January 8th, 2020
Preventing overuse and underuse in the emergency department (ED) is especially tricky because of the fast-paced environment, time constraints, and increasing utilization of emergency care. Emergency medicine clinicians are often under pressure to do conduct tests for patients who come to the ED, even if the possibility of a life-threatening condition is rare. Also, clinicians generally have little time to care for patients who come to the ED with untreated chronic conditions or unmet social needs.
In a recent article in the Emergency Medicine Journal of The BMJ, members of the Right Care Alliance Emergency Medicine council Maia Dorsett, Richelle J Cooper, Breena R. Taira, Erin Wilkes, and Jerome R. Hoffman outline ten ways in which clinicians can bring “value, balance and humanity to the emergency department.”
The Right Care Top Ten has been years in the making. In 2016, each of the Right Care Alliance councils began developing a list of 10 evidence-based recommendations for health care value in their specialty. Through a modified Delphi panel process, the council voted for what they considered the most important recommendations, based on how much the recommendation matters for patients, its potential for positive impact, and how well it illustrates broader system failures.
Here are a few highlights from the top ten list:
Avoid additional testing for patients at minimal risk of heart attack or pulmonary embolism. Many patients come into the ED with symptoms that could be related to blockage of the heart or lung arteries, but are determined to be at minimal risk based on the initial clinical evaluation. Often, these patients are given extra tests in the ED like cardiac imaging “just to make sure” that their symptoms aren’t being caused by a blood clot or blockage; however, these tests can lead to a cascade of harm and additional cost. “Clinicians should be empowered to not test for the disease that they do not suspect,” the authors write.
Avoid routine lab testing. Often clinicians in the ED schedule lab tests automatically, regardless of whether or not the outcome of the test would change how the patient is treated. Unnecessary lab testing can lead to patient discomfort, false positives, overtreatment, and hospital-acquired anemia. And it’s incredibly wasteful – hospitals spend nearly $150 per patient per day on unnecessary lab testing. “Individual laboratory tests should be performed when there is clinical suspicion of a specific medical illness and the test is likely to contribute to a change in treatment plan,” the authors write.
Take into account non-medical factors in the ED. Often health issues are caused by non-medical factors like stress, financial insecurity, trauma due to violence, food insecurity, and more. ED alone cannot solve these problems, but working in an interdisciplinary team with social workers and community partners can help get to the root causes of chronic health issues and connect patients with social resources.
Tailor intensity of care to the goals of the patient. We often assume that patients “want everything done,” but this is not necessarily true. Further, it is often unclear to patients and family members what “everything” entails. Establishing patient goals early during an ED visit can help avoid extensive testing and other treatments that patients do not want, and are especially important in cases of serious illness.