COMMENTARY

Fixing Problems in the ED Goes Beyond 'Up or Out'

Robert D. Glatter, MD

Disclosures

March 19, 2020

This transcript has been edited for clarity.

Robert D. Glatter, MD: Dr Gina Siddiqui, a fourth-year emergency medicine resident at Yale New Haven Hospital, wrote an essay entitled "A Doctor's Diary: The Overnight Shift in the E.R.," which was recently published in The New York Times.

It's a provocative piece that examines the social and economic forces that shape how demand eclipses our ability to provide adequate and appropriate care for a large percentage of patients we see in the emergency department (ED). Gina's previous experience as chief operating officer of a healthcare startup has also influenced her approach and outlook on healthcare and medical education.

Welcome, Gina. It's such a pleasure to have you join us today.

Gina Siddiqui, MD: Thanks for having me.

Glatter: Congratulations on this piece. It rings so true, and many of my colleagues have read it. I wanted to reach out and interview you because the reality that you describe really strikes at the heart of emergency medicine. And the "up or out" thesis you have is very true. Can you describe that and what your impetus was for putting this piece out?

Siddiqui: I think that the fundamental problem of "up or out" is really about us having basically one hammer in the ED, and that's the hospital. Either we admit somebody into the hospital or we have to send them home. There are a lot of patients for whom the hospital really isn't going to solve their problems.

If I see a homeless patient who has cellulitis on his foot, I can give him antibiotics that are going to cure it. But if I send him "home" (out to the streets), he's going to get cellulitis again. If I send him up into the hospital, he can have safety and protection, and his feet aren't going to get infected while he's there. But as soon as we discharge him, the same problem is going to occur.

Neither "up" nor "out" is really enough for that patient. And I think that is a really difficult place to be if you're a doctor, a nurse, or a tech taking care of people in the ED and wanting to help them.

Glatter: Absolutely, and we face this on a daily basis. Observation (obs) units have been one potential solution that many hospital systems have integrated. I'm not sure if you've had experience with those at Yale or your other outside rotations. Has that made any difference in this paradigm that we currently deal with?

Siddiqui: It's a great question. I think obs units are a really good example of a problem-solving specialty. Emergency medicine doctors are trying to deal with this very hard constraint that there are not enough beds to take the patients that we need. Obs units are more efficient and faster at taking care of an asthma exacerbation, somebody who needs telemetry monitoring for a few more hours, and expediting a stress test. And for some hospitals, obs units have helped speed things up and led to good cost containment, not too many adverse events, and decreased admission rates. But regarding the problem that I just described of having the one hammer, obs units still leave us with the option of a hospital stay versus somebody going home. That fundamental dilemma remains whether we have obs units or not.

Questioning the Value of 'Superutilizer' Interventions

Glatter: This brings us to the more critical question of the "superutilizers," which was highlighted in a recent article published in the New England Journal of Medicine. It strikes at the heart of what we're trying to do to reduce these patients from coming back. Interestingly, that study found that there was no change in usual care versus a special program that has been used in Camden, New Jersey, and other locales throughout the country.

With that study in mind, what are your thoughts about how we go forward in this segment of the population that we serve?

Siddiqui: I think that's a fascinating piece. It was wonderful to see a randomized controlled trial on this question that there's been a lot of speculation about. I think that it actually reinforces some things that we knew before the study started. We know that these kind of high utilizers and outliers have a likelihood to regress toward the mean, which makes it difficult to study whether your program had an impact or whether patient visits were going to decrease kind of organically on their own.

There are two takeaways that I have from that study. The first is that a program to prevent these superutilizers has to be a little bit upstream of where it was. It can't be reacting to last year's group, because you're sort of chasing your tail. It's thinking about the people who declare themselves as high-risk in the population this year, who we would anticipate seeing if things spun out of control or get worse next year. If we analyze them with the same bias, by only comparing last year to this year, we wouldn't catch that we actually saved a lot of costs by intervening with them.

The second thing is that with these programs, the devil's in the details. There's so much fine-tuning with who the program leads are, how they're going to get in touch with the patients, what the specific patient demographics are, and how targeted and tailored the intervention is.

I think some people interpreted this paper as a reason to dismiss social programs, and I'm more optimistic than that.

Keeping Care Humane, Despite Multiple Obstacles

Glatter: I think we can do both. There can be a systems approach to reducing the cost of care, but also approaches focusing on certain hotspots and these superutilizers.

I want to quote from a part of your article that I think really represents the feelings of many of us who work in the ED. You wrote:

Private exams on stretchers in hallways, patients languishing without attention for hours, nurses stretched to the breaking point; all of it has become business as usual. I think about this on nights like tonight, when I start my shift inheriting 16 patients in the waiting room. I think about what I will learn that these people need, and about what I will fail to provide.

This really strikes me at the core. Having just done a night shift, I thought about your piece and how you drove home these points about the yearning and drive to really reach out to people, to touch them in a way that's positive. Practicing medicine in an environment where people are on stretchers, to me, is in some ways so inhuman. But what you do in your piece is you make it human, to ensure that this process of care makes a difference. I can see that in my mind, and I assume that's what you are trying to drive home.

Siddiqui: I think that some people read those parts of the piece and thought that I was painting the emergency room (ER) as a grim place, with ER doctors as these gruff, insensitive, seen-it-all types. It's like that old stereotype, "treat them and street them."

In reality, that couldn't be further from the truth. The nurses, technicians, and doctors that I work with in the ER are incredibly dedicated to doing the right thing, despite the difficulties placed on them by working under certain constraints. That's far and away the experience I've had with them. I don't know how you felt at your hospital, but I think that's clearly what the intent is. We just have to do a better job of making sure that people aren't put in unrealistically difficult circumstances where they can't get that right.

Innovating Our Way to Better ERs

Glatter: The reality is that our ERs are full of patients. We don't have enough space. As you write in your piece, "The demand is such that new ERs are already too small by the time they are built."

That brings me to the next point. You talk about how an ER's success is currently measured by how fast we see patients, and not by whether we break these cycles by intervening in social issues and dealing with these dilemmas where patients come back. One in 10 patients return to an ER within 3 days of being discharged, which is a problem. This is really what we're trying to get at.

How do we break these cycles? Can we change it so that speed isn't the only measures of quality that we're looking at?

Siddiqui: We can consider it almost like an overbooked restaurant. Some people view these as intrinsically doomed. However, I'm sure you've had the experience of going to some overbooked restaurants that are pretty well run and people are doing the best they can under the constraints. They're respectful of every person who's waiting. Then there are some overbooked places that are in total chaos and leave you worried. I think ERs are the same. Everybody's trying to react to the constraints and there's a range of how well that's done.

I think credit is due to a lot of the innovations over the past few decades dealing with ER boarding. The ER used to be seen as the most chaotic and unsafe place. The waiting room was where a lot of tragedies would happen. You'd even see somebody who was already in the hospital die in the waiting room, which could have potentially been avoided if only somebody were looking at them and they'd gotten a workup sooner. ERs have responded by pulling those people back to be assessed even at really busy times.

So, great progress has been made. A lot of it does have to do with us trying to rigorously measure what we're doing. You know the expression that sometimes the simplest things are the hardest to measure? The simple thing that I would want to measure is whether a patient who comes in feels better off when they leave the ER. What's complicated about that is it's not whether we have decreased the length of stay. It's not necessarily going to be solved if their stay is longer either. It's not about whether we decreased total testing or increased the number of tests that we offered. It's more nuanced and case-to-case than that.

Glatter: I agree. I think patient satisfaction surveys should change. There should be a whole realignment to what you're speaking to. Speed is not the most important measure of an ED's efficiency. There are so many other things to talk about.

Siddiqui: What's complicated is that it's not as if it is wrong to measure speed, but rather that eliminating speed or taking longer isn't necessarily the solution either. It's really hard to measure this and prove it.

Glatter: There's also been talk around using artificial intelligence and sensors to monitor patients in the waiting room and the ED. New startups are also looking at virtual care for patients in the home setting, creating an almost virtual hospital. Integrating that model with a standard hospital would be an interesting way to intervene in our paradigm of care. Do you see this virtual hospital model as a segue between the ED, between the hospital and the outpatient center?

Siddiqui: It's a really interesting and active area of research. I'm by no means an expert, but there are some people who believe that the future of the hospital is going to be just an ER and an intensive care unit. Everything in between, all of the other hospitalizations that we deal with, are going to be managed at people's homes and other facilities through all these monitors and sensors that you're talking about.

Glatter: Do you have any parting thoughts about your article that you'd like to share?

Siddiqui: A lot of people have asked me what the solution is, and obviously it's complicated. There are a lot of really smart people who've been working on this for a long time. The shift in perspective that I would like us to have is to stop thinking about the ER as being the problem.

There are reasons why we've been trying to reduce ER visits—primarily, the expense and the fragmentation of care. But the ER is a place where anybody can come. The doors are always open: 24/7, 365 days a year. People are coming to us when they feel that they don't have any good alternatives, and I take my responsibility to them very seriously.

For progress to occur, it's going to have to happen between the ER and the rest of the health system to make sure that we're finding the right ways to take care of the people coming to our doors. Maybe we are the entryway, the first step for being connected to follow-up for behavioral health, coaching, detox—all the different resources that people have a really hard time finding. I think we are a huge asset to a lot of people.

Glatter: Absolutely. I will agree with that. I want to thank you so much for your time and your insights. This has been incredibly valuable for our audience.

Siddiqui: Thanks so much for having me.

Robert D. Glatter, MD, is an attending physician at Lenox Hill Hospital in New York City and assistant professor of emergency medicine at Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. Glatter is an editorial advisor and hosts the Hot Topics in EM series on Medscape. He is also a medical contributor for Forbes.

Gina Siddiqui is a fourth-year emergency medicine resident at Yale New Haven Hospital. Prior to treating patients in the ER, Gina founded and led a digital health company in Silicon Valley called Remedy Inc. Follow her on Twitter @zaberdasst.

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