Thursday, October 16, 2008

When to use the ER.

Appropriate Use of the Emergency Room

By JP Saleeby, MD

Medical Director of MPH ED

Recent national statistics collected by the American Hospital Association illustrate that between the years 1990 and 2004 there was an increase in the utilization of our emergency departments (ED) of about thirty percent (30%). This represents an average increase of more than 1.5 million visits to emergency rooms per year. Mirroring the increased use was the closures of our nation’s EDs at a rate of 12.4% during the study period. These are quite disturbing statistics as it all points to the poor delivery of health care in the emergency rooms. Certainly a multi-factorial problem the main stress on emergency rooms are the large number of uninsured or self-pay patients where payment for services is delayed or non-existent. The Federal and State governments are contributing by cutting into the already thin financial margins by reducing reimbursements for services. With the cost of delivering health services increasing yearly, this financial stress is catastrophic for hospitals to support their ED.

A thirty percent (30%) increase in the number of patients seen in the ED is quite significant and is leading to delays in care (with wait times exceeding two hours on average, greater in our larger urban centers). It also leads to increased department length-of-stay for patients being treated, admitted from and transferred from the ED. With the increase crush of patients in the ED coupled with nursing and staffing shortages there is an inevitable rise in ambulance diversion (a situation where ambulances are told by radio communications to go to another less crowded hospital further away). Additionally, one can expect medical errors and increased mortality and morbidity due to delays in care. Part of the problem stems from the dysfunction of our current healthcare system. Many patients today are under or un-insured and often turned away from primary care practices. When sick or in need of medical care they come to the ED. Often times the emergency room visit is not for an emergency condition. During the decade long analysis of EDs it was determined that 21.8 percent of patients seen were classified as semi-urgent and 12.5 percent were classified as non-urgent. Education of the populace will help alleviate the inappropriate overuse of the ED for non-emergent conditions and lessen the burden on the system.

This article will be focused on some general guidelines for the use of the emergency department. Typically they are broken down into two types of general conditions: acute medical conditions and chronic medical conditions. The emergency rooms for the most part are set up to diagnose and treat acute conditions such as falls with fractures and sprains, chest pains (heart attacks), sudden changes in mental status (stroke or hypoglycemia) for example. Sudden medical illness ranging from sudden infections (stomach virus with profuse vomiting and dehydration for example), to almost any type of trauma (motor vehicle accidents, lacerations, etc.) is the realm of the ED physician. Additionally, acute exacerbations of chronic illness (examples being a flare up of asthma, shortness of breath due to congestive heart failure, ketoacidosis in a diabetic patient, to name a few) are also appropriately handled in the ED. Keeping our rooms open for true emergencies in the department is crucial for our system to work.

Circumstances such as minor non-urgent illness and chronic conditions are not efficiently or economically managed in the ED as the department is typically not set up for these things. Examples would be medication refills (patients often present to the ED only to have their blood pressure or pain medication refilled, and that is not an appropriate use of this healthcare entity), pregnancy testing, simple colds and coughs. Chronic pain management is best and almost exclusively handled by a primary care physician (PCP) or pain management specialist and not by an ED physician. It is the responsibility of the patient to make appointments prior to medication running out. There are legal ramifications of not following protocol when dealing with scheduled/controlled pain medication. Additionally, the PCP is better adept at managing the sometimes complex regiments that can include opiates, antidepressants and pain-modulator drugs. This is certainly not the realm of the ED doctor.

Other wellness and health concerns fall through the cracks when patients with chronic conditions or situations not appropriate use the ED as a primary care clinic. For example annual physical examination of men’s prostate (PSA, DRE) are not performed in the ED. For women the recommended cancer screening tests such as the breast examination (and mammogram) and PAP smear are not performed in the department. Should patients utilize the ED for their medical maintenance and preventive care, they are sure to miss out on obtaining these critical tests and more (cholesterol screening, diabetic screening, routine immunizations, etc.) In recent years ED’s have been implementing programs to better educate patients who present inappropriately to the ED, not only as a means to lighten our burden, but to refer those patients to the most appropriate healthcare provider. With an estimated 112-million ED visits annually in this country and steadily rising, it is critical for the population to know where to turn for the best and most affordable care. If education of the public is ignored it will only contribute to the implosion of our healthcare system, which would be disastrous for all.

(c) 2008


Dr. Saleeby is the medical director of the ED at Marlboro Park Hospital. He is also medical control of Marlboro Co. Rescue Squad. He maintains a blog at


Emergency Room Crowding: High Impact Solutions, April 2008, ACEP

The Disappearing Hospital Emergency Department, Phillip Kletke, August 2006, HHN Magazine

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