Before I worked as a medical scribe, I didn’t realize how many mildly ill people visited the emergency department (ED). In my first few weeks, though, I learned that patients with minor complaints, such as sprains, cavities, rashes, and common cold symptoms, actually present to the ED quite often – often enough that the hospital where I worked had to dedicate an entire 12-bed wing to them. In most EDs, these non-emergent cases account for up to 30 percent of all patient traffic.
Patients with minor complaints take resources away from the ED. They take time and energy from registration, nurses, imaging technicians, and doctors, who are almost always overworked and in short supply. Our limited personnel and energy are better spent on critical patients than low-acuity cases that could be treated in urgent care or primary care offices.
Our resources are especially constrained due to COVID-related increases in patient volume. At the moment, patient volume is surging due to the new Omicron variant of coronavirus. This steep increase in patients is draining our hospital staff, who are already fatigued from combatting the pandemic for two years. In addition, the new variant is infecting medical personnel and causing widespread call-outs, on top of a nationwide nursing shortage. In short, our hospital staff is thinner and more exhausted than ever. We need to take action to ease the burden of health care workers, and I believe part of that plan should include keeping non-emergent patients away from the emergency department.
So, what can be done? Is there a way to keep low-acuity patients out of the ED? Policymakers have noted this issue and have implemented different strategies to thwart the non-emergent population that presents to the ED.
Some policymakers argue that we can decrease non-emergent ED use by extending primary care office hours and opening more urgent care centers. The problem with the first of these proposals is that primary care reimbursement rates are low and do not incentivize primary care physicians to work longer, more inconvenient hours. In addition, these physicians are being crushed by the coronavirus pandemic too, and it would be difficult for them to see even more patients. As for the second proposal, opening more urgent cares is a tempting solution, but a recent study showed that for every 37 urgent care visits, non-emergent ED visits only decrease by 1. Urgent cares are actually used so often, and have so little effect on expensive ED visits, that they increase health care spending.
Other people propose increasing co-payments for low-acuity complaints, to dissuade people from using ED services for non-life-threatening symptoms. In certain states, policymakers succeeded in raising co-payments for Medicaid patients presenting to the ED for non-emergent complaints. This intervention, though, did not actually deter non-emergent ED use. Raising the price of low acuity ED care is also a moral issue, since it limits health care for the poor.
Most importantly, many non-emergent conditions cannot be distinguished from emergent when the patient first presents to the ED. Indeed, research supports that patients’ chief complaints are not valid predictors of their final diagnoses. Some patients that present with “benign” symptoms are actually quite sick (for example, a patient that arrives with “jaw” pain is later found to be having a heart attack). Other patients arrive with highly concerning symptoms but are later deemed non-emergent (a patient arrives with chest pain, but is later diagnosed with indigestion). If the triage nurse turned away all the minor complaints that arrived in the ED, 93 percent of those people would later be given an ED-appropriate diagnosis. Even if triage is given patient vital signs, they still cannot readily differentiate between emergent and non-emergent cases, since about 80 percent of patients with benign ailments have abnormal vitals.
The final proposal is to educate patients, to teach them which symptoms merit emergency treatment, and which do not. As noted above, though, even triage nurses can have difficulty discerning an emergency from a non-emergency at first glance. Why should we expect patients to make this distinction if medical personnel can’t readily tell what deserves ED treatment and what doesn’t?
So, it seems that despite our interventions, low-acuity patients will keep going to the ED (and maybe they should). The question then changes from, “how do we get these non-emergent patients out of the ED?” to “how do we better integrate low-acuity patients into the ED flow?”
The coronavirus pandemic has provided us with one promising solution to this problem: telemedicine. A recent study on ED telemedicine reports that using online visits to see low-acuity patients in the ED is faster than but just as safe as face-to-face evaluations. When providers used telemedicine, they were no more likely to miss serious diagnoses than during in-person evaluations, and the patients stayed just as well after discharge as they would with face-to-face care. Additionally, patients were just as satisfied with telemedicine as with normal care.
In time, I hope that we can comprehensively solve the low-acuity ED problem. For now, though, low-acuity patients will continue to utilize the ED instead of the other resources available to them. It is up to ED management, then, to facilitate speedy low-acuity care, with the help of novel tools like telemedicine. When we are better able to fast-track low-acuity patients, we can redirect our time and energy to the critical patients who are in greater need of our help and attention. We will also be one step closer to making health care more manageable during this exhausting pandemic.
Dillon Mercado is a premedical student.
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