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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. 
 

Comments   

# EMS medical director Highland Park Hospital EMS systemJack Whitney M.D. 2008-11-06 18:19
We just lost an Illinois flight crew: pilot, nurse and paramedic, as well as, the infant patient in a crash after collision with an aerial tower stay wire. Flight services should offer Critical care ground responses and transfers with appropriate review of risks vs. benefit of flight transfer with patients or families. A national model for risk and benefit will need to be created and tested.
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# More questionsDan Bledsoe, MD 2008-11-07 11:33
I know that Greg's point in this column is to stimulate thought, and he has again succeeded with this installment. There is an allusion to the use of EMS all together being a piece of the health system with questionable cost-benefit issues. I agree with Dr. Henry in that we definitely overutilize helicopter EMS and that this industry requires careful oversight and national standards for utilization of HEMS. As for ground based EMS, it is an essential piece of the public safety mileau. The potential benefits of ground based EMS have not been touched yet, and this new century will hopefully find some common sense expansions of the BLS scope of practice and the paramedic scope of practice expanding into public health areas (flu shots, childhood vaccinations, more treat and release to primary care physician follow-up, etc.).

EMS is high cost but has many untapped areas of potential for improved utilization.

As for the first point, boarding is bad. We all know it. The key is getting the rest of the hospital to take ownership of their capacity issues to relieve the outflow obstruction in our EDs.
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# Evan Weinstein 2008-11-07 14:27
I think the issue of boarding is one that have us camped out in front of the administration wing every day, and should make us tell the administration we aren't going send out one more Press-Ganey Survey until they deal with this issue since it is a huge pt saisfaction issue (or at least it should be). I think hospitals just need to realize many days there will just be a flood of patients and EVERYONE in the house will have to deal with them. No more "the beds are full upstairs so hold them in the ED or transfer them. When I was a resident, I would say, if the can be in the hallways down here, why can't they be in the hallways upstairs. Evryone thought I was crazy until the research starting comming from SUNY Stony Brook saying the same thing. At some point, hopefully soon, we need to stand up for ourselves and our patients, and tell the administrators this is how it is going to be, and stop asking, and having meetings etc.
As for helicopters, while I agree in general that they are over used. I am 1.5 hours from Boston in a small community hospital, cuurently, a helicopter is the only way to get a critically ill pt, on complex drips or a vent to Boston. When I have a choice between sending a nurse and an RT in the back of an ALS ambulance bagging the pt for 90 minutes, or a nurse and medic with all of the critical care transport toys with a 20 minute transport time, I pick the helicopter.
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# RNJohn 2008-11-09 21:47
I am an ED Nurse and here is my 2 cents about the holding of patients in ED. I think at least partial responisbility with the care should be placed upon the receiving unit. If we are holding 2 ICU level patients in the ED, along with the other 3 or 5 regular ED abd/ cardiac/renal work-ups per Nurse, Send down an ICU person to care for the 2 ICU patients. I dont personally care where they are being taken care of. We should all be concerned with HOW they are being taken care of. If it is staffing that is the issue, ie: "we dont have a nurse to send down" .. Do what it takes to recruit and retain staff.. Treat and pay your nurses well, stop appling the industrial model of management when peoples lives are at stake.. and you will have all the staffing you could want just by word of mouth. Then nurses dont feel over burdened and patients get the level of care they should receive.
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