The Waits That Matter

Division of General Surgery, University of California, San Francisco, School of Medicine, San Francisco, USA.
New England Journal of Medicine (Impact Factor: 55.87). 06/2011; 364(24):2279-81. DOI: 10.1056/NEJMp1101882
Source: PubMed
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    • "Patients should not be routinely evaluated and treated in ED hallways where care is inferior.17 Accurate monitoring is difficult to achieve in the hallway. "
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    ABSTRACT: We report the case of a 32-year-old male recently diagnosed with type 2 diabetes treated at an urban university emergency department (ED) crowded to 250% over capacity. His initial symptoms of shortness of breath and feeling ill for several days were evaluated with chest radiograph, electrocardiogram (EKG), and laboratory studies, which suggested mild diabetic ketoacidosis. His medical care in the ED was conducted in a crowded hallway. After correction of his metabolic abnormalities he felt improved and was discharged with arrangements made for outpatient follow-up. Two days later he returned in cardiac arrest, and resuscitation efforts failed. The autopsy was significant for multiple acute and chronic pulmonary emboli but no coronary artery disease. The hospital settled the case for $1 million and allocated major responsibility to the treating emergency physician (EP). As a result the state medical board named the EP in a disciplinary action, claiming negligence because the EKG had not been personally interpreted by that physician. A formal hearing was conducted with the EP's medical license placed in jeopardy. This case illustrates the risk to EPs who treat patients in crowded hallways, where it is difficult to provide the highest level of care. This case also demonstrates the failure of hospital administration to accept responsibility and provide resources to the ED to ensure patient safety.
    The western journal of emergency medicine 03/2014; 15(2):137-41. DOI:10.5811/westjem.2013.11.18645
  • JAMA The Journal of the American Medical Association 12/2011; 306(22):2500-1. DOI:10.1001/jama.2011.1819 · 35.29 Impact Factor
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    ABSTRACT: Concern exists regarding care patients receive while boarding (staying in the emergency department [ED] after a decision to admit has been made). This exploratory study compares care for such ED patients under "Inpatient Responsibility" (IPR) and "ED Responsibility" (EDR) models using mixed methods. The authors abstracted quantitative data from 1,431 patient charts for ED patients admitted to two academic hospitals in 2004-2005 and interviewed 10 providers for qualitative data. The authors compared delays using logistic regression and used provider interviews to explore reasons for quantitative findings. EDR patients had more delays to receiving home medications over the first 26 hours of admission but fewer while boarding; EDR patients had fewer delayed cardiac enzymes checks. Interviews revealed that culture, resource prioritization, and systems issues made care for boarded patients challenging. A theoretically better responsibility model may not deliver better care to boarded patients because of cultural, resource prioritization, and systems issues.
    Medical Care Research and Review 08/2012; 69(6). DOI:10.1177/1077558712457426 · 2.62 Impact Factor
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