The news from the recently released Canadian Institute for Health Information report on emergency department (ED) congestion is not new. Nor is the news from the survey by the Ontario Medical Association on ED congestion.
Once again, we find the blockage in admitting new patients is because we have no acceptable place or robust process to offload patients currently occupying vital bedspace but no longer needing intensive medical care. The problem is connecting them to an appropriate level and type of care.
This issue has been around for literally decades as I remember debating solutions around the board table in the early 2000s. While acknowledging that some progress has been made, several recent visits to the ED have revealed other opportunities for improvement not captured in any of the recent surveys and reports.
As a medical community, we have become quite good at creating efficient streams of practice to deal with many of the issues we commonly see. These streams are both cost effective and time efficient for the patient and practitioner alike. In creating these clinics and streams, we have improved the situation for the majority, but we also have created a trap. What happens to the patient whose symptoms don’t nicely fit into a stream? How are they identified and managed by the system?
Often these folks present to the ED looking for resolution. They may or may not have tried to visit a family doctor, if they have one, but ED is their last resort. They may or may not get admitted, but the impact on the system is numerous ED visits until they are properly diagnosed and the problem resolved. This situation begs several questions:
- Does the ED track patients who have presented multiple times with the same/similar symptoms over a number of weeks or months? If not, why not? The data is available in most hospital systems. When a triage nurse or ED staff are able to say “oh Mr. X, you are back again I see,” then we have a recurring problem that needs to be fixed.
- Is their family doctor routinely being notified of this red flag? While not everyone has a family doctor, are we making sure that the MRP (Most Responsible Physician) is aware of the visit and taking action to prevent a recurrence.?
These patients are a factor in ED crowding because they did not get the appropriate standard of care, a “problem identified and fixed on first presentation.” While this may not resolve ED congestion completely, it can take a small bite out of the problem with little effort.
The trap we have created is that when patients do not fit our model, the system tries to force fit them into one of the streams. Case in point: Patient A went to the ED with acute abdominal pain and diarrhea, was admitted and then subjected to numerous tests including a sigmoidoscopy. Upon conclusion of the procedure, the performing physician pronounces the patient has cancer. The four biopsies taken during that procedure would all prove negative for cancer a week later but no mitigating treatment of the inflammation could be administered as cancer was assumed. A week later, a second sigmoidoscopy was performed taking six further biopsies. The patient was discharged to await results. The second scoping was to verify that in fact cancer was not present and that the earlier biopsies were not anomalies. The patient was back in the ED, by ambulance, seven days later, again with abdominal pain, and learned the results of the latter six biopsies were also negative. This is an example where we tried to fit the patient’s symptoms into our model of care except that he did not have cancer but rather Ischemic Colitis. Ultimately, he underwent surgery to remove a badly inflamed and constricted Sigmoid colon.
The unfortunate aspect of this patient’s case lies in the prior diagnosis before any ED visits. He had been admitted several weeks prior and was diagnosed with HHS (Hyperosmolar Hyperglycemic State). This resulted in the patient being classified as a diabetic even though there was no prior indication or history of diabetes. Other potential diagnoses (such as stress hyperglycemia or other endocrine disorders) were discarded and he was slotted into the diabetic stream because of the HHS determination. As a diabetic, he was prescribed a strong dose of metformin, a common diabetic medication with the well-known side effect of diarrhea, acerbating the inflammation and constricted colon issue that had not been addressed on his initial admission. While the symptoms of the Ischemic Colitis were present, they were masked by the side effects of the prescribed medication.
Mistakes in diagnosis can be made but force-fitting people into our practice streams is not helpful to the patient who does not belong there nor does it help the stream that must deal with a patient that is not responding to the standard treatments or, worse, has an adverse effect from those treatments.
Catching these outliers early by tracking their multiple ED visits and flagging that to their primary care provider would bring patients closer to the gold standard and out of the system faster. Linking them to the right specialist as a priority becomes the key success factor and keeps them out of the ED.
If someone does not fit the criteria for a particular stream of care, force-fitting them into one does a disservice to patient and provider alike. Flagging multiple ED visits so that priority can be given to getting these patients to the specialist they need won’t solve all ED congestion issues, but this simple step will improve things for patients and ED staff alike.
