Why are there bad outcomes in the ED?

First, as an emergency department doctor, let me make it clear that the vast majority of emergency patients in this country receive excellent and professional care. The emergency department environment is not conducive to long, leisurely visits between doctors and patients. The physicians – and to a lesser extent, the nursing staff – are pressured to care for more patients in a shorter time period. If the ED happens to be exceptionally busy, well, you just “gotta work fast.”

Too many patients, too little time
An emergency physician may care for as many as ten or twelve patients at once, each waiting for a test result, treatment response, consultant, or inpatient bed. Nurses may care for up to six.

This is a “perfect storm,” the place where small but important items can be missed. Each of the dozen patients presents with a unique set of problems, a unique medical history, and an individualized response to therapy.

How can you keep them straight? Four middle aged men all with similar complaints, two kids with fever, a couple of ‘diagnostic challenges’ and the unpleasant distraction of someone with a non-stop stream of complaints.

The answer? It can be very difficult. Our patient population is skewed. Chronically ill patients with multi-system disease taking over ten different medicines are more frequent emergency department visitors than the average, usually healthy individual. Their problems are much more complex, and treatment options vary widely. Keeping straight each patient’s individual medical condition can be a daunting task, particularly while the results of extensive testing – often needed – must be incorporated into any treatment plan.

Occasionally, in the “heat of the battle,” test results may be overlooked; a medication interaction may be overlooked; a patient’s prior response to therapy might not be obvious or considered.

In patients with multiple chronic problems, any small change in the balance of medications may have a great impact. A minor problem in a healthy individual can be life threatening for someone chronically ill.

An example of an ED patient
Let’s look at an example. Assume our patient has multiple chronic conditions that accompany aging and obesity – a realistic example in today’s society, where people live to older ages and a greater percentage of the population is obese.

Our patient has type 2 (adult onset) diabetes and atherosclerosis or hardening of the arteries. The atherosclerosis has led to a cardiac condition, renal (kidney) insufficiency, strokes, peripheral vascular disease, and a decreased resistance to infection.

The atherosclerotic cardiac disease leads to a requirement for warfarin/Coumadin, a widely used blood-thinning pill. The patient presents after a minor scrape that led to infection on the lower leg. Note that this patient has an obvious, easy-to-diagnose problem.

Part of the evaluation is a slew of lab tests, including testing the effectiveness of the warfarin. Warfarin interacts with scores of medications. If the doctor selects the wrong medication to add to the patient’s regimen, the patient can bleed from blood that is too thin, or suffer a heart attack because the blood isn’t thin enough.

A routine urinalysis might show an occult (hidden) asymptomatic (without symptoms) infection … but because it’s not directly related to the patient’s presenting complaint, this can easily be overlooked. Unrecognized, a urinary infection can lead to systemic illness that can be dangerous if not deadly.

The ED doctor’s challenge
Try to manage a dozen such patients at a time. Remember, each is already taking ten or more different medicines.

Assume each patient requires half a dozen lab tests, each of which is reported at a different time by the laboratory. Each lab test gives a half dozen independent values. For example, a blood chemistry profile gives values for serum electrolytes (all four), two kidney function tests, calcium, serum albumin, and four liver functions. Even the urinalysis includes the specific gravity (density), content of sugar, protein, acetone, leukocyte esterase (occult white blood cells), nitrite (frequent by-product of metabolism from bacterial infection), and a microscopic analysis of at least four different types of cells.

Now imagine you’re under time pressure, and there’s a dozen patients waiting to be seen. Analyze all the data, come up with a treatment plan, arrange follow-up care or admission, and do it fast. Add in a couple of x-rays, an electrocardiogram, changing vital signs, the complaining lady to distract you … and here is the set up for something to be missed resulting in a “bad outcome.”

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