American College of Emergency Physicians

The Emergency Department Role in Patient Safety Initiatives: The Need for Collaboration

Additional Statement, Submitted by Susan M. Nedza M.D., F.A.C.E.P., Chair, Patient Safety in the Emergency Department Task Force, American College of Emergency Physicians

Executive Summary

In order for any researcher to study the impact of factors that affect the safety of patients in our healthcare system, collaborating with emergency medicine will be essential. Why? The emergency department serves as the entry point or front door in many of our institutions for the most seriously ill patients. The emergency department also is the point where those suffering morbidity or mortality from errors in the outpatient system will need to be captured. Perhaps most importantly, the emergency department functions as the largest homogenous site in healthcare for the treatment of acute traumatic injuries or episodic, unscheduled care. Thus, partnering with these providers and developing systems to capture data to be used throughout the healthcare system is imperative.

Emergency medicine is not practiced in a vacuum. As a specialty society, we recognize that efforts to fully study and to implement safe practices in our environment will require collaboration. The ability to recognize those barriers to collaboration and to overcome them will determine our success or failure. What are some of the barriers to this collaboration? These include the need to link outpatient care to inpatient care, the need to build research collaboration not only with classic health care providers but with non-traditional partners, and the ability to develop meaningful data collection systems that cross these barriers.

Emergency departments are unique as the location where many policy issues converge and can be studied. In the context of error reduction, the policy question we must answer is, "How do we ensure patient safety in an environment that is now functioning as the "safety valve" or overflow system for all of healthcare?" This is the greatest challenge we face in developing solutions that are actionable.

This testimony will further elaborate on these key issues. Through this discussion, the argument will be made that emergency medicine is a key partner in error reduction efforts across the healthcare environment. Research initiatives linked to policy issues that affect the safety of emergency care will also be explored. The final point will be to discuss barriers to change as they relate to the culture of emergency medicine.

The Need to Link Outpatient Care to Inpatient Care

Initial Site of Care

The greatest source of hospital admissions in many institutions is through the emergency department. According to the CDC, over 100,000,000 visits were made to the nation’s approximately 5000 emergency departments in 1998¹. Many of these visits are for acute illnesses and diseases related to cardiac symptoms, respiratory symptoms and digestive symptoms such as abdominal pain. In many cases, the link between initial symptoms of presentation and medical history is made that determines a presumptive diagnosis. This is a critical decision point that can lead to morbidity and mortality if not made correctly. A research priority for all of inpatient care should be linked to this decision point. In addition, if we are to impact on the reduction of errors on the inpatient side, studying how that data is collected, where errors occur in that collection and methods to improve the accuracy and availability of that information must begin in the emergency department.

Link to the Outpatient Setting

What of those who are not admitted? On average, 80% of ED visits end in discharge. The ability to study adverse outcomes and events in this population is fully dependent on partnering with providers in long-term care facilities, physician practices and public health providers. This is an area where little research has occurred and which must be explored in order to begin to define the level of medical errors as related to these episodes of care.

Point of Re-entry

The emergency department is also the point of re-entry into the system for individuals who may have had an adverse outcome linked to a prior hospitalization. Methods must be developed to link the two visits together as often they might not be in the same facility or might not involve the same health care providers.

Critical Issue: The Provider's Frame of Reference

A significant barrier is the culture of emergency medicine. Emergency medicine research has often treated the time of discharge either to the outpatient or inpatient setting as the end point for the determination of outcomes. The relationship with the emergency physician terminates at this point, and in the mind of most practitioners, the outcome of the interaction is judged at the time of that final disposition. In order to begin to further explore the full impact of errors in emergency departments, it is imperative that the frame of reference of the provider be expanded. This will only occur if collaboration can be developed between those caregivers within the hospital setting, and/or those in the outpatient setting. This "loop of continuous care" must be established across specialties and across geographic boundaries and must be reflected in our research initiatives.

Barriers to Research Collaboration with Classic Health Care Providers and with Non-Traditional Partners

Emergency medicine must partner with the long term care facilities, with public health clinics, with large group practices. These are the types of relationships that need to be built in order to facilitate research in this area. Research priorities and funding to support research across these boundaries will help to define and to study errors. Without that support, efforts to define errors as they are mapped across traditional boundaries of care will not succeed. We may discover a piece of information, but it will only become actionable in the context of the entire episode of care.

As to non-traditional partners, how do we collaborate with the employer community? For a significant portion of the working population, their contact with the healthcare system for injuries or unscheduled care is more likely to be in an emergency department than in the traditional office setting. In order to determine what the actual economic benefit of error reduction is to the employer community these visits must be studied. The emergency department must also be recognized as a major provider of acute care for work related injuries. Thus, the ability to study missed workdays both from inappropriate treatment and from the lack of treatment is an important issue. The ability to initiate relationships with these non-traditional partners must be facilitated by governmental agencies and larger organizations that have the vision and resources to target this area for research.

The Ability to Develop Meaningful Data Collection Systems that Cross these Barriers

The greatest logistical challenge we face with both traditional and non-traditional partners will be the ability to develop systems that allow for the collection of relevant data across the above mentioned boundaries. The development of a set of research priorities and questions that need to be answered must be a first step. Assistance in convening meetings of these various constituencies and the development of guidelines for data collection and shared data points would facilitate this groundbreaking work. The sharing of databases that have been developed to link similar groups would also help to jumpstart these initiatives.

The Environmental Question: How Do We Advocate for and Insure Patient Safety in an Environment that is Now Functioning as the "Safety Valve" or Overflow System for all of Healthcare?

The greatest challenge to patient safety in emergency medicine is the role these departments currently play as the "safety valve" for the entire healthcare system. In many communities, each day it is becoming more difficult to provide a basic level of care to patients as opposed to the highest quality of care. One will not be able to impact on the errors that occur in this complex environment without acknowledging and investigating these environmental factors that contribute to this complexity.

The Uninsured Crisis

Emergency departments are the de facto caregivers for many of the 44.3 million uninsured individuals in this country². We have both an opportunity and an obligation to link patient safety efforts to the needs of this group. The level of uncompensated care is threatening the ability of many departments to provide care. As the burden of increasing numbers of patients continue to grow, inadequate reimbursement may not allow for increasing emergency department space, ancillary services, and adequate nursing or physician staffing, The mixture of inadequate resources and system saturation crates a ripe environment for errors. A basic question that needs to be answered is how this phenomenon is linked to safety in the emergency department setting.

The evaluation of errors as they relate to this group of patients should also be a research priority. The Emergency Medical Treatment and Active Labor Act³ requires that hospitals screen and stabilize all individuals presenting for care to determine if they had an emergency medical condition. As a result, any individual with no other access to healthcare can present to the ED and regardless of type of insurance or lack there of, will receive access to the system. This regulation alone has been beneficial in serving the uninsured, the non-legal immigrant population, and underinsured individuals in the US. What is the impact of errors on this population? Errors often have been linked to continuity of care issues, and in no population is this a greater problem than for these individuals. Their care is often linked to a series of prescriptions written in a variety of emergency department settings or in public health clinics with no connection to the site of acute care or to each other.

Finally, language and cultural barriers must also be considered in this group. For a significant number of our patients, English is not their first language. How many errors can be attributed to the issue of inadequate and/or incorrect translation in this setting? As a nation of immigrants, studying and implementing systems of care that address this area must also be included in our efforts.

The Volume Crisis

It has often been said that the emergency department is the only limitless area of any hospital. It has little ability to control its inflow or outflow. This in conjunction with the downsizing of inpatient beds has created a crisis in many institutions. This can be illustrated by the events of the last influenza season, where length of stays increased to over 24 hours in some departments due to the lack of inpatient capacity. This coupled with an influx of individuals who were seeking immediate access to the health care system for diagnosis and treatment created a gridlock situation. Emergency departments are not designed for, nor are their staffs trained to provide inpatient care⁴. Research must be undertaken and systems developed to ensure that patients who are in need of inpatient treatment can safely and adequately be cared for in the emergency department setting. This must be a priority as policy issues; financial issues and population issues that lead to saturation are unlikely to change in the future.

The Nursing Crisis

Emergency department nurses are unique and essential members of the care team. The team approach to care in emergency medicine has recognized this within the area of patient safety and quality care⁴. The ability to perform the triage function, in which a nurse determines the relative need for immediate attention and the possible acuity of a patient presenting for care is at the core of emergency care. For example, errors in this determination can lead to myocardial infarctions and sudden death in the waiting room, or to delays in treatment of meningitis in the two-month-old infant. Judgement and experience are essential to patient safety in this setting. Another critical task that requires experienced nurses is the ability to monitor patients with acute conditions. We have only begun to recognize and to discuss the issues of a diminishing pool of such qualified individuals in the work force and its impact on emergency care. It must be a research priority to quantitative this risk and to look to develop best practices and systems to deal with this shortage.

The Culture of Emergency Medicine and the Challenge to our Specialty Society

The culture of emergency medicine is one of functioning on the edge of chaos. It is easy to accept this premise if one accepts the popularity of the television show "ER". The very nature of emergency medicine and the complexity of the practice create challenges for those trying to implement changes and processes that support and are driven by patient safety. As a specialty society, our ability to impact on errors will be directly related to developing and sharing best practices that facilitate this shift in culture.

For example, research previously sited by the MedTeams group clearly demonstrates that efforts can be successful in developing processes and systems to diminish errors. The difficulty we often face is in addressing those cultural barriers that inhibit adaptation of such systems. This can also be illustrated by our lack of adoption of best practices related to shift work and staffing that have been developed and studied in areas outside of healthcare. A significant portion of our research initiatives will need to include studying these culture issues and developing strategies for adoption of safety practices that will be widely accepted.

The Institute of Medicine in its report, "To Err is Human…Building a Safer Healthcare System"⁵ made several recommendations for specialty societies. These recommendations included the need to:

1. Develop a curriculum on patient safety and encourage its adoption into training and certification requirements.
2. Disseminate information on patient safety to members through special sessions at annual conferences, journal articles and editorials, newsletters, publications and websites on a regular basis.
3. Recognize patient safety considerations in practice guidelines and in standards related to the introduction and diffusion of new technologies, therapies and drugs.

None of these efforts will be effective or adopted without research into and recognition of the culture issues that we face. Support for this initial and key endeavor is essential to our success.

As to the other recommendations, we are actively seeking to develop collaborative relationships as discussed at the onset of this report. We are also seeking venues and opportunities to work with other societies and disciplines in this effort.

Conclusion

This testimony is representative of the type of dialogue and effort that is being undertaken within our organization and across our own barriers within the emergency medicine community. Support in surmounting these barriers and aid in our efforts to collaborate with others will be essential to our efforts. We recognize the key role that our members play in the healthcare system and fully embrace the opportunity to take a leadership role in redefining and building a culture of patient safety in emergency medicine and in the healthcare system.

References

1. McCraig LF. National Hospital Ambulatory Medical Care Survey: 1998 Emergency Department Summary. Hyattsville, MD: U.S. Department of Health & Human Services; National Center for Health Statistics; 2000.

2. U.S. Census Bureau. Suitland, MD. www.census.gov

3. Health Care Financing Administration. The emergency medical and treatment act, as established under the consolidated omnibus budget reconciliation act (COBRA) of 1985 (42 USC 1395 dd) Federal Register. 1994;59: 32086-32127.

4. Risser DT, Rice MM, Salisbury ML, et al. The potential for improved teamwork to reduce medical errors in the emergency department. The MedTeams Research Consortium. Ann Emerg Med 1999;34:373-83.

5. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.

Current as of September 2000

Internet Citation:

American College of Emergency Physicians. Additional Statement. National Summit on Medical Errors and Patient Safety Research. September 2000. http://www.quic.gov/summit/aacep.htm

Return to Additional Statement Directory
National Summit on Medical Errors and Patient Safety Research
QuIC Home Page
Department of Health and Human Services