ER Medicine: The First Line of Defense

Emergency room (ER) medicine is not only the first line of defense, but perhaps the best hope of getting better for a patient in the hospital. In most critical illnesses, the first few hours determine not only the morbidity and long term outcomes, but perhaps the very survival of patient. Most of us who have had the unfortunate experience of being in the emergency room as a patient know what a terrifying and anxious experience it can be. While the process often runs smoothly and emergency room physicians do a great job, it does not take much for things to go crazy in an ER. A few critical patients arriving at the same time, a boarding problem (lack of beds in the hospital), a shortage of nurses… You name it. While the hospitalist specialty has transformed in-patient care, its effect on the ER has not met the standards of what was expected.

The presence of in-patient physicians or hospitalists 24/7, or even for most of the day time hours, would seemingly put an end to these ER woes. One would expect a synergy or continuum between ER physician and hospitalists, to shorten a patient’s stay in ER, to see and treat critical patients, to improve the ER throughput, and to decrease boarding. Besides a few exceptions, these changes have by and large not materialized. There continues to be conflicts between ER physicians and hospitalists. On the one hand, hospitalists continue to complain about ER physicians dumping patients who have not been “adequately” investigated, admitting patients who can be treated as outpatients, and admitting patients to hospitalists who should have been admitted to surgery. Ask an ER physician, on the other hand, and he will off load his own list of complaints: hospitalists do not respond in time, try to avoid admissions, ask for investigations which have no room to be done in the ER, and want to keep the patient in the emergency room forever.

In my opinion, the best way to solve this problem is for the Society of Hospital Medicine and the American College of Emergency Physicians to create a joint task force, assigned with the responsibility of working out guidelines, processes and algorithms to improve the ER to Hospitalist transfer of care. As far as I can tell, there is presently no systematic effort towards this end. While we, the hospitalists, are wondering what can we do next to improve the in patient care and management, a compact with ER should be a priority.