The Busy Emergency Department

Abstract

“The office is closed at this time and will reopen at 9 am tomorrow morning. If this is an emergency, please call 911 or go to the nearest emergency room.” There has been an important evolution in the practice of medicine in the past decade. An article included in this issue, “Exploring New Intake Models for the Emergency Department,” clearly highlights the emergence of the emergency department (ED) as a primary portal of entry for many patients. Within the context of the issues raised by the authors we must answer the following questions: “Why does the percentage of nonurgent ED visits as a percentage of overall visits continue to rise (ie, 10% in 2002 and 13.9% in 2005)?” “Who uses the ED for nonurgent care?” “Where are the opportunities to reduce ED overuse?” The National Quality Forum’s National Priorities Partnership (NPP) has identified eliminating overuse while ensuring the delivery of appropriate care as one of 6 national priority areas. The NPP envisions health care that promotes better health and more affordable care by continually and safely reducing the burden of unscientific, inappropriate, and excessive care including tests, drugs, procedures, office and hospital visits, and hospital stays. Making overuse a national concern will reduce harm, disparities, disease burden, and waste. Assuring access to appropriate care on a timely basis will also reduce more serious chronic disease consequences downstream. Examples include hypertension, congestive heart failure, and early detection of malignant disease. Potentially preventable ED visits is one of the 9 areas targeted by the overuse committee of the NPP. The Commonwealth Fund 2008 National Scorecard on US performance noted that 26% of adults went to the ED in the previous 2 years for conditions that could have been treated by their regular doctor, if available. The United States fared the worst in a comparison with 6 other countries (Germany, Netherlands, New Zealand, the United Kingdom, Australia, and Canada). Nationally, 60 million, or half of the 120 million annual ED visits, are potentially avoidable. In 2006, there were 119.2 million visits to hospital EDs, 15.9 million of which were considered emergent or urgent. Emergency services are often the only alternative for the uninsured or underinsured as their access to primary care services is limited. However, the New England Healthcare Institute notes that lack of timely appointments and after-hours care also drives patients to the ED. Primary care practices often instruct patients to seek care in the ED. Patients can receive care in the ED anytime—regardless of the severity of their condition—and in view of the wide array of services available in the ED, patients can receive immediate feedback about their condition. These factors contribute to the fact that all payer groups and age groups contribute to the issue of nonurgent care in the ED. This trend applies to Medicare and Medicaid beneficiaries in particular. Insured patients with a primary care alternative also inappropriately use the ED; one third of ED visits are made during regular business hours when primary care offices are open. According to statistics from the Centers for Disease Control and Prevention and the Massachusetts Division of Health Care Financing and Policy, the estimated nonurgent, preventable/avoidable ED visits in Massachusetts in 2006 were made by 22 000 patients with private insurance, 15 000 with Medicaid, 10 000 uninsured, and 9000 Medicare patients. The average cost of an ED visit is $540 more than the cost of an office visit. If we can reduce ED overuse (ie, if all 60 million avoidable ED visits were redirected to a less costly setting), there is an opportunity to improve care and a potential savings of $32 billion. Overuse of nonurgent ED services results in potentially avoidable hospital admissions in 5.5% of cases as well as higher volumes of more expensive testing. The unintended consequences of harm inherent from inappropriate testing, procedures, and hospitalizations have been well documented and affect quality and patient safety. The frequent lack of follow-up on recommendations given to the patient in the ED and poor communication with the primary care physician (if indeed there is one) add to the concerns of poor coordination of care—particularly in the elderly and patients with chronic illnesses—and ED revisits. To ensure quality, safety, and patient satisfaction when the patient arrives in the ED, the recommendations inherent in the Welch and Davidson article in this journal should be carefully reviewed. Timely access to primary care services must be a focus of quality improvement efforts if we