In which I shall depart from the party line
The conventional wisdom has been that as the crisis in American healthcare has deepened, as the number of uninsured Americans grew and the access to primary care dwindled, the nation's ERs have been choked with patients seeking primary care, with non-urgent complaints, with trivial stuff that chokes up the departments and distracts staff from the truly ill patients with real emergencies.
ACEP and the house of Emergency Medicine have pushed back hard on this perception. They contend that most ER patients are in fact in the ER appropriately and that the real problem is a lack of inpatient beds which force admitted patients to be boarded in the ER, thus exacerbating the overcrowding crisis. ACEP is right to focus on patient boarding -- it's a real problem, and it's a more tractable problem. But I've always thought it strains credulity to claim that there are few non-urgent patients in the ER. It actually seems a self-serving bit of fiction, designed to protect the turf, protect the business, to justify further investment in the ER.
I saw this triumphant tweet from ACEP's public affairs office yesterday:
And my initial response was: hogwash. 7% of patients non-urgent? No way.
So I started by actually reading the linked publication: the National Health Statistic Reports 2007 Emergency Department Summary (warning: PDF). The methodology is simple: they looked at a statistically valid sample of ER visits and complied the descriptive data, including triage level. Apparently everyone uses the 5-level triage scale now, or enough that they could extrapolate to national figures, and I am sure that their statistical prowess far exceeds my own, so I'm not going to quibble with the results. As stated, only 7.9% of ER patients were triaged at the lowest level of urgency. The triage scale, for those not familiar, is this:
Sensible enough. So are the PR guys at ACEP right? Are 92.1% of patients in the ER in fact, emergent? Maayyybe. But I think not. Note that green category, "semi-urgent." That includes another 21% of patients. Now this is where things really get subjective. What's the difference between a level 4 and 5 triage? What's the difference between Semi- and Non-urgent? I have no idea. Sure, there's a definition (green means the patient should been seen in 61-120 minutes), but in my experience the triage nurse simply picks a level kind of arbitrarily when the patient is on the low end of the spectrum. Quite frankly, the nurses tend to use green as "non-urgent" and blue as "so fricking non-urgent that I am mad at you for coming to the ER." So my contention would be that the more accurate interpretation of the NHSR report reflects the reality that somewhere around 29% of ER patients are not true emergencies.
This is also consistent with the larger trend we have been seeing in medicine - the rate of ER visits over the last decade has increased at twice the rate of population growth. To some degree this is due to the aging of the population and the increase in the number of Americans living with chronic disease. It is also, I suspect, due to the slow death of primary care and the rise in the number of uninsured and medicaid patient who effectively have no access to primary care. (It's worth noting that the uninsured patients in the NHSR report skew to the lower acuities.)
This is also consistent with my experience. It's reasonable to take triage acuity as a sense of whether a patient had, prospectively, a potential emergency. But when you do look retrospectively at diagnoses, it paints a very different picture. Of the 22 million pediatric visits, about 9% were due to otitis media and URI's alone. When I look at the most common diagnoses in our ER (a relatively high-acuity ER) I see a lot of not-exactly-emergent diagnoses on the list:
Now none of this is to say that I blame patients for coming to the ER with these complaints. Generally they are doing the best they can in the system we have. If there were primary care docs and urgent care clinics who could care for their urgent problems, many would choose to go there. Even more would choose to go to urgent cares if they had an economic incentive to do so -- like a higher co-pay. However, the ER is "free" for many and we are open 24/7 with no appointment needed, so we become the convenience clinic in addition to the safety net.
In an ideal world, we would have a front desk with two doors behind it: one to the main ER and one to an urgent care clinic. Or even if we had the ability to screen patients and refer them to clinic appointments. But EMTALA makes such endeavors dicey: you make mistakes with that sort of policy and you can be in a world of trouble. Moreover, the economics of office-based practice are so marginal and the crummy payer mix of the average ER makes it worse, so few hospitals or medical groups are eager to open up such urgent care centers. So we are stuck seeing all comers, the emergent as well as the urgent and the semi/non-urgent. It's not an ideal situation, but it is not going to change any time soon.
It does not behoove ACEP, however, to make and persistently repeat claims which are false or misleading about the acuity of the patients we serve. It reduces our credibility in the policy debates and wastes energy on an issue which is a distraction from the other (more tractable) issues challenging the emergency care system
ACEP and the house of Emergency Medicine have pushed back hard on this perception. They contend that most ER patients are in fact in the ER appropriately and that the real problem is a lack of inpatient beds which force admitted patients to be boarded in the ER, thus exacerbating the overcrowding crisis. ACEP is right to focus on patient boarding -- it's a real problem, and it's a more tractable problem. But I've always thought it strains credulity to claim that there are few non-urgent patients in the ER. It actually seems a self-serving bit of fiction, designed to protect the turf, protect the business, to justify further investment in the ER.
I saw this triumphant tweet from ACEP's public affairs office yesterday:
And my initial response was: hogwash. 7% of patients non-urgent? No way.
So I started by actually reading the linked publication: the National Health Statistic Reports 2007 Emergency Department Summary (warning: PDF). The methodology is simple: they looked at a statistically valid sample of ER visits and complied the descriptive data, including triage level. Apparently everyone uses the 5-level triage scale now, or enough that they could extrapolate to national figures, and I am sure that their statistical prowess far exceeds my own, so I'm not going to quibble with the results. As stated, only 7.9% of ER patients were triaged at the lowest level of urgency. The triage scale, for those not familiar, is this:
This is also consistent with the larger trend we have been seeing in medicine - the rate of ER visits over the last decade has increased at twice the rate of population growth. To some degree this is due to the aging of the population and the increase in the number of Americans living with chronic disease. It is also, I suspect, due to the slow death of primary care and the rise in the number of uninsured and medicaid patient who effectively have no access to primary care. (It's worth noting that the uninsured patients in the NHSR report skew to the lower acuities.)
This is also consistent with my experience. It's reasonable to take triage acuity as a sense of whether a patient had, prospectively, a potential emergency. But when you do look retrospectively at diagnoses, it paints a very different picture. Of the 22 million pediatric visits, about 9% were due to otitis media and URI's alone. When I look at the most common diagnoses in our ER (a relatively high-acuity ER) I see a lot of not-exactly-emergent diagnoses on the list:
- Lumbar sprain
- Bronchitis
- Headache
- Migraine
- UTI
- Unspecified Viral Infection
- Lumbago (really?)
- Otitis Media
Now none of this is to say that I blame patients for coming to the ER with these complaints. Generally they are doing the best they can in the system we have. If there were primary care docs and urgent care clinics who could care for their urgent problems, many would choose to go there. Even more would choose to go to urgent cares if they had an economic incentive to do so -- like a higher co-pay. However, the ER is "free" for many and we are open 24/7 with no appointment needed, so we become the convenience clinic in addition to the safety net.
In an ideal world, we would have a front desk with two doors behind it: one to the main ER and one to an urgent care clinic. Or even if we had the ability to screen patients and refer them to clinic appointments. But EMTALA makes such endeavors dicey: you make mistakes with that sort of policy and you can be in a world of trouble. Moreover, the economics of office-based practice are so marginal and the crummy payer mix of the average ER makes it worse, so few hospitals or medical groups are eager to open up such urgent care centers. So we are stuck seeing all comers, the emergent as well as the urgent and the semi/non-urgent. It's not an ideal situation, but it is not going to change any time soon.
It does not behoove ACEP, however, to make and persistently repeat claims which are false or misleading about the acuity of the patients we serve. It reduces our credibility in the policy debates and wastes energy on an issue which is a distraction from the other (more tractable) issues challenging the emergency care system
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