01 October 2012

Are low acuity patients congesting the ER?

I had an interesting twitter chat the other day with one of my colleagues, a young ER grad studying healthcare policy by the name of Seth Trueger. You should check out his blog over at MDaware.org. The twitter conversation wound up involving about a dozen ER docs and nurses. You can review an edited summary over at storify. Yes, of course Gruntdoc was involved. That guy never shuts up.

The point in contention is an interesting one: we know the nation's ERs are overwhelmed and overcrowded. That's old news. We also know a big driver of this is boarding of admitted patients in the ER due to limited inpatient beds. If you're a 20-bed ER and you're boarding 5 patients, you've lost 25% of your throughput capacity. Common sense that this is a big issue. But, the argument hinged on, what is the contribution of the proportion of ER patients who "don't need to be there," the patients whose care could have better been delivered elsewhere?

There was, I hasten to add, no disagreement as to why the "worried well" and the "walking wounded" come to the ER. PCPs are too busy to see them, both because their clinics are booked up and also because they often don't have the resources to provide much in the way of acute care services — IVs, nursing staff, etc. In part this is because it may not be economical to provide this care in the office. Furthermore, most medical offices are only open during working hours and acute care centers are only slightly more accessible. There are also many patient-side barriers, including the hassle involved in making an appointment, the need for co-pays and insurance status. So, given the many obstacles involved in getting care in the more appropriate, most cost-effective settings, the ER becomes the default for many of these patients.

Now Seth argued at some length, that these low-acuity, ambulatory care patients were "a drop in the bucket" of ER overcrowding and cited the example of the ubiquitous URI patient who can be seen and streeted in less than 20 minutes. These folks, he and others argued, are not the problem that our nation's ERs struggle with. This is, I might add, in line with ACEP's argument that only 7% of ER patients are non-emergent.

I have pointed out in the past that my BS-meter starts pinging when people start claiming that the ER is only caring for emergent patients and that non-emergency cases are rare. So this set me off, of course. My perception — and that of many of us in the trenches — is that we are absolutely beset by non-emergencies and that the ER is viewed by many as the "convenience clinic," if not the "vicodin clinic." But is this true? How can we quantify this?

ACEP has, for their PR campaign, relied on the National Health Statistics Report to establish whether a patient in the ER was actually an "emergency." The problem with that method is that it takes the 5-point triage scale perhaps a bit more literally than the typical triage nurse does. To the point, it considers a level 4 "green" patient to still be an emergency since the definition of that level is that a patient needs to be seen in 1-2 hours. Which is not at all the way it is applied in the real world.

In this case, I would advocate using the coded level of service by the ER physician to stratify patients. Low acuity probably correlates nicely with the E/M code applied. The lower-level ER codes, level 1, 2 and 3 tend to be associated with not being admitted to the hospital, with not receiving advanced imaging studies like CT scans and with not receiving complex work-ups with blood tests, CT scans and X-rays. Put simply, an ER patient level 3 or lower may receive one or two ancillary tests (like a simple x-ray or a single lab test) but not much else before they get bumped into the level 4 range. So a level 3 patient is one that generally is simple and hopefully quick and one who, in theory, could have been cared for elsewhere were an appropriate care environment available.

So I pulled our numbers. Our ER is a pretty typical, moderately high-acuity community ER. We seen nearly 300 patients every day, and of those about 20% get admitted to the hospital. Our numbers indicate that we see about 100 patients every day who fit this definition, about 1/3 of the total volume and about 45% of the non-admitted volume.

Is this "a drop in the bucket"? Are these patients who we should be seeing and streeting in 20 minutes? Put simply, the answer is no.

When I look at the time stamps on the charts of these patients, it's clear that they are not in and out of the ER all that fast. It's all relative, of course, and your mileage may vary. We have a very efficient ER. We don't board patients and our average door-to-bed time is about 15 minutes. Pretty good. But for the majority of patients who are not admitted, the typical time in the ER is still in the 1-3 hour range:

The lower-acuity patients are there less time, it is true. About 1-2 hours on average.  Why so long?

There are two factors at play here. First of all is the fallacy that just because a patient is easy and quick from the physician's point of view, they are also quick and easy for the facility. But unfortunately, the many steps which a patient must go through in the ER are fixed and take about the same amount of time for each and every patient. Let's use our shop's numbers for perspective. The patient must present at the greet desk and be entered into the system, must be placed in a bed, must be triaged, must be registered, and there are often obligate waiting periods between each step. In a highly efficient ER, where patients are bedded rapidly, much of this takes place in the treatment area. Then the doctor swoops in, does his or her black magic and is gone. If there are orders or treatments to be applied, that takes time from when the orders are entered to when they are executed. Eventually, the physician enters a discharge order, and after some time, the patient is actually discharged. Each step in this process takes time. So from door to bed: 15 minutes. The triage process itself takes a good ten minutes (bear in mind all the irrelevant data points ERs are required to capture, like domestic abuse screening, etc). The patient must be registered, which takes another 5-10 minutes. Then there is a waiting period until the doctor gets in to see the patient. That's another 5-10 minutes. So we are talking 30-45 minutes even before the doctor assesses the patient, on average. Assuming the doctor has no orders, the time from the decision to discharge to the actual discharge may be another 15 minutes, depending on nursing workload. So in a typical case where the doctor's face time is very minimal and there are zero orders entered, the process phase of the ER visit takes an entire hour! This is, I might add, a "best case" for an ER visit. (Bear in mind that we are talking average times here. So for each person who comes in at 5AM and is seen immediately there's one who comes in at 7PM and has to wait twice as long.)

The second fallacy at play is the idea that a low-acuity patient is in fact a low workload patient. Seth cited the URI patient. Nothing faster from the MD's point of view. In our department, that represents about 4% of patients. That's maybe 15% of the total low acuity patient load. What are the other typical level 1-3 patients here for? Well, based on our ICD-9 coding, in rough order of frequency, things like:

  • Back pain
  • Headache
  • UTI
  • Neck Strain
  • Minor head injury
  • URI/Bronchitis/Pharyngitis/Sinusitis
  • Extremity Cellulitis
  • Laceration
  • Dental pain
  • Extremity sprains/strains/contusions
  • Pediatric fever (non-infant)
  • Abscesses
  • Corneal Abrasions
  • Rashes
  • Allergic reactions

A lot of these are, in fact, not at all easy from a time point of view. Abscesses/Lacerations/Corneal abrasions all take physician time doing procedures (and associated set-up time, etc). The musculoskeletal injuries often require imaging and splinting. The back pain/headache/cellulitis often require medication administration. Concussions and toddlers with fevers may not require tests but do consume a lot of physician time face-to-face. Some of these cases require multiple physician assessments. Some require labs. Each additional step adds time, sometimes quite a lot of time, to that one-hour best case baseline I described.

So what's the total time burden?

Our experience is that for the ambulatory population, i.e. excluding admitted patients, we have about 510 patient-hours per day in our ER. Of this, almost exactly a third, 160 patient-hours is attributable to the lowest-acuity patients, the E/M level 1-3s. That correlates also to nearly a third of physician staffing and RN staffing. Bear in mind that our institution just built a whole new hospital at a cost of $500 million, in part because the ER needed a much larger physical plant. The costs involved in this care are not insignificant, and the burden placed on the nation's ERs from these less acute cases is major, not at all a drop in the bucket.

I want to take a moment here that I am not commenting on whether these patients should be in the ER. In the current healthcare environment, they have to be here because there is nowhere else to go as often as not. And many of these cases will always be with us: if you have neck pain after a car accident at 2AM, the ER is the right place to be treated, even if it winds up being just a sprain. We embrace our role as the care provider of last resort, the ones who are always open and always available, no matter what. It is also true, however, that we are an expensive place to receive care. The fixed costs of operating an ER are horrendous, compared to a clinic. Our health care system would be far better served if there were accessible sites of care that could care for these less intense patients in a more cost effective manner.


  1. Doctors need to stop reinforcing seeking behavior with narcotics. Most of the nonsense isn't just poor migrant workers going to the ER as a last resort for whatever, it's addicts.

    There should be a national/Federal law or at least accreditation guideline that does not allow MDs to prescribe controlled substances to an ER patient more than 2-3x/year, especially without objective findings such as a fracture.

    That would put the kabosh on most of this nonsense instantly and save thousands of lives yearly. Tens of thousands die of fatal prescription drug overdoses, including a good friend's brother most recently.

    Hospitals that routinely give out narcotics for "chronic migraines"? 2 mg dilaudid for atraumatic knee pain without issues weight-bearing? No accreditation for the hospital. Sorry.

  2. As I see it, this still overestimates the number of people who "needed" to be seen in the ER.

    For many (if not most) people, cough + fever, N/V x 1-2 days (let alone 1-2 hours), and most abscesses to name a few conditions, could be effectively taken care of at the doctor's office.

    However, they come to the ER and get:
    Cough+fever: iv, labs, cxray, iv abx, and poss IVF, poss bcx
    N/V: iv, labs, AAS or flat/upright, IVF, poss IV abx
    abscess: iv, labs, iv abx, poss bcx

    All of the above treatments can be justified, but aren't strictly necessary all or even most cases (though definitely necessary in a few, select cases).

    All of that treatment does more than just elevate the visit level -- to the patient, it reinforces the idea that the ER visit was necessary and that this wasn't something that could be taken care of at the doctor's office.

    In my view, THAT is what really leads to ER crowding.

  3. It seems kind of odd that ACEP uses a number generated by RNs at the beginning of the visit to measure this when there is an easily available, and more specific, number generated by physicians (who are their members and their audience) at the end of the visit. Could it be that the E/M level doesn't agree with he picture they are trying to pain so they went out and found a number that does?

    The triage levels we use don;t tell you much really and can very greatly from nurse to nurse. Also the five levels are effectively really just three. Green and Blue are effectively the same as far as actual sorting and priority to get seen everywhere I've ever worked, and there is a lot of overlap between orange and yellow and between green and yellow.

    I my (humble?) the five level system is not really all that useful for actual triage, not is it really ever used as designed. It is perhaps more useful for compiling statistics that for actual sorting, but sorting is what we are supposed to be doing.

    What works, and what I think most of us actually do, is a three level system something like the old Emergent/Urgent/Non-urgent, with almost all patients fitting in either Urgent or Non-urgent.

    That system is effective for sorting patients, but probably useless for generating statistic, but I have always agreed with Clemens' comment on statistics.

  4. There are extremes of acuity. STEMI patients undoubtedly need to be seen and treated emergently. Belly button lint removal undoubtedly does not. How the patients in-between are labeled is largely driven by who is using the numbers and why they are using the numbers.

    I think that ACEP's assertion about only 7% of ED visits are non-emergent is low, but as Vince and Anon noted, that "non-emergent" label is subject to interpretation. ACEP is advocating for emergency medicine and chooses a definition that maximizes the apparent utility in emergency medicine. Only 7% of visits are non-emergent - don't cut our funding or our resources or you'll effect the care of emergent patients. EPs may raise an eyebrow at the numbers ACEP uses, but the numbers resonate well with the public and are a great sound bite on the news.

    Others may choose a different interpretation of ED acuity. How would a legislator who is hell-bent on cutting costs use the available data? "If 33% of emergency department visits are non-emergent, then we could save 33% of emergency medicine costs by making those patients go somewhere else." Oversimplified, but another good sound bite to sell the idea to the public. Instead of addressing the underlying problems that cause patients to go to the ED with non-emergent complaints, they create policies that penalize the hospitals and/or the providers for providing "non-emergent" care to all those "non-emergent" patients. Cut reimbursements. No payments after three non-urgent visits. No payments for a list of non-urgent diagnoses.

    When you ask "How can we quantify this?", I propose a different question: "Why do we *want* to quantify this?"

    Obviously being able to accurately triage emergent patients will affect outcomes in single patients - a chest pain patient probably shouldn't be triaged as "non=emergent". Acuity data on a case-by-case level can therefore affect process improvement. However, most reasons I can see to quantify aggregate acuity levels lead back to reimbursement.

    The more that we allow our role as emergency physicians to be marginalized as "vicodin clinics" or "convenient care", the more that those who control payments will marginalize us and our profession as a whole.

  5. Speaking about cherry picking data ...
    Check out these comments in an article today about John Edwards' campaign strategist/pollster:

  6. While I agree that there are more than 7% non-emergent patients who no doubt take up time as you noted, the one topic missing from your argument is any idea of patient responsibility. As a med student and past ED Tech, I agree whole heartedly with your ideas and values behind the ED being a place for all to come for care at any time of the day. However, I personally feel more should be done to educate the patient about their choice to use the ED and provide adequate resources for them to get an appt. elsewhere. If they don't want to use other providers beyond the ED, there absolutely needs to be a co-pay put in place so that there is some skin in the game for all parties.

  7. How about mid-levels and the use of "fast tracks" for non-acute patients? Do you consider this an efficient and sustainable alternative to free up the "main" ED? This does place more importance on the triage nurse (some in Memphis use a mid-level for an MSE & labs/rad orders).
    Since the patients and resources are already in one place why create another entity of service?
    - thoughts?

  8. Open Letter from a fellow dock the ED

  9. Took me time to read all the comments, but I really enjoyed the article. It proved to be Very helpful to me and I am sure to all the commenters here! It’s always nice when you can not only be informed, but also entertained!


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