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by Carolyn M. Clancy, MD

In recent years, hospital emergency departments (EDs) have increasingly become settings where routine treatment is provided alongside emergency care. This evolving role has important implications for patient safety. In this commentary, I will examine those implications and provide suggestions for safeguarding our ED patients.

Increased ED Utilization
The broader role of EDs is captured in the title of a recent history of emergency medicine, Anyone, Anywhere, Anytime (Zink, 2006). Federal law requires that EDs provide care to everyone regardless of their ability to pay, insurance status, or citizenship. This mandate has led to EDs being considered "providers of last resort." However, EDs may be the only resort for many Americans, including the uninsured and underinsured.

The Centers for Disease Control and Prevention provide the following statistics on ED utilization in 2004 (McCaig & Nawar, 2006):

• One-fifth of the U.S. population had made one or more ED visits within the previous 12 months.
  
  
• About 209 visits to EDs across the United States took place each minute.
  
  
• Approximately 10% of all ambulatory medical care visits in the United States occurred in EDs.
  
  
• From 1994 to 2004, the overall ED utilization rate increased by 6%, from 36 to 38.2 visits per 100 persons.

Institute of Medicine Findings and Recommendations to Improve Emergency Services
In June 2006, the Institute of Medicine (IOM) issued three seminal reports that examined EDs, emergency medical services, and emergency care for children (IOM, 2006a; IOM 2006b; IOM 2006c). In those reports, emergency care in the U.S. was described as "overburdened, underfunded, and highly fragmented." Some of the major findings related to EDs:

• From 1993 to 2003, there was a dramatic increase in total annual ED visits (McCaig & Nawar, 2006).*
  
  
• During the same period, the total number of EDs declined by 9%, and total hospital beds dropped by 17%.
  
  
• In 2003, overcrowding resulted in 501,000 ambulances being diverted to other EDs; an average of one ambulance diversion every minute.
  
  
• ED boarding — when patients remain in the ED for extended periods of time — is a hospital-wide problem that results from limited availability of inpatient beds.
  
  
• Ineffective coordination between emergency medical services (i.e., pre-hospital services provided by paramedics, emergency medical technicians, and medical first responders) and EDs results in poorly managed flow of patients within a geographic region. This leaves some EDs below capacity and others overcrowded.

The IOM reports presented an action agenda for improving emergency care in the U.S. which included recommendations to (1) develop a coordinated, regionalized, accountable emergency care system, (2) create a lead Federal agency that would consolidate emergency care functions, (3) improve operational efficiency and patient flow to address ED boarding and diversion, (4) increase Congressional funding for emergency care, (5) promote EMS workforce standards, and (6) enhance emergency care research.

Emergency Services Research
In support of the last recommendation, the Agency for Healthcare Research and Quality (AHRQ) has invested in emergency services research for many years. One example includes providing funding in 2001 to develop the Center for Safety in Emergency Care. This multi-disciplinary consortium of the University of Florida, Dalhousie University, Northwestern University, and Brown University serves as a research center that has improved ED safety through their published research and development of research proposals that subsequently received funding from other sources. One of AHRQ's current investments is a 5-year grant to HealthPartners Research Foundation in Minneapolis, entitled "Emergency Department Crowding: Causes and Consequences." Already this work has led to publications that document the problem of ED crowding and propose effective solutions.

The depth and breadth of AHRQ activities related to emergency care are too numerous to fully describe in this commentary. Instead, I will focus on practical tools that AHRQ has supported that can be readily adopted or adapted to improve safety and quality in many ED settings.

Triage and Patient Flow
One of our long-standing projects is the Emergency Severity Index (ESI). ESI is a five-level ED triage algorithm that yields rapid, replicable, and clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of patient acuity and resource needs. The program can help EDs rapidly identify patients who need immediate attention, distinguish those who could be treated safely and more efficiently in a fast-track or urgent care center, and determine thresholds for when diversion of patients to other EDs would be necessary to ensure quality care. Since the publication of the first edition in the late 1990s, research has led to further refinement of the algorithm. In June 2005 we issued ESI Version 4 (Gilboy et al., 2005). A link to the newly revisedİESI Implementation Handbook is available at www.ahrq.gov/research/esi/esihandbk.pdf.

ED Staffing and Processes
In 2005, AHRQ awarded over $9 million for Partnerships in Implementing Patient Safety (PIPS) grants. These two-year grants focused on research and the development of evidence-based toolkits that can be adapted to other settings of care to improve patient safety. Seventeen toolkits, including three focused on the ED setting, will be released this summer. One toolkit is based on work by Rollin Fairbanks, M.D., M.S., and colleagues at the University of Rochester. Their research assessed the use of clinical pharmacists in EDs as a mechanism to provide increased medication safety in the fast-paced ED environment. In addition to documenting the value of ED pharmacists, the researchers created a comprehensive Web-based toolkit (www.emergencypharmacist.org) that documents the intervention, describes barriers to implementation, and provides strategies to overcome those barriers.

Another ED-related PIPS toolkit focused on improving patient safety includes a patient flow process that minimizes wait time for evaluation and helps to eliminate or minimize the number of patients leaving without treatment. A third toolkit instructs users on the implementation of a multidisciplinary, simulation-based curriculum that emphasizes team behaviors to decrease and mitigate the effects of medical errors in a pediatric emergency department. More information on these and other PIPS toolkits is available at www.ahrq.gov/qual/pips.htm.

Information Technology in the ED
AHRQ has invested in research on the use information technology (IT) to improve the safety and quality of care provided in the ED. As part of a three-year grant, the Louisiana Rural Health Information Technology Partnership will improve continuity of care by implementing and evaluating the use of a computerized medical record in the ED of 17 facilities in their critical access hospital network. The technology is expected to improve information exchange by documenting all elements of an ED visit. A related grant will evaluate the use of IT to ensure that acute myocardial infarction patients seen in the ED are stabilized according to best practices, while a second grant will evaluate the use of IT to increase the timeliness of treatment provided to cardiac patients in the EMS setting. These two-year grants will be completed in September, 2007; results will be available soon thereafter.

Patient Involvement
AHRQ is also working to minimize unnecessary ED visits and hospitalizations by encouraging patients to get more involved in their care. Research has shown that patients who are more involved improve the quality and safety of their care. For example, patients with diabetes and hypertension who took an active role by asking questions, expressing concerns, and requesting information from their clinicians experienced better blood glucose and blood pressure control compared to patients who took a less active role (Kaplan et al., 1989; Greenfield et al., 1988). This participation can both prevent emergency situations — such as severe hypoglycemia, diabetic ketoacidosis, or hypertensive emergency — and help alleviate unnecessary visits by patients who turn to the ED for treatment when they experience complications of chronic conditions because they have no other alternatives for care.

We know that patient involvement is critical, but we also know that patients can be reluctant to ask questions because they are embarrassed, intimidated, or too trusting of us as clinicians. To address this, AHRQ partnered with the Ad Council to launch "Questions Are the Answer: Get More Involved With Your Health Care." The campaign includes upbeat television, radio, print, and Web advertising, as well as a Web site at www.ahrq.gov/questionsaretheanswer, which provides tips on preventing medical mistakes. The Web site also features a "Question Builder" tool that allows patients to create a personalized list of questions to take to their medical appointments to ensure they receive the information they need to improve the quality of their care. Later this year, AHRQ and the Ad Council will unveil a similar campaign for Spanish-speaking patients and another campaign on preventive health. Each has the potential to improve the quality and safety of care and minimize unnecessary ED visits.

The resources described here are just a sample from a full spectrum of AHRQ investments in the emergency services arena. AHRQ is committed to enhancing and ensuring the quality and safety of care provided to the millions who visit our nations EDs every year.

* Data subsequently released by NCHS indicate a decline in total visits from 2003 to 2004, resulting in an increase of 18% for the period 1994 to 2004 — an average increase of more than 1.5 million visits per year. More recent data from NCHS indicate that the total number of ED visits declined to 110 million in 2004.

References

Gilboy, N., Tanabe, P., Travers, D. A., et al. (2005). Emergency severity index, Version 4. AHRQ Publication No. 05-0046-DVD. Rockville, MD: Agency for Healthcare Research and Quality.

Greenfield, S., Kaplan, S. H., Ware, J. E., Jr., et al. (1988). Patients' participation in medical care: Effects on blood sugar control and quality of life in diabetes. J Gen Intern Med. Sep-Oct, 3, 448-57.

Institute of Medicine (2006a). Emergency care for children: growing pains. Washington, DC: National Academy Press.

Institute of Medicine (IOM). (2006b). Emergency medical services at the crossroads. Washington, DC: National Academy Press.

Institute of Medicine (IOM). (2006c). Hospital-based emergency care: At the breaking point. Washington, DC: National Academy Press.

Kaplan, S. H., Greenfield, S., Ware, J. E., Jr. (1989). Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care 27, S110-27.

McCaig, L. F. & Nawar, E. W. (2006). National Hospital Ambulatory Medical Care Survey: 2004 emergency department summary. National Center for Health Statistics (NCHS). Adv Data 2006 Jun 23(372), 1-29.

Zink, B. J. (2006). Anyone, anywhere, anytime: A history of emergency medicine. Philadelphia, PA: Elsevier/Mosby.