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Emergency Medicine News:
Quality Matters

Holding Your Own

Welch, Shari J. MD

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Dr. Welch is the quality improvement director in the emergency department at LDS Hospital in Salt Lake City, a clinical faculty member at the University of Utah School of Medicine, a quality improvement consultant to Utah Emergency Physicians, and a member of the Emergency Department Benchmarking Alliance.

Thanks to a new understanding of ED overcrowding iterated by the Joint Commission on Accreditation of Healthcare Organizations, hospitals are at last viewing patient flow in the ED as a system problem, not just an ED nightmare. Shouldn't emergency practitioners be optimistic about their future prospects for expediting patients through busy departments? Perhaps not.

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The work that emergency physicians do and the care given grows more complex each day. We are well aware that the demand for emergency services continues to increase. From 1993 to 2003, the ED utilization rate went from 35.5 percent to 39.9 percent. (Advance Data from Vital and Health Statistics. CDC, National Center for Health Statistics, May 26, 2005, No. 358.)

Though the utilization rate increased for all age groups, those over 65 have a higher utilization rate than other age groups, and those over 75 have 60 ED visits per 100 people annually. Further confounding this picture, the number of diagnostic services and procedures performed rises linearly with age. As the U.S. demographics change and tilt toward the elderly, demands on emergency departments will only increase.

Still more sobering is that the two most common chief complaints presenting to the ED are abdominal pain and chest pain. Such complaints are high risk by nature, time consuming in their work-ups, and they do not lend themselves to any expeditious “treat-and-street” model. Currently ED visits result in diagnostic services for 89.7 percent of patients, imaging for 42.9 percent, and medication administration for 77.3 percent.

With aging patients and their complicated medical histories, this can be expected to rise. Complex and time-consuming tests such as CT of the abdomen with contrast, MRI, and cardiac stress testing are on the rise. In fact, in a survey this year of some of its member hospitals, the Emergency Department Benchmarking Alliance found that MRI utilization by the ED had risen fivefold since 2000.

Another source of bottlenecks in the ED involves subspecialty consultation. In a survey conducted by the American College of Physician Executives, 64 percent of respondents reported having problems getting subspecialists to take call at their hospitals. (“EDs Face Shortage of Specialists.” ACEP News 2005;24[6]:17.) Neurosurgery and orthopedics are two difficult specialties to cover, but in some areas, even general surgery may be uncovered at times.

An ED holding area may offer answers for patients who do not require observation but four to six hours of diagnostics

As emergency departments are being forced increasingly to operate in overcapacity situations, patients who may not need admission but who require four to eight hours of ED services pose a liability when trying to maximize operational efficiency. More than 10 years ago, Louis Graff, MD, first proposed the idea of observation units and subsequently wrote a book about the concept. (Observation Units: Implementation and Management Strategies. ACEP Publishing. 1998.)

He had in mind patients who needed 24 hours of care to improve (asthmatics, overdoses, diabetics) or prolonged diagnostic work-ups (possible appendicitis or cardiac enzymes to rule out MI). With advances, the diagnostic uncertainty of the latter group can be alleviated with CT scans and stress tests in less than 24 hours and avoid even the observation stay. On the other hand, they frequently need more than four hours of ED care, so the ED holding area was born.

Such an area would ideally be a large multifunctional space much like the wards of older hospitals. They would be designed for less therapeutic intensity than the main ED or observation units and likely would be staffed by less skilled workers such as ED technicians. Attention would be paid to comfort and diversion (through movies, magazines, radio, family members) in this area. ED techs would maximize their skills at keeping patients comfortable (ice packs, blankets) while communicating with their nursing team members if patients had any medical problems such as requests for more pain medicine.

Bear in mind that the gap between full-time nurse equivalents versus requirements will continue to widen to a shortage of 800,000 by 2020! (AHA Hospital Statistics, Health Forum, LLC, American Hospital Association, 2005: xv.) In addition, patients requiring such prolonged work-ups would have a sense of moving through the system by physically advancing to the holding area.

Such ED holding areas would keep the main ED beds open for patients requiring a higher level of therapeutic intensity or diagnostic procedures, and would keep nurses dedicated to nursing care. In this model, patients waiting for CT, MRI, and stress testing would be shuttled to the holding area. Likewise, stable patients waiting for subspecialty consultations such as a plastic surgeon or orthopedist could be placed in the holding area. During overcapacity situations, patients waiting for an inpatient bed who are now stabilized also could be transferred to holding.

The practice of emergency medicine keeps changing and so too should the model for providing appropriate services. Many demographic and technological variables are converging to create a new population of patients in the emergency department. They do not require a 24-hour observation admission but four to six hours of service (typically diagnostic in nature), which is a burden to the busy department. The ED holding area just may be the conceptual answer. As emergency department directors and managers address patient flow in the future, ED holding areas offer a number of advantages to all stakeholders.

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Examples of Patients Eligible for Holding

Stable Patients Waiting for:

* ▪ Diagnostics

* ▪ MRI

* ▪ Stress testing

* ▪ EEG

* ▪ Ultrasound results

* ▪ Repeat labs in trivial overdoses

* ▪ Consultation

* ▪ Plastic surgery, orthopedics, teaching

* ▪ Diabetic care, wound care

* ▪ Social services

* ▪ Inpatient bed (rarely in overcapacity situations)

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Characteristics of the ED Holding Area

1. Multifunctional open space

2. Designed for less therapeutic intensity

3. Designed for patient comfort (blanket warmer, ice packs)

4. Built-in diversions (television, radio, reading material)

5. Staffed by ED technicians

© 2005 Lippincott Williams & Wilkins, Inc.

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