Viewpoint

Abstract

hallway care, trafficking, abuse: hallway care, trafficking, abuseOne common adage we learn in medical school is that 80 percent of a diagnosis can be made from a careful medical history and physical exam. The remaining 20 percent, as often taught, is comprised of the myriad laboratory, radiographic, and advanced diagnostic testing available. If this statement is, in fact, true, then the prevalent practice of caring for patients in the hallways of our emergency departments is directly challenging our ability to provide the best care. Hallway care for emergency department patients has been a necessary reality for decades. Recently, rising demands for care from patients with otherwise insufficient health care access coupled with the increasingly common practice of boarding admitted patients in the ED have exacerbated the problem of having too many patients with too few resources for care. Hallway corridors and shared spaces, which used to serve as improvisational care areas reserved for unusually high utilization periods, have now become part of the daily routine in many emergency departments. Our survey study conducted with 409 emergency clinicians showed that 72 percent of respondents reported providing care in ED hallways at least sometimes. (Emerg Med J 2018;35[7]:406; http://bit.ly/2ARAubQ.) Our study further corroborates the common-sense assessment that caring for patients in the hallway is suboptimal and compromises the emergency physician's ability to practice the fundamental diagnostic skills of a detailed medical history and thorough physical exam. Ninety percent of those who practice in the hallway altered their history-taking, while 56 percent altered their physical exam. This then led to delays or failures in diagnoses related with these alterations in the history (35%) and exam (41%). These challenges put the emergency physician right between the rock of providing rising volumes of high-quality care and the hard place of increased limitations to carry out even the most basic practices of emergency medicine. Basic patient care challenges aside, this reality also has implications for other important motivations for emergency physicians. Many of us chose to pursue emergency medicine because of the ability to care for those at the margins of society, the most vulnerable and disenfranchised who have nowhere else to turn for help besides our emergency departments. Attempting to provide care in crowded ED hallways further subjects these vulnerable patients to violations of privacy, loss of dignity, and worse communication. Emergency physicians and staff have often been identified as the front-line defenders against traditionally hidden evils such as human trafficking, domestic violence, and child abuse. Our importance in recent years has also been solidified in challenges involving substance abuse and mental health. Alarmingly, our study identified that each of these issues was negatively affected among those who provide care in the hallway and who reported delays or failures in diagnoses. Approximately 12 percent reported clinical failures related to child abuse, eight percent related to human trafficking, and 37 percent to domestic abuse. Despite these alarming figures, we suspect these are underestimates because of these cases' hidden nature. This will remain a substantial portion of our practice unless some pretty drastic changes are made in our health care delivery model. Legislators, hospital administrators, inpatient care clinicians, and the rest of the care continuum need to recognize the reality that our compromised ability to provide patient care in the appropriate setting will necessarily lead to worse quality of care and outcomes. Inadequate access to care, inpatient boarding in the ED, and prolonged length of stay in the hospital all lead to the downstream effects we have described. We have tolerated this extrinsic factor as status quo in providing care in the emergency department for far too long. It's what we have known since the start of training. But as this practice becomes increasingly prevalent, let's pay attention to the challenges it poses and the mistakes for which we are set up. We ought to recognize that this goes beyond a convenience or comfort factor. Our patients deserve better.