John B. McCabe, M.D., FACEP, is professor/chair emeritus at Upstate Medical University. In 1987, McCabe was the only physician in Syracuse trained in emergency medicine. He was the first chair of the Department of Emergency Medicine at Upstate, and he practiced and taught emergency medicine in CNY for over 30 years. He has served as CEO at University Hospital and as president of the American College of Emergency Physicians. In retirement, he is the medical director for CAVAC, the Cazenovia Area Volunteer Ambulance Corps, and he volunteers as an ambulance driver, frequently bringing patients to all area hospitals.
Reporter Jim Mulders recent article (Syracuse emergency rooms are jammed, dirty and frustrating; waits are among worst in U.S., Feb. 27, 2023) and the editorial board opinion (ERs are in crisis in Syracuse and across US. When will Washington act? March 5, 2023) described the horrific state of affairs of the emergency departments in Syracuse hospitals.
Unfortunately, Mulder presented an accurate view of ERs that are overcrowded, dirty and chaotic. There are too few staff who, frustrated in their inability to deliver the care they know would be best for patients, may seem uncaring. At the same time, frustrated and angry patients are either waiting to be seen by a doctor or waiting for the hospital bed they have been promised. Patients feel lost in the system.
The inability to care for patients in a timely manner and to move them to an appropriate hospital bed, resulting in severe overcrowding, is not an ER problem. It is a problem of hospital operations and system-wide dysfunction.
There is no simple solution, nor a solution that will change things overnight. The editorial board makes the case for federal, congressional and presidential action. While reasonable, none of these levels of government will yield near-term results. Similarly, the states push for workforce development, although necessary, is the beginning of a training pathway that will take years.
Let me suggest several actions that could make a difference:
1. We could change existing state regulations to allow nursing staff to initiate appropriate diagnostic studies and basic ER treatments before evaluation by a physician. Such decision-making would be based on complaint-driven protocols, a common practice in many states. This change would allow earlier initiation of care, helping to speed patient throughput and improve waiting room conditions. Such a change should be a high priority for state lawmakers and regulators.
2. Hospitals could improve the speed and access to care by ensuring that all medical, surgical, ancillary and support services are available 24/7. With ER overcrowding, it is hard to accept that a patient in a hospital bed, ready to be discharged to home or to a long-term care facility, waits for days to receive a diagnostic study, a piece of durable medical equipment, a specialty service consultation, a home care referral or a needed pharmaceutical treatment.
The same can be said for facilities that receive patients discharged from hospitals. No patient who is ready to go to a nursing home on Friday afternoon should wait in a hospital bed until the following week for transfer.
3. Severe overcrowding does not happen suddenly. It can be anticipated. Previously, Central New York hospitals used an objective scoring system (National Emergency Department Overcrowding Score, or NEDOCS) to regularly assess the state of overcrowding in the ER. Such an objective score should be linked to a written plan that determines how hospital operations will adjust as the ER gets more and more crowded.
For instance, the number and function of social workers, discharge planners, bed supervisors, transport staff and physician staff need to change as crowding worsens. Means to alert the entire system to worsening overcrowding must result in an all-hands-on-deck approach that more quickly moves patients through the system to discharge or transfer. All hospitals should have a mechanism to communicate the status of their ERs to the public, so that patients and their physicians can make informed decisions, in real time, about going there for care.
As another example, hospitals should implement systems to efficiently move ER hallway patients to other hospital locations. While awaiting inpatient beds, such patients could be moved to defined hallway spaces on each inpatient unit. What seems better for the patients: 20 patients waiting for beds in ER hallways, or one or two patients in hallway beds, awaiting a room, on each inpatient floor?
Administrators must be prepared, at times, to make the hard decision to cancel profitable elective admissions or surgeries to free beds and ease ER overcrowding. They should be prepared to utilize preoperative, postoperative and other non-ER spaces to accommodate the overflow of ER patients.
Hospitals can change the mindset in implementing disaster plans. If 20 patients were to show up suddenly from a bus crash or a mass shooting, the disaster plan would kick in, with extra staff and resources being made immediately available to the ER. Why should the presence of 20 sick patients waiting for inpatient beds, in a congested and overrun ER, result in any less of an aggressive approach to care for them?
4. In addition, the physician community as a whole must bear some responsibility for ER overcrowding and must be a part of any viable solution. Many physicians have focused on outpatient care, not on the care of hospitalized patients. Some physicians choose not to cover the ER, as they used to, and not to provide specialty consults on hospitalized patients, as they used to.
With the emphasis on office care, physicians in the community should rethink the all-too-common response of go to the ER when their patients call with health complaints. While perhaps the easiest answer, going to the ER may not be the best approach for an individual patient, for the hospital, or for the ER staff.
Community specialists and subspecialists should recommit to being active partners in systems that deliver comprehensive and timely response for the evaluation, management and disposition of ER patients. It is unreasonable for commonly needed physician specialties, who are plentiful in the community, to be unavailable to patients in our ERs or inpatient units (as noted for GI/ endoscopy services in Mulders article).
5. The typical response of we have no money and no staff doesnt fix anything. Solutions must be found with policy change, creative staffing, innovative thinking, hard decisions, and prioritization of ER care.
This is where healthcare insurers and federal and state governments must step up. These community and civic leaders must realize that the funding decisions they make have real consequences in ER hallways and exam rooms and on the floors of hospitals and nursing homes.
As CEO, I often commented that people in CNY didnt always realize the breadth, depth and quality of medical services available locally. The current circumstances in the ERs are preventing patients from receiving this quality care in a timely manner, if at all.
Finally, as troublesome and difficult as ER overcrowding is for patients, this situation is also grossly unfair to the dedicated ER staff who struggle every day with inadequate resources and poorly functioning systems to provide care to our most needy and vulnerable populations.
It is time for a concerted effort to fix this problem for our patients and for our healthcare professionals.
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5 things we could do right now to ease ER overcrowding (Guest Opinion by Dr. John B. McCabe) - syracuse.com