“Poor planning on your part does not necessitate an emergency on mine.” -Bob Carter

In health care, “quality” refers to care that is coordinated, integrated and cost-effective. Care that is delivered to the "right person, at the right place, at the right time."

Yet when systems are challenged to deliver necessary but routine non-emergency care, the emergency department (ED) can become an attractive solution. Though the care may be fragmented, the ED is the only location with robust, functioning around-the-clock resources. In the eyes of administration, this can make it seem like a viable solution for a system's needs.

Many emergency providers would agree. Regardless of an unfunded federal mandate to care for Anyone, Anything, Anytime, the culture of emergency medicine is one of patient advocacy. ED clinicians view themselves as having a moral imperative to care for patients despite the presence of an emergency condition. Strong patient advocacy is a core feature of emergency clinicians; it’s often what draws us into the specialty.

But true patient advocacy means advocating for quality care; not care for care’s sake. 

This care does not always fall on the ED because it is the best location; it falls on the ED because there is no better location. Correcting system gaps with an emergency department is often a convenient decision, not a quality one.

If the ED is going to play this role (and in many cases it should), the exit strategy should be planned more vigilantly than the entrance.

Opportunities For System Coordination

A few examples of missed opportunities managed by ED's:

• Routine dialysis patients who have been “fired” from dialysis clinics
• Undocumented care (dialysis and general)
• Routine admission of patients (insurance purposes and otherwise)
• After hours pain control, imaging, labs or refills
• Routine testing that primary providers want faster
• Weekend clinics for sub-specialists
• Referral center for sub-specialty care
• Vaccinations
• Screening for non-emergency, unrelated conditions
• Employee health

Every specialty has a Primary Care and Public Health responsibility. Neurosurgery can refill insulin and Urology can vaccinate as well as the ED can. However, systems often prioritize the ED for this care when no simpler option exists. 

Primary Care and Public Health functions are inextricably linked to the ED.  The ED is a safety net critical to population health. My point is not to disentangle Emergency Medicine from Primary Care or Public Health, it's to emphasize the importance of deliberately planning for each of their optimal deliveries.  It's easier to place (or leave) processes in the ED for convenience rather than consciously pursuing the path to their ideal location.

The Magic Button

If you could press a magic button and develop an ideal health care system, where would you put the care process in question?

You would never plan for a patient to go to an emergency department for routine dialysis, you’d want them going to a dialysis center where they’re known. If they have behavioral issues, you’d want them optimized by a psychiatrist and social worker, not an emergency physician.

If they’re undocumented, the barriers to their care reach beyond what an ED can provide. They may have language, housing, legal, social, child care and financial issues that impact their overall health. If these determinants aren’t addressed, their overall health will never be optimal.

In general, you wouldn't want routine care delivered by a team who has never met the patient.

You wouldn't do these things because it’s disproportionately expensive and  uncoordinated care. In an ideal system, you would do everything possible to keep patients out of the ED, particularly the medically vulnerable. The patients who are falling into this safety net are the ones who should never see it. They will be done the greatest disservice.

The care EDs provide is necessary. But if there is no clear long-term vision for optimal delivery, it's ultimately a plan for sub-optimal care. 

Have An Exit Strategy

“Nothing is so permanent as a temporary government program.”

-Milton Friedman

In many situations, the ED is the only option and is therefore the necessary location for care delivery. For now. The ED can do for a system what it does for individuals: Stabilize until definitive care can be provided. ED's are staffed by a robust group of highly trained providers who are known as hard-working, flexible and competent. Their skillset is broad enough to absorb many of these patients and provide a temporary service until a better one is created.

But if an ED is planning on adopting a new process that would be better initiated in a different care area “because there is no better option”, then the initial conversations need to include an exit plan. Care shouldn't be initiated for the sake of saying it's been completed. The best care may be no care until it can be provided at the proper time, in the proper place.

If you're planning to build something new, plan on building it correctly.

This planning requires a conversation between emergency departments, hospital administration and the community they serve. Often, hospital leaders have an incomplete understanding of life in an ED and mistake the broad scope of practice as permission to house all issues. It’s up to these decision makers and their community to ensure that if a temporary care plan is being put in an ED, it’s treated as temporary.

Just like we don't achieve ROSC and then manage the patient until discharge, we shouldn't be filling in system gaps and owning the process indefinitely.  The permanent fix needs to be budgeted and planned for more deliberately than the Band-Aid that’s being placed on it.