Too often, emergency physicians have acted like piano players in the whore house of medicine. We simply keep plunking the keys and never ask what goes on upstairs. The expenditures of money never seem to interest us very much. The larger running of the hospital only becomes of interest when it interferes with our lifestyle. This month we will review two studies which pull back this curtain and raise fundamental questions as to the way we practice emergency medicine.
First, we’ll start with a question: “Does staying in the emergency department really kill people?” I ask this because we often use this kind of rhetoric as a means to fight ED boarding. However, when we do, we send the message to the public that our EDs are so bad they’re literally killing people. We need to be careful how we frame such issues, because it certainly isn’t that simple.
Article: “Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit” Chalfin, D. B., et al, Critical Care Medicine 35 (6): 1477, June 2007.
A brief summary of this article, which looked at over 50,000 delayed admissions (i.e. those that spent more than six hours in the ED after the decision to admit was made) is frank and startling. Although they could not measure the affect on the patients who were forced to stay in our waiting rooms because they couldn’t get a bed, they could look at what happened to the patients who were admitted. The article concludes that there was no difference in the severity of illness between non-delayed admissions and delayed admissions. They were just as sick if they laid down in the department or got admitted. It was a matter of convenience, not medical necessity. For those patients who were rapidly admitted (within the six hour time frame) hospital stays were decreased from seven down to six days. Also, inpatient mortality was 17.4 percent on the delayed patients and only 12.9 percent on the non-delayed patients. Does this bother anyone? Independent variables for poor outcome did include age, male gender and high APACHE II scores. So the new thinking is obvious: boarding is bad! Get them upstairs! Patients are not like wine, they do not improve with age. This article should be copied and put on the desk of every hospital administrator in the country.
So what’s the hold up? Right now, the thinking is that patients can go upstairs once a bed has been cleared. Why is it that whenever I ask, it feels like the nurses are on break or they’re still cleaning the bed? Why is it that the Marriot seems to be able to clean beds, but we can’t. How come we can’t put people upstairs quickly? None of these things seem to make any sense. Also, the nursing ratio in the unit is two patients to one nurse. It’s never that good in the emergency department. Why are we willing to tolerate a critical patient in the ED with a four or five-to-one ratio when they wouldn’t tolerate it in the unit? None of this makes much sense!
The second question is intimately tied to the current financial condition of the country and our need to bring marginally effective therapies under scrutiny. The question is, “Do helicopters change the outcome in trauma patients?”
There’s no doubt that helicopters are fun. They’re fun to fly in and they’re fun to jump out of. But the old wisdom of “faster is better,” simply may not be true. The ruling is this: there’s no proof that cardiac arrest is actually helped by what we do in the field. This can be extrapolated to helicopters. The old thinking was that if you fly them out of a traumatic event, they’ll do better. After all, if it works in Iraq, it has to work here. The last time I checked, our ambulances weren’t under attack from Al Qaida on their way from the trauma site to the hospital.
Article: “Impact of discontinuing a hospital-based air ambulance service on trauma patient outcomes.” Chappell, V.L., et el, Journal of Trauma 52:486, March 2002.
This article was an attempt to show the necessity of the helicopter system in a trauma setting. The authors compared transport times and outcomes twelve months before and 24 months after suspension of a helicopter service in Texas. After discontinuance, transport times were not negatively affected. Morbidity and mortality were also not affected. What they expected to prove they could not prove. In fact, if anything, it proved the opposite. Considerable money was saved and no difference in patient outcomes could be shown.
This is deep water. In the new reality we are about to face, the critical issue of health care for the dollar will not be avoided. If you want to be in a business that does not ask serious questions about what we get for our money, then you better get out of health care now. The fact that no evidence exists that helicopters in the civilian setting change outcomes is sobering. We have bought into this as if it were a given. What are we going to do from this point on? How are we going to analyze these systems? To what degree are transport times and distances truly affected? And which communities actually need helicopters to change outcomes?
I raise these two issues because they are essentially bellwether issues. What we apply to this we can apply to all things done in EMS. There is very little proof that lights and sirens change outcomes and we need to start seriously looking at expenditure we can truly eliminate without substantially changing the health care outcome in the United States.