Mid-sized ER Madness; Thoughts?

I know, I know, I spend way too much time ranting about work in the emergency department.  But after some recent shifts, my box of rants is full once more.  And what I want to point out is the enormous struggle of the mid-sized emergency departments in America today.

I know this is a problem; I work in them, and I know and talk with people who work in them.  It’s getting harder all the time.  So what is that ‘mid-sized’ ED?  For purposes of my discussion, I’d say (depending on coverage) somewhere from 16,000 to 40,000 visits per year.  Now that’s not scientific, that’s just for the sake of discussion, and based on personal experience.

I’d love to hear commentary from readers, because I’m trying to figure it all out.  But let me start with a story.  When I was fresh out of residency, I worked at dear old Oconee Memorial Hospital in Seneca, SC.  Our volume as I recall was around 23-25K per year.  We had pretty good coverage at first, with three 12 hour physician shifts a day.  Patients were sick but we moved them through.  And when I worked nights, I remember that it wasn’t unusual for me to lie down about 3 am and sleep till 7 am.

Fast forward.  Even at my current job where I see 19K per year, there’s barely a night when patients don’t come in all night long.  So is volume spread out more?  Maybe.  Are patients sicker?  Possibly.  I think some of this may be that patients have no primary care, and so they don’t even have an option to ‘wait till morning.’  In addition, a large number of patient (in all ED’s) are jobless.  So in their defense, 3 am is as good as 3 pm when you don’t have to go to a job in the morning.  (I’m not disparaging; but I do think this is true.  Think about your teenagers who sit up all night in the summer if they don’t have jobs!)

I also wonder if our patients are sicker.  I mean, medicine is pretty amazing nowadays, and people who would certainly have died when I was in medical school now repeatedly survive significant heart failure, MI, stroke, pulmonary embolism, respiratory failure, various infections and all sorts of problems.  And when they do, they have to come back to the ED frequently.

For those with docs in the community, I’m sure the offices are crazy busy all the time. Even those docs have patients they just can’t squeeze into appointments. They use the ED.  And maybe, just maybe, our patients are much more ‘medicalized’ than before.  So much of what the emergency departments see is really psycho-social.  Anxiety, depression, suicidality, substance abuse.  The numbers of these conditions seem to be exploding, and they can seldom afford primary care, much less mental health care.  The all-night ED is the place they go.

And there is a subset of patients who use the emergency department for entertainment or convenience; rides, snacks, a way to avoid arrest.  ‘Officer, I…have…chest pain!’  These also take time and space.

So what happens is all of this descends on departments with limited resources and staff.  And all day, and all night, one physician or two, maybe a PA or NP, struggle to sift through five or six chest pains alongside two stroke alerts, a suicidal overdose, two septic senior citizens, a dialysis patient who missed two appointments and has a potassium of 10 and a femur fracture.  Add to that the family of five with head colds.   Sure, this is what we do.  We are emergency physicians and nurses and mid-levels.  But into this mix, in the mid-sized department, recall that there is:  no cardiologist, no neurologist, no psychiatrist or counselor, sometimes no available ICU beds, possibly no pediatrician and definitely no dialysis in the hospital.

The day is spent sorting, stabilizing, making phone calls, transferring and waiting for ambulance or helicopter to become available.  All the while?  Sifting through very cumbersome and inefficient computer documentation systems designed for billing not flow.  And being scrutinized for through-put, time stamps, protocols, national standards, Medicare rules, re-admissions and all that mess.

I really don’t want to sound like a complainer. What I’m concerned about is 1) the safety of the patients and 2) the physical and emotional health of the caregivers.  At the end of the day, we’re all exhausted.  And so much is going on that we can barely find the obvious stuff, much less the subtle things that can also kill.

It sometimes seems as if departments are intentionally understaffed to save money.  I understand that it’s expensive to have doctors, nurses, etc.  But administrators get mad at folks ‘standing around,’ without realizing that in the chaos and suffering of the ED, sometimes it’s really important to ‘stand around.’  To breathe, to think, to rest, to gather oneself, to look up a condition or problem, to debrief.  To eat.  To pee.

I think that the world of medicine has decended on the emergency department.  I know that we handle it valiently.  But I don’t think it’s safe; and it’s nowhere as unsafe as in the relatively under-staffed and under-equipped mid-sized community hospitals of the world.

I’m proud of what we do.  But some days, most days, I wonder how we do it.

Any thoughts?


11 thoughts on “Mid-sized ER Madness; Thoughts?

  1. Similar to you, fresh out of residency I worked in a mid volume facility. They saw 19 to 20,000 per year and I could sleep 3 to 5 hours a night.

    Now, I’ve been doing some shifts in a facility could only seats 8000 patients per year, but I haven’t gotten more than an hour and a half of sleep at one time. Our culture has very much shifted to a 24 hour one. In addition to the reasons you cite, so many businesses stay open 24 hours a day now that people don’t think twice about going to the emergency department at 3 AM.

  2. We’re at 64k-ish/yr, and I’d still consider us “upper-midsize.” And yes, particularly at night, its busier, patients are sicker, and the spike in psycho-social stuff in my opinion, has skyrocketed.

  3. I’m not medically trained but have worked in healthcare in different administrative capacities for much of my career. It seems that more and more it’s about the bottom line. My region has been building hospitals and standalone EDs all over but we have fewer and fewer urgent care options. Urgent care doesn’t pay out quite as much. Since most patients “don’t pay” for their care, it’s all the same to them. What they don’t realize is they are the ones losing out, because what they really need is the thoughtful human touch of a qualified physician as you described. My solution is to only offer catastrophic health insurance and provide more free clinics for those who can’t pay but whose problems are not an emergency.

  4. I work in the UK, so a totally different system. 60000 would be considered a ‘very small’ ED. 80000 average. >100000 average to large. I work in a large ED (not tertiary, not trauma centre, bypassed for stroke and STEMI).
    We’d staff with 4-5 juniors (interns/jnr residents) and 2-3 seniors (snr residents) and 1-2 consultants (attendings) on the shopfloor by day, and a little less overnight. Plus 2 or 3 of what you’d call mid-levels.
    There is almost never a time when we are ‘quiet’. There is a queue to be seen throughout the night. This has become more marked over the past 5-7 years.

    It feels like patients are older, sicker, more complex. Require more and we can provide more. The minor illness aspect is there, but not the main issue. Social care issues (lack of it), mental health problems, drug alcohol etc play a big part.

    It’s going to get worse before it gets better.

  5. 100% agree. We’re given the bare minimum staff, especially overnight, and when 30 patients check in between midnight and 6AM with only 1 doctor and a handful of nurses and nobody dies and everyone who is truly ill gets great care, but a few toothaches and sniffles leave without being seen….. that’s all we hear about. We only hear what we do wrong, rarely thanked or even acknowledged for what we do right (sometimes straight up miracle working). I’m amazed everyday that more people don’t die in the ER. We’re amazing at what we do so it’s still a relatively rare occurrence. We’re held to the unrealistic expectations of our patients, our overlords and lately even our colleagues in other specialties and I’m afraid the breaking point will have to come soon. Unfortunately it will probably still get much worse before it gets better, if it ever does. Still trying to hang in there though. Thanks so much Edwin Leap for giving us a voice

  6. You described my ED/job exactly! Never thought I’d look forward to the day I don’t have to deal with it. The system seems too big for me or any of us really to change it. Maybe rock bottom in a few years will swing the pendulum the other way. Towards what it used to be. It feels good that I’m not the only one dealing with what you just described. Thanks!

  7. Sorry, this is pretty long…..

    Do these smaller community hospitals have the resources for social work or community health workers?

    I am a clinical social worker in a large urban hospital in the Midwest. Between our children’s hospital and and much smaller sister hospital down the road, it is reported that collectively we see more than 126,000 patients annually. These numbers are a few years old and we have seen a great deal more as of late.

    Social work is staffed 24/7 at all 3 hospitals, and at the large hospital, there are 2 social workers on staff between the hours of 1600-0230. While it used to be adequate coverage, it is not enough now.

    Since May 2017, between all 3 hospitals, we have had 4780 cases that we have been called on. While we are paged to every STEMI, CVA, Priority 1, CODE, Deescalation, ERAP, and Level 1 and 2 Trauma’s, the majority of what we see is psycho social. At any given moment in the day, we can have between 6-9 safety cases (acutely suicidal patients) . The numbers and increase in these types of cases, both adult and pediatric psychiatric cases, is staggering. Making sure these cases have a safe d/c either home with resources or to a psychiatric facility can take a great deal of time. I can not imagine our MD’s or mid levels doing their jobs without us there to assist.

    We recently added one CHW (Community Health Worker) to our largest ED. He is bilingual and meets with our patients who are accessing the ED like they would a PCP. He helps people to find a primary care provider, assists with knowledge about transportation in their area, and other community resources that they may need knowledge of. If the patient comes in when he is not on, social work makes a referral to him and he follows up with the patient the next day.

    While we have not had this new worker long enough to collect substantial data to see if there have been any decreases in visits form certain populations, we have been encouraged by the work he is doing.

    I don’t think these numbers are likely to decrease any time soon. I do believe though that work done on the local level in the communities is a good place to start. Our community mental health agencies need to be better funded and if local providers or community health agencies could develop robust community health worker programs, this may help to create a small floodgate to the surge that is sure to keep coming.

    Thank you all for your dedication and hard work! Believe me, we ED social workers do recognize the struggles and applaud you all for the tremendous work you do.

  8. This is why after 10 years on the floor as a CNA first, LPN, then RN, i had to get out. Most that are there are trying to get out, the stress and expectations suck the life out of you.

  9. Medicalizing much of interpersonal conflict benefits few people. Unfortunately, such conflicts are basic to the human condition. Psycho-social patchwork of sufferers in the ED is hit or miss. The person with a resulting anxiety reaction shows up at your ED at 3AM seeking relief. That ironically adds to stress of staff setting priorities, trying to accommodate. The unhappy anxiety patient later complains to management, which at the time is sleeping soundly at home. 8-4:30 management orders: “Do something!” Teaching coping skills for walking mentally-wounded could be provided by public schools, walk-in clinics, parents, parent, grandparents, and “concerned”. Failure to address that solvable problem means the next visit is at 2AM.

  10. The EDs today are more indigent care clinics and rapid diagnostic centers than true emergency care facilities. I have seen this evolution over 30 years as an emergency medicine PA in “medium” volume EDs as you describe. In fact, I have worked with a couple of your locum friends and colleagues. The increases in volume and percentage of no pay visits will continue to grow. EMTALA requires that we see all comers, regardless of complaint or ability to pay. Patients know this. Harried primary care physicians know we can rapidly diagnose concerning complaints and make an informed decision regarding disposition. Hospitalists of course prefer that admissions are worked up and diagnosed in the ED, making their life much easier. They very rarely accept direct admissions from primary care offices for that reason. The ED is truly the front door of most hospitals, and for many compelling reasons, some of which are mentioned above, there is no reason to expect this will change in the foreseeable future. The demands on EDs will only increase. What needs to change is the reimbursement model for ED physicians. This group is the only one I know of that is required by law, at the virtual point of a government gun to provide services to anyone and everyone regardless of their ability or willingness to pay for those services. It is indentured servitude and clearly unsustainable. Groups staffing rural, mid-sized EDs are having increasing difficulty recruiting good clinicians at a time when additional staffing is badly needed.. Locums are expensive and only a thumb in the dike. Our government can mitigate this in at least of two ways: 1) Allow ED physician groups (and/or their members) to write off uncompensated care at Medicare rates against practice revenue, or 2) directly subsidize “charity” care at Medicaid rates after reasonable efforts at collection. Either would help preserve the vital role of EDs in our current health care non-system. Don’t hold your breath.

    • Incumbents in both parties in Congress are AWOL regarding ACA repeal and replacement. But, the primary elections early in 2018 when health insurance premiums spike will finally benefit the public. So, there’s no need to hold our breath.

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