Give emergency medicine true departmental control

As early as 1958, confronted by a 400% rise in emergency department (ED) visits in 15 years, the medical community called for a modernization of the staffing patterns in emergency rooms.¹ This critical mass of need resulted in the establishment of the first “ER” and emergency physician group in 1961. Over the next 2 decades, emergency medical services developed, and emergency medicine became a specialty with its own training and board certification.

In 1966, the American Medical Assocation reviewed the increased use, staffing patterns, and quality of care in EDs and recommended “the recognition of the emergency service as a department” as “the first step in solving its problems.”²

Since these early days, the number of patients attending EDs has continued to grow as much as 2% annually. In 1995, 100 million patients visited EDs in the United States. This huge increase occurred despite aggressive legislative and economic strategies led by managed care that aimed to shift patients away from EDs to their primary care physicians.

In 2000, Richards and colleagues report that ED overcrowding is once again a serious problem. The authors attribute it to many factors, most of which they think are beyond the control of EDs.

The recognition of the emergency service as a hospital department should be genuine and comprehensive. This must involve giving it true control over 3 key areas: decision making, financing, and maintaining efficiency.

The ED leadership should be able to directly monitor and alter the processes of patient registration and hospital admission. Access to emergency physicians, treatment delivery, and transfer to a floor or unit bed should not be delayed by, for example, the need for preauthorization. Managers of EDs should be empowered to monitor and seek solutions to lengthy delays in the provision of studies and their interpretations. Legislation is needed to mandate that adequate screening and stabilization are provided to patients before any preauthorization of care. Managed care gatekeepers are unable to reliably address the urgency of a complaint by telephone and should not second-guess the judgment of a treating emergency physician. Current law restricts the primary responsibility for the quality and outcome to the emergency physician and treating facility. Gatekeepers remain legally unaccountable for pressures they exert during preauthorization calls, despite inherent financial conflicts of interest. Legislation should prohibit prolonged authorization processes for poststabilization care, such as admission or specialized consultations. Emergency physicians should be enabled to designate the service to which a patient is admitted and to mobilize without delay emergent consultations they deem necessary. Managed care plans and hospitals must provide clear-cut on-call panels for all patients, regardless of their funding status.

Professional and facility charges for care provided in an ED should never be “bundled” with those of the inpatient care phase. Capitation rates for ED services should not be bundled with primary care groups who are using them. Both forms of bundling will result in “reverse utilization,” a process of convenient overuse of the ED safety net, which is mandated by federal law to see and provide care for all unscheduled patients. Emergency department resources and revenue must not be shifted away through taxation or management schemes that exceed fair market value. They are not meant for non-ED—related expenses or for profit-driven management corporations. They are needed within EDs to reduce overcrowding and to provide optimal care. Laws restricting the corporate practice of medicine should be enforced. Physicians and nurses provide patient care; they are not businesspeople.

To reduce costs, hospitals and insurers shift time-consuming tasks to the ED for each patient visit. New tasks have also been added, such as superfluous documentation and computerized order entries. Such “right-sizing” increases the time needed per patient, compounding the overcrowding. Staffing and resources should not be allocated based on average patient flow. A safety margin must be provided for the often-unpredictable peaks of patient volume and urgency. Finally, ED physician and nursing administrators should maintain clinical involvement to experience directly the results of their decisions.

Future population growth and aging will only worsen ED overcrowding. The right-sizing of emergency medicine and the shifting or bundling of its revenue are not new. They are, however, growing trends in this dynamic “marketplace.” Doing more with less will no doubt compromise the quality of care for all our patients.