Before COVID, emergency medicine in the United States was already in the throes of an identity crisis. Emergency departments (EDs) across the country had plenty to do — in fact they were busier in terms of per capita visits than ever before — but the majority of business did not fall within the areas of expertise that had conventionally defined emergency medicine.
Kidney stones and ruptured appendices were getting outpaced by weak grandmas and weekend binges. Problems with a sudden onset and a surgical solution were losing ground to problems whose roots arose slowly, insidiously, and had no quick solutions. These chronic problems rarely could be definitively solved by a single visit to the ED. One hospitalization would beget another, and another. In the twenty-first century, some people visited EDs more days than they didn’t.
Then COVID happened. Very quickly, and dramatically, who sought care in the emergency department changed again. As we spent our entire shifts adjusting ventilators and oxygen supports, we wondered how all of our old patients were doing without us. Now that restrictions have lifted, more people have started to come back, though not exactly the same groups of patients as before.
All this changing of traffic patterns can’t but lead those who reflect to ask: what is the job of the emergency department? Little satisfaction comes from a prescriptive answer to the question. The old definition of emergency medicine doesn’t reflect our job as it is now: much of what we do is not about acute injuries but injuries that have been around for a long time, and many patients we see are less in need of immediate medical attention than of regular, reliable medical attention.
Perhaps it is time for a descriptive approach: defining emergency medicine by whatever comes through our doors, not by what we say ought to come through our doors. What would happen, if from now on, we defined our jobs based on how the public interpreted the red sign outside, not on how we did?
Defining the Problem
Democratizing the definition of emergency care matters, because what we say is our job defines when we say we did our job well. We can say that patients without primary care doctors who come to the ED for treatment of minor complaints should not be in the ED (prescriptive). Or we can acknowledge this group’s ongoing presence in the ED, despite the ACA, and despite COVID (descriptive). When we call it our problem, we can adapt.
MD, Yale Department of Emergency Medicine; NYC Health + Hospitals
Democratizing the definition of emergency care matters, because what we say is our job defines when we say we did our job well.
Because of how we define ourselves,
this is how EDs define success:
And if we defined ourselves differently, this is how we could see success instead:
“throughput:” seeing as many patients as efficiently as possible. Trying to stay full (generating bills) all the time
“quick disposition:” patients need to leave the ED. We send them home or into the hospital or to a facility based in part on how expeditiously it can be done
our purview is emergencies, so our main job is ruling out life-threatening emergencies
not getting sued
narrow scope of responsibility
saving as many patients the trip to the ED as possible. Helping people from home. Trying to maintain a reserve
patients need to end up in the right place. Doing disposition right the first time, even if it takes a little longer, to avoid problems down the road, and
limit dependency on the ED
helping patients deal with
non-emergent, and sometimes even non-medical, problems
not missing the root problem
broad scope of responsibility
When we classify certain “non-emergencies” that keep winding up in the ED time and time again as not our problem, we absolve ourselves. We resign these groups to sub-par care, and we too are harmed in the process. It makes us less satisfied with our work, passing much of our day not helping patients be any better off than when they came in.
But when we think of these patients as ours, we correct our blindspot. We bring the same urgency to finding a solution as we would to any sine qua non of our job. And when we apply urgency like that, things start to happen — here are two examples:
EDs today are only paid for patients they see in-facility. Similarly, ambulances are only paid when they transport patients to “covered destinations” like the ED. This means even when ambulances and EDs know a patient shouldn’t be in the ED, bringing them there is the only way they will get paid. No one wants to fight an uphill battle and not get paid.
To correct this, the Center for Medicare & Medicaid Innovation launched ET3, a new model whereby ambulances and hospitals are paid for treating patients in “alternate destinations” such as clinics or right on-scene wherever the ambulance arrives. It also pays emergency medical service agencies to coordinate more with patients at the time they call 911. All of this rewards systems for meeting patients’ needs flexibly, rather than reflexively ushering them to the ED.
2. Dispatch Health
Another company taking on the patients not treated well by the status quo in EDs is Denver-based Dispatch Health. The company replaces trips to the ED with home visits, by taking calls from patients intending on coming to the ED and characterizing their level of medical need. Through this more in-depth assessment up-front, they identify a large subgroup of patients for whom they can drive over with a few meds and supplies in their car, and avoid the ED altogether.
As long as the quality of service is high, many patients feel treatment at home is more convenient for them and prefer it over going to the ED. Insurance companies also favor treatment at home over the ED, because it’s less expensive. Unfortunately, many EDs, however, oppose programs like this. Why? Because less-complicated patients offer departments the highest profit margins.
Across the country, there are patients coming to EDs to face long wait times, higher bills, and, in times of COVID and other pandemics, exposure to sick persons, while we have safe medical alternatives that make all of this unnecessary. Should the ED own this problem, or say that these patients are not how we define ourselves?
You are what you do every day. Like it or not, we are whatever society necessitates of us. When we start thinking of our jobs in terms of the needs declared to us, we see where we are well-equipped, and where we need help. But when we ignore patients we aren’t serving well, we don't develop alternative pathways for them. We end up stuck doing what we’re not good at.
EDs that partner with communities will retain value and never be out of a job. In contrast, COVID has put EDs and their affiliated hospitals that rigidly stick to old definitions of their purpose at risk. Defining emergency medicine to include all of our patients makes the goal of serving all a challenge we want to meet and can meet — not one we keep avoiding.
The old definition of emergency medicine doesn’t reflect our job as it is now... Perhaps it is time for a descriptive approach: defining emergency medicine by whatever comes through our doors, not by what we say ought to come through our doors.