by David P. Sklar, MD; Cameron Crandall, MD
Emergency medicine has evolved from a location, with variably trained and experienced providers ("the ER"), to a discipline with a well-defined knowledge base and skill set that focus on the diagnosis and care of undifferentiated acute problems.(1) The importance of rapid diagnosis and treatment of serious conditions (e.g., myocardial infarction, stroke, trauma, and sepsis) has made timeliness not simply a determinant of patient satisfaction but also a significant safety and quality concern—delays in care can be deadly.(2) Emergency physicians (EPs) have identified delays caused by crowding from boarding of admitted patients as their most significant safety problem.(3) We present a model for understanding emergency department (ED) patient safety and identify solutions by deconstructing care into three realms: individual provider, patient, and environmental system (Table).
Individual Provider Issues
The EP workforce is diverse, and practitioners have varied training and experience. Of almost 40,000 practicing EPs in the United States, only 22,000 are board certified in emergency medicine. Physicians lacking board certification may be inadequately trained. Nevertheless, the need for non–board-certified EPs is partly due to a significant shortage in trained EPs, a shortage that is expected to continue for at least 20 years despite the 143 emergency medicine residency programs currently operating in the United States. The workforce problem is particularly severe in rural areas.(4,5)
Less experienced EPs make more errors than those with experience.(6) Moreover, physicians entering practice without emergency medicine residency training often learn on the job, without the benefit of experienced mentors. Inadequately trained physicians, combined with limited specialty consultation support, create a serious safety risk for patients in rural EDs. Addressing the training, experience, and general competence of physicians practicing in EDs requires multiple strategies: increasing the number of emergency medicine residency trainees; adding EP-supervised midlevel providers; retaining experienced EPs who are considering retirement; and providing training and support for non–ED-residency-trained, non–board-certified physicians practicing in EDs. Making specialty consultation available through telemedicine can supplement on-site consultation in areas where in-person consultation is limited.
ED physicians face cognitive challenges not commonly confronted by other physicians.(7) The ED is a 24/7 operation, and providers often work at night. Rotating shift work disrupts sleep, causes fatigue, and creates problems with thinking, memory, and decision making.(8) Lack of sleep is associated with increased medical error.(9,10) To address fatigue and sleep-related cognitive problems, appropriate shift scheduling that recognizes research on sleep and performance should be encouraged or mandated.(11) Physicians can improve alertness and efficiency during night shifts by using short naps during night shifts and limiting consecutive night shifts except when a night float system is used.
Individual Patient Issues
Many patient characteristics create diagnostic challenges, particularly in patients who are elderly, burdened with chronic disease, and not previously known to the provider or health care system.(12) The ED often acts as the health care entry point for uninsured patients who lack a primary care provider to offer follow-up. Other sources of problems include provider–patient language barriers, challenges with medical literacy, psychiatric or neurological diseases, homelessness, and substance or alcohol abuse.(13) Although interpreter services, telephone translation, and interconnected electronic medical records provide some support, the lack of follow-up (particularly for uninsured patients) complicates efforts to diagnose diseases that are early in their evolution or present atypically. Other patient characteristics associated with fatal errors linked with ED visits include unexplained abnormal vital signs, unrecognized decompensation of chronic disease, and impaired communication or follow-up compliance.(14)
Potential solutions to safety problems associated with the ED patient population include (i) broadly available professional interpreter services for patients with limited English proficiency; (ii) development and implementation of education, consultation, and support services oriented to the management of patients with chronic diseases; (iii) recognition of high-risk patients with appropriate alerts built into the care process and use of decision aids that help structure problem analysis and resolution (5,15); and (iv) provision of follow-up, patient education, and on-going care in a comprehensive primary care practice (i.e., "medical home").
Environmental System Issues
The ED care environment can be a significant source of safety problems. Inadequate staffing with nurses, physicians, and consultants; problems with teamwork; and inadequate continuity of care can harm patient safety. Financial and workforce constraints may drive ED staffing to levels that, while adequate for average ED volumes, are not adequate for higher volume days. Additionally, some patients will leave without being seen when ED volume is high, increasing the risk of bad outcomes. Excessive noise, repeated interruptions (16), inadequate space to see patients, and delays or inaccuracies in laboratory and radiologic study results create additional environmental burdens. These problems can delay diagnosis and treatment or lead to errors due to breaks in procedural routine. Because emergency care requires the cooperation of multiple physicians, failure to accurately transfer information between them can result in incorrect decisions and time-consuming repetition of studies.
The practice of boarding admitted patients in the ED creates the greatest environmental contributor to safety problems. ED crowding has steadily worsened due to increasing numbers of ED patient visits, fewer hospital EDs, and a lack of commensurate increase in inpatient hospital beds for our growing population.(17) The boarding of newly admitted patients in the ED creates a huge burden on ED nurses because of the resources needed for newly admitted patients and lack of familiarity of ED nurses with inpatient nursing procedures.(18) Filling ED beds with inpatient boarders crowds other patients into hallways, waiting rooms, and other non-private areas. Confidential information cannot easily be obtained, and physical examinations are severely limited. Solutions to boarding in the ED have been advocated.(19) In Great Britain, government policy strictly limits ED length of stay. Unfortunately, despite growing evidence of the risks of ED boarding, patient safety regulatory organizations such as The Joint Commission and the Centers for Medicare & Medicaid Services have not developed or enforced effective limits on ED boarding.
There are several potential solutions to address environmental system issues. (i) Nurse and physician staffing should build in adequate buffers for high-volume periods, so that delays in care and task saturation are avoided. (ii) Boarding of admitted patients in the ED should stop. (iii) Noise and interruptions should be minimized by provision of adequate security and provider assistants, while allowing for maintenance of situational awareness. During high-risk procedures, providers must be allowed to focus on the procedure without interruptions or distractions. (iv) ED systems for teamwork and handoffs as well as guidelines for procedures and checklists should be developed, implemented, and evaluated for effectiveness and cost. (v) Information systems can provide valuable patient-specific data as well as reference materials, and provide assistance with follow-up. However, such tools as computerized physician order entry have not been evaluated to clarify the benefits and costs of the various systems and should be adopted with caution.
ED safety requires a multi-faceted approach that addresses provider knowledge, experience, and cognitive errors; unique patient population characteristics; and the systems or environment of care. Each specific area can be improved, but at a cost. Additional providers, training, and nurses all cost money. Checklists and formalized handoffs may slow the flow and productivity of the ED and ultimately reduce revenue. In light of this, each safety initiative must be analyzed based upon cost, benefit, unintended consequences, and current risks within the system. Today's safety efforts are focused on specific disease performance measures such as myocardial infarction (time to cardiac catheterization laboratory) or pneumonia measures (time to antibiotics). These efforts may improve care for some patients but may worsen care for other patients who are not measured. There may also be unintended consequences of poorly designed measures, as described by Wachter and colleagues.(20) Only an integrated approach that addresses the characteristics of providers, patients, and the overall system of care and that takes system performance and well-designed specific disease performance measures into account will bring about the needed improvements in ED safety.
David P. Sklar, MD
Associate Dean, Graduate Medical Education
Designated Institutional Officer
Professor of Emergency Medicine
University of New Mexico
Cameron Crandall, MD
Associate Professor and Vice Chair for Research of Emergency Medicine
University of New Mexico
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2. National Healthcare Quality Report, 2008. Rockville, MD: Agency for Healthcare Research and Quality; 2009. AHRQ Publication No. 09-0001. [Available at]
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14. Sklar DP, Crandall CS, Loeliger E, Edmunds K, Paul I, Helitzer DL. Unanticipated death after discharge home from the emergency department. Ann Emerg Med. 2007;49:735-745. [go to PubMed]
15. Croskerry P. Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med. 2003;41:110-120. [go to PubMed]
16. Chrisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency department workplace interruptions: are emergency physicians "interrupt-driven" and "multitasking"? Acad Emerg Med. 2000;7:1239-1243. [go to PubMed]
17. Derlet RW, Richards JR. Overcrowding in the nation's emergency departments: complex causes and disturbing effects. Ann Emerg Med. 2000;35:63-68. [go to PubMed]
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19. ACEP Task Force. Emergency Department Crowding: High-Impact Solutions. Dallas, TX: American College of Emergency Physicians; 2008. Retrieved from: http://www.acep.org/workarea/downloadasset.aspx?id=37960 Accessed April 1, 2010.
20. Wachter RM, Flanders SA, Fee C, Pronovost PJ. Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure. Ann Intern Med. 2008;149:29-32. [go to PubMed]
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Table. Model of Patient Safety.
(Go to table citation in the text)
Individual Provider Issues
Environmental System Issues
- Knowledge and skills
- Transfer of care/signout
- Communication difficulties
- Atypical presentations
- Age extremes
- Abnormal vital signs
- Intoxication/mental illness
- Chronic disease
- Inadequate staffing
- Inadequate teamwork
- Inadequate consultation
- Noise, interruptions
- Lack of equipment
- Missing medical records
- Boarding of admitted patients
- Shift scheduling
- Duty hour limits
- Limitations based upon sleep and rest requirements
- Cognitive forcing strategies
- Structured handoff documentation
- Interpreter services
- Alerts about atypical presentations
- Admission-observation of high-risk patients
- Medical home for patients with chronic illness
- Adequate staffing based upon safety analysis
- Team training
- Consultation available in person or via telemedicine
- Environmental analysis of noise and interruptions, security
- Equipment, checklists, redundancy
- Electronic medical records, analysis of medical record systems
- Stop boarding