The Emergency Department as a Partner in Care
References
Seema Marwaha. Serena Thompson. CMAJ 2020;192:E900-E900.
Venkatesan T et. al A survey of ED Use in patients with cyclic vomiting syndrome BMC Emer Med 2010 10:4
Saver JL, et. al. The “Golden Hour” and Acute Brain Ischemia 3 Jun 2010https://doi.org/10.1161/STROKEAHA.110.583815Stroke. 2010;41:1431–1439
In this article Serena Thompson shares her travails dealing with Sickle Cell Disease and declares “My relationship with the Emergency Room is that there is no relationship.” (1) A survey of US patients using Emergency Department confirmed that directive letters are ignored in approximately 50% of visits. (2) I learned more about the resistance of ED physicians being “told what to do” by “outside” doctors when I was appointed the acting ED Chief for a two year stint. Like police, physicians bring a certain skepticism to “received wisdom”. Physicians are independently accountable for their care. They are vulnerable to being blamed (or sued) for patient misadventures that are often systemic in nature. “I based my actions on the suggestion of another physician” is a weak defense. They are sensitive to being considered “handmaidens” of outside physicians who send patients down to the ED with unrealistic expectations of having tests or admission. In most instances, they are seeing patients they don’t know and likely won’t see again. Their concern about being manipulated by “drug seeking” patients is real. Nevertheless, there are small groups of patients, who despite ongoing medical care, need to come to the ED for medical treatment. Complex Migraine, Cyclic Vomiting Syndrome, Sickle Cell Crisis and Inborn Errors of Metabolism come to mind. While these events are not life-threatening, the principle of the “golden hour” developed for the treatment of severe illness should be applied to these groups as early treatment results in milder illness, shorter duration of stay and fewer hospitalizations.(3) It is better for both the patient and the ED that these patients be rapidly identified and the appropriate treatment commenced quickly. Reframing this challenge as a process problem rather than as a physician problem is critical. Working with the ED Head Nurse, we developed an Alert System issuing the patient with an “Alert Card" that identified the patient’s Clinical Treatment Plan in the Hospital’s Sharepoint information system. This worked more consistently when the treatment plan was placed on the patient’s chart at registration. From this experience, we would suggest the following to patients struggling to get predictable care for a chronic disease from your local ED. 1. Identify a physician advocate to help develop your treatment plan. 2.The physician advocate should try to meet with the ED Medical Chief to vet the plan that can be used patient ED visits 3. In other instances, the physician advocate or the patient themselves should seek to meet with the ED Head Nurse at some time between crisis events to organize the Treatment Plan. 4.In the event of resistance, it might be reasonable to contact the hospital’s “Patient Experience” department to get a dialogue going. 5.In the absence of open-minded response, think about taking the issue to a member of the Hospital Board to get things going for groups of patients like you.