT. In fact, ICU personnel were not involved until the protocol was completed.

The solution is complex and multifaceted. Admitted patients who have no reason to remain in the ER for a specific intervention (e.g. EGDT) should be transferred as soon as possible. Inefficiencies in bed control should be sought and addressed. Ambulance diversion should be judiciously employed, Institute of Medicine recommendations notwithstanding.

This study raises another issue which hasn’t been addressed, and is ignored in the Emergency Medicine News piece: Given that ER crowding is going to be with us for some time, someone needs to address the quality of patient care during “boarding”, whether it takes place in the ER or other areas of the hospital.

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