Where to for Emergency Medicine? What model of care do we want?

I am always left a bit flummoxed by exhortations to dream up a new model of care for the ED. I feel as though the person doing the exhorting has some specific image in their head that they are hoping everyone else might share but I can never quite work out what it is.

The traditional model that I grew up into was that people decided what constituted an emergency themselves and either called an Ambulance or walked in to the ED and the triage system rewarded those who had what we agreed was an emergency by giving them prompt treatment, while punishing those who we disagreed with by banishing them to the waiting room. As demand went up it became normal for those banished to the waiting room to wait for 4, 5 or 6 hours, with stories of people waiting 24 hours to be treated being possibly true or possibly urban myth.Then we started to get the patients who even we thought had an emergency waiting hours. Bed block bypass, ambulance ramping. Something wasn’t working.

It wasn’t long before that started getting taken apart though. Part-way through my second post-grad year the Victorian trauma system was born. Along with the redirection of most of the trauma to the major trauma services, it was also heralded the arrival of the formal trauma team model in our urban district emergency department. Suddenly, while an ATS category 2 stroke or chest pain could theoretically wait 10 minutes to be seen (and would sometimes wait much longer unfortunately), a Cat 2 trauma was being seen by a multidisciplinary team immediately.

Then came the fast-track. My training hospital was already running an “Acute Care” side and an “Injury Clinic” side reasonably successfully. Fast Track took this idea into a lot more EDs. There is no doubt that Fast Track eases the waiting room and allows efficient care to be provided to the kind of people who are hard to take care of outside the ED (cut, sprained and broken things that need some imaging and a simple fix) but it also has the potential to prioritise the sore finger over the septic abdomen simply because the Fast Track side of the ED is actually flowing and the main side is blocked up.

Now we have Code Stroke, Code STEMI, Trauma, Sepsis, Neonates all competing for immediate care. What’s more, nobody else wants to wait to be seen either. People are talking about the wait-free-ED. A previous Prime Minister of Australia decided that no patient should stay in ED longer than 4 hours and although that is about the length of time an Australian Prime Minister currently stays in office, the 4 hour rule has stuck, for better or for worse. Short stay units, acute medical units, clinical decision making units have all changed the way we move patients out of the department.

And the patients still wait too long to be seen.

There are a lot of EDs in the US and Australia that have attempted to get rid of their waiting rooms and that have created discharge lounges and results lounges and various similar spaces, attempting to shift the waiting process to the end of the stay rather than the beginning. I have seen a lot where the results/discharge lounges are being used for equipment storage and they have stuck temporary seating in next to triage to accommodate the waiting patients now that there is no waiting room. In others, the resus patients are sieved off to one side and the fast track patients sieved off to the other. The remainder are seen at the front door by a team lead by a (frequently disgruntled) emergency physician and then… well they wait of course. Because these remain the bulk of the patients. The fact that we have sieved off all the easy ones into categories with individual names doesn’t change the fact that the undifferentiated maybe-sick-maybe-not patient is the bulk of the ED census. They are also the bulk of the hospital admissions.

So does this mean the only way to see everyone straight away is for the EP to run faster? Because that doesn’t sound like innovation to me.

In order to try and rebuild the way we practice emergency medicine we really need to think about what the role of the ED is and what we want our specialty to do. We definitely need to do more than demolish the waiting room.

Why do we need EDs?

First of all, we would all agree that the community needs a place where critically ill patients can be rescued at any time of the day or night, every day of the year, by doctors and nurses experienced in resuscitation.

Resus however is not really why Emergency Medicine was born. Essentially EM came to be because there were patients who either needed to be admitted to the hospital acutely, or who were worried that they might need to be, and the way these patients were being treated was an embarrassment and medico-legal liability for the hospital. Junior doctors, inadequate equipment, poor supervision were the standard way to access the hospital system if you became ill or injured in such a way that you weren’t able to come via an experienced doctor’s rooms.

Since establishing the role of EM as a gateway to the hospital for unscheduled care, and as a resuscitation unit, the mission has progressively expanded, to providing a form of acute primary care for ambulant patients, acute psychiatric care, a screening service for all acute hospital admissions even those coming from the rooms of the admitting physician, a minor injuries service, a second opinion service, a proxy outpatients service and so on.

What do we want an Emergency Physician to be?

Here are some ideas that I have about how we might rejig our work, based around the different faces of the FACEM community. I don’t really know how it would all operate, I just have some ideas about the different kinds of EM practice that might exist and ways that we might like to stream our patients along those lines to get the best for all of them.

The critical care EP

This FACEM would happily just run a 5 -10 bed resus room with 3 ED-ICU short stay beds and a 10 bed Short stay (nursed at 1:3 – 1:4 night and day) and never see a weak and dizzy or a back pain or a broken arm unless their FastTrack colleague was bringing them a broken arm patient to sedate/anaesthetise for a manipulation and plaster. They would see chest pain, sepsis, COPD, pneumonia, trauma, acute heads, and nothing much else. Running a no-wait system would be straightforward in this area. You need a registrar, an intern and a final year med student to run this unit and the EP, when nothing is happening, would be working on writing a paper about what a great job they’ve got.

There are some amongst us who would be very happy in this role and would be delighted for this to be the totality of Emergency Medicine. There are some troubles with this system however. First, there isn’t enough work for all the EPs out there. Second, there will be the problem of over and under triage. There is still going to need to be a place for all the people who don’t immediately seem like they belong in the ED-ICU but who might turn out that way, unless you want to really overtriage into the ED-ICU in which case you have just reproduced the current ED.

Which brings us to…

The needle in the haystack EP

This doc takes care of the biggest group of ED patients. These are the triage Category 3 and 4 patients, none of whom have simple binary questions to answer and many of whom end up needing admission to hospital.

This EP’s main tool with a critically ill patient is the ability to recognise them and send them to the right place. Their greater strength is in taking care of all the weak, wobbly, tired, dizzy, frightened, puffy ankled, short of breath, belly aching, more confused that usual, pregnant and bleeding, muddled-up-my-tablets patients that occupy the the mass of our cubicles away from resus. They can make people feel listened to and cared for and can find the sick patients without putting the whole ED census through a CT scanner.

Running a no-wait system for the needle in the haystack EP’s patients is a very challenging notion. The problems they present with do not truly justify no-wait; providing a top notch no-wait service for them is potentially taking business away from the GPs (and in Australia, where the government runs the hospitals but the GPs are operating in a private practice model, there are issues with “big government” stealing customers from “the little guy”). The better this service is the more it will creep into less and less emergent problems because people will choose it over the GP who costs money and can’t get everything done on site in one visit.

A more efficient system for these patients could start with patients not owning a bed but lying down for a purpose. It is mad that someone who is not incapacitated should be tucked up in bed in the middle of the day while a sick person doesn’t see a doctor for lack of somewhere to be seen. So get the patient into a gown and onto a trolley. Take the story and examine them, get the ECG, bloods and imaging.Then get them out of their ED trolley and somewhere else and free up the acute assessment space for someone else.

These are the patients who might be more efficiently managed using a results lounge or discharge lounge or some arm chairs. The Needle in the haystack EP needs to use their beds like a consultation space, to speak to and examine patients and then stream them to somewhere else (straight home, SSOU- like area, resus-critical care area). The needle in a haystack EP probably needs a different sort of SSOU from the critcare EP.

What are the barriers to these systems being used?

Patient gowns
Once you are in a gown you want to be in a bed because otherwise the world can see your arse. We need to rethink how we dress/undress our patients if we want to use a “return to waiting room” strategy. Surely we can do better than those awful gowns.
IVs:
We probably place a lot of unnecessary IVs and we give a lot of unecessary IV fluid but having an IV up will stop someone moving out of their trolley. If there is a need to use IV therapy or meds in a non-critical care environment we should probably stream those patients off to a short stay unit (although the fact that people can have IV infusions of horrendous poisons whilst sitting in armchairs in day oncology suggests that we don’t strictly need a patient to be lying on a trolley just to have an IV medication.
Monitoring:
Don’t we just love monitoring? And don’t the patients hate it, especially the horrible NIBP cuff that brutalises their arm every 15 minutes. We need to think more rationally about monitoring. The patients requiring ongoing monitoring and obs should be streamed into the resus-critcare ED or the SSOU.
Patients are tricky:
As much as we make a thing of EPs being able to make a split second decision and predict where the patient is going, the truth is that only works most of the time. We still get screwed often enough that the quick look/superficial front door assessment can get us into trouble. The primary care EP is most at risk from this because they treat the large numbers of haystack patients. The patients triaged to the critical care ED are assumed to be sick so the critcare EP starts by throwing everything at them and gradually trims back. The patients in the primary care ED are assumed to be not so sick and so will catch us out sometimes. There needs to be a good system for moving back from SSOU if things are not right with these patients without it being punitive. It needs to be accepted that we are putting some patients into SSOU in order to let them declare themselves as sick or well.

The bumps and breaks EP:

Fast track is working pretty well for us. There are lots of models that work well with this. In the US is is almost all run by Nurse Practitioners and Physician’s Assistants. At our place it is supervised by a FACEM or registrar but the bulk of the work falls to the intern and physiotherapist (and our one and only NP when she is on shift). I like the idea of medical involvement in FT as it provides a good training ground in surgical and orthopedic skills and it can be satisfying work. It seems a shame to hand it all over to another profession.

The ongoing care EP:

There are some of us who really enjoy the ongoing care side of medicine and are a bit misplaced in the 4 hour ED. We need to think about how to keep a role for ourselves in the 4 hour rule world. I think we need to look at what we are good at: decision making, working with different people, coordinating and keeping up a good tempo of work at 24/7/365. As the 4 hour rule shrinks the Emergency Physician’s domain, the EP needs to look at new territories to conquer.

Departments of Emergency Medicine need to look hard at whether they could take over Hospital in the Home, “frequent flyer programs” (HARP in Victoria), Residential Care In-reach programs and Telemedicine programs. Innovative staffing solutions including nurse practitioners, paramedics, physician home visits should all be considered. In Montreal, I am told, it is common for family medicine residents to share an oncall service for assessment of nursing home patients, a centre in Pittsburgh is using paramedics to do home visits for their admission reduction program, in Bendigo we use an experienced nurse who can consult with the Geriatrician and Emergency Physician on call, to do nursing home visits and to support their staff with acutely unwell patients.

Further than this, EM should be looking at whether we are the people to run clinical decision making units, acute medical units, even acute surgical assessment units. These would be a big reach from where we currently sit but I don’t believe they are out of our reach. Our tempo of work suits these units. Taking our skills into these units would mean that we were not taking patients who really needed the attention of an EP and sending them prematurely on to an internal medicine physician or a surgeon just to satisfy a mandate to get patients off ED trolleys in 4 hours.

It is likely that a shared care model would be required. The ultimate decision on a surgical decision making unit is when to take a patient to the operating theatre, a decision which is the domain of someone who will be operating on them.Acute medical units, while mostly managing common conditions in a fairly standard way, are a place that the more esoteric diagnoses need to be explored, and the complexities of interacting comorbidities carefully considered. This is the domain of the internal medicine physician.

In each of these units, an EP could  use their expertise in managing the flow of patients and coordination of care, and applying their familiarity with rapid turnaround times and frequent revision of plans, hand in hand with the surgeon or physician (internist).

This kind of sharing of expertise is something I believe we are getting better and better at due to growing experience in the resus room as team leaders. In Australia, the UK and parts of Canada it is common for the EP to team lead trauma resuscitation with a trauma surgeon in attendance for their specific surgical expertise (this happens less in the US where trauma surgeons spend a third of their life as intensivists and tend to combine the jobs of resuscitationist and surgeon). In our hospital we are working hard on taking a similar approach to Neonatal Resuscitation, this time sharing care with the general paediatritian (we have no neonatologists in regional Australia). Anyone who has done a pre-hospital physician role will be familiar with the process of sharing care and expertise with an intensive care paramedic. As we all get better at understanding that we are all working to the same end we (we being the health care provider world in general) we will get better and better a this process.

The front door EP

I don’t even want to talk about the front door job. I think we made a big mistake by stressing that we can usually make a decision in a few minutes because now there are places that are expecting us to do that, accurately, every few minutes for a 9 hours shift, with no ongoing connection with the patient and no chance to get feedback on those decisions. I am yet to meet an EP who, when asked about the front door role, doesn’t roll their eyes and groan (except a few directors who speak expansively about the wonderful effects on ED wait times).

In summary

Emergency Medicine has come so far since its birth in the 1960s, too far for us to allow it to be defined out of existence by changes to KPIs from above. Luckily for Emergency Medicine, we remain a new specialty which means optimism, agility and a preparedness to adapt and develop. What we need is passionate and imaginative Emergency Medicine innovators prepared to try new things to get good results for our patients and the community and to further develop our specialty.

We are not short on such people.

3 thoughts on “Where to for Emergency Medicine? What model of care do we want?

  1. Nice synthesis.
    Agree with all of it – particularly the front door bit.
    This model guarantees that almost every cognitive bias is amplified – premature closure.. Zebra retreat. Concord fallacy, Suttons slip, Bandwagon effect, triage cueing and my favourite – the Dunning Kruger effect.
    dangerous territory indeed…

  2. I read this post when it was first published last year. A great synthesis indeed. I then forgot about it.

    Today I finished my first shift as a rat doctor (rapid assessment and treatment/triage/whatever) and followed up the day with an evening of studying crit care echo. For some reason I felt a nagging tension between these two functions, both of which are arguably core emergency physician skill sets. I was worried I would find it difficult to be good at everything under the EM roof. I wanted answers and ended up back at Mark’s blog post, but have frustratingly (and amusingly) found more questions.

    Since signing up to ACEM as a trainee I’ve been an ultrasound enthusiast. But some embarrassing over-calls (and probably a host of undercalls I’m oblivious of), with varying degrees of consequence, I decided to put my money where my mouth was and pay for an expensive university qualification in clinical ultrasound. As a result, I’ve aged prematurely… within a very short space of time I turned into the old curmudgeon grumbling about young enthusiasts who pick up the probe because they know where the “ON” button.

    Critical care ultrasound seems to be an invaluable tool for providing patients with the best care during their moments of physiologic crisis. Unfortunately it’s not necessarily as simple as eFAST, EGLS or HI-MAP. Sure, for most of our “sick” patients it will be adequate, but if we really want to walk the walk of a critical care clinician we should probably develop more robust resuscitation strategies than giving 2L of CSL, intubating and starting a noradrenaline infusion +/- antibiotics.

    To develop that kind of skill set whilst wielding a sector probe, it would take time, practice, and departmental structures that foster accountability and quality control/improvement. That being the case, how does the RAT doctor get time to practice diagnosing the viral myocarditis with fever? Or the short stay/fast track doctor practice their carotid VTIs after a passive leg raise? Should we trust the ultrasound guru who can get a good A4C view in the 200kg ventilated patient to always recognise the posterior fossa stroke in a patient with vertigo? I am not convinced these dilemmas are simply a matter of more education or a broader training curriculum. For me, as soon as I begin to become better at a particular skill, my ability in other advanced skills invariably starts to attenuate. So what kind of an EP should we try to train? And again, what model of emergency care do we want?

    Mark is right – there just isn’t enough emergency critical care work to go around for everyone. Is there enough for EPs to keep their skills up? Is the critical care we provide “good enough” for the people who do roll through the door in compromised states, or should we leave it to the intensivists?

    Most of the time it is great. I think there are times when we can do better, however, and in the future it’s possible we may see the evolution of a more hybrid emergency department faculty to further improve patient care. FACEMs could bring to their departments different skill sets such as advanced echo skills, paediatrics, ongoing care provision, administration and logistics. They would be supported by having time to maintain their unique skill sets (possibly/probably outside of the ED), and operate as co-operative cogs in the day-to-day departmental sprocket, rather than trying to be an overheating dynamo aspiring to be excellent at everything for everyone. The ideal model won’t land in our laps, and it will be important for us to experiment with various styles and structures of care provision if we are to get there. Even if attempts to mix up the structural status quo fail, they’ll still be hopefully leading us closer to our wait-free ED shangri-las where patients are safe, staff are happy, care is cutting edge but sensible, and patients with acute ischaemic strokes are not thrombolysed except as part of ongoing randomised trials to identify the subset of patients who might actually benefit from the therapy.

    For the record, my ideal near future job would be 0.1 rotating to other units doing some sort of meaningful clinical work and building relationships with other departments, 0.3 critical care EP, 0.2 needle in haystack EP, 0.3 teaching EP, and 0.1 running the department, boosting morale and talking trash in the fishbowl EP. If anyone’s advertising such a position in a few years time…

    Postscript:
    1) gowns are rubbish. If there are any aspiring tailors out there with a new design of garment for patients to wear, get in touch because you’ve got three investors – thanks CK for the idea (however for the needle-in-haystack patients, their own clothes are probably fine)

    2) I do not know how to stop the insanity of frequent obs other than through a culture of education and encouraging clinicians (doctors and nurses) to think sensibly. It isn’t just clinical observations/vital signs though: there is something seriously rotten in the house of medicine when you discover interns and HMOs filling out limitation of treatment/resus forms for toddlers and teenagers because there is a tick box on the generic admission form asking if it is done… (no solutions there sorry, only stones to throw)

  3. […] read this post when it was first published last year. A great synthesis indeed. I then forgot about […]

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