A physician's perspective on why the ED model is stuck

As some you will recall, in a recent column I looked at the issue of how EDs handle patients with non-critical but acute illnesses. (I'd suggested that some form of step-down care, probably in the form of an on-site urgent care clinic, would make a lot of sense.)

However, when I ran my argument past a veteran emergency physician with decades of experience in California EDs, he told me a different story, one that made me sit back and think about whether my suggestion was practical, given the culture of the ED as it stands.

'Why,' I asked him, 'should acutely but not critically ill patients be booted to the curb, rather than cared for via a different track (as happens in some re-worked emergency departments)?'

Here's his reasons why you're not likely to integrate urgent care with ED care anytime soon:

* Culture: Emergency physicians choose the specialty and do the residencies to deal with emergencies.

* Process design: EDs, by and large, are not designed for anything but emergency evaluations.

* Health system stresses: The failure of primary and specialty care to meet demand; having that demand forced into the ED limits how flexible ED staffers can be.

*  External pressures: The fact that most EDs and emergency physicians are pressured to produce at greater than 2-3 patients per hour makes it unlikely that that they could adjust to a partially urgent-care-based model. ("You can't do semi-elective workups with that degree of pressure," he notes.)

* Financial credential concerns: "We are profiled by insurers, and do not want to be the outlier" by investing extra resources in patients who aren't in serious trouble, he says. 
 
* Managed care standards: "Length-of-stay and other ED metrics are driving the industry now--and a protracted workup in the ED skews the LOS and may make you an outlier," he says.

* Reimbursement models: Investing more resources in the less-critical patient can be particularly difficult if health plan incentives discourage it. "Where I'm at, with 95 percent capitation," there would be tremendous resistance to have "workups" occur in different cost silos," he notes.

It sounds to me as if integrating critical care and urgent care in the ED setting would be one hell of a challenge, at best. Still, with some hospitals managing to create separate tracks for the critically and acutely ill, it must be possible.

What do you think would need to happen to turn your emergency room into a system that had distinct workflows (other than basic triage) for sick patients versus mortally ill patients? Do you think it would even be a good idea to try and make this happen? Tell me what you think! - Anne

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