Expectations
and Reality in the Emergency Department
As the demands on healthcare in general
increase, so do the demands for both the quality and quantity
expectedof emergency departments and personnel. As more patients
have less access to primary care, the number of patients presenting
to local emergency depts has burgeoned.
Many of these patients do not fit the classical
profile of a patient who has a true emergency but are categorized
as seeking care for non-urgent treatment.
Most of these patients also expect that
they will receive timely and quality service no matter what else
is going on in the emergency department. This increasing demand
for primary care services as well as a general decrease in staffing
and resources has led us to what is a substantially broad gap
between patients' expectations and reality in the emergency department.
As healthcare providers, emergency dept.
personnel are thereby faced with the following options:
- Emergency department personnel can take the stance that patients'
expectations are unrealistic and should not be catered to.
- Emergency department personnel can adjust to the increasing
demands and expectations.
Considering the two options, emergency
department
personnel can take the stance that patients' expectations are
unrealistic and should not catered to. Such depts. are likely
to have little patience for those with non-urgent conditions (despite
the fact that statistically most of these patients have the means
to pay for their care.)
Ultimately, these departments develop an
attitude that all patients must prove that they deserve to occupy
a bed in their busy emergency department. The literature, as well
as real life, is full of examples of this attitude leading to
missed triage assessments with bad patient outcomes. Providers
come to view system issues as not their problem, unchangeable
and just the way it is, eventually taking the attitude that the
patients don't deserve any better for imposing non-emergencies
on their busy department.
Triage becomes such an onerous task that
providers try to discourage patients from coming to the emergency
department for minor complaints (resulting in these providers
breaching both ethical and legal standards.) Although such providers
will be the first to deny it, they actually create a department
that they consider their personal domain, where patients have
to prove they deserve to be there.
They see themselves as championing the
cause of patients who really need their invaluable life-saving
services, despite the fact that no department in the country can
exist solely providing what they consider worthy "emergency
care." Patients become the enemy, the ones who abuse the
system, who should have gone to their doctor's office, waited
until tomorrow, or for their non-emergency to become an emergency.
Such departments become
unhappy places for providers and patients, the bane of the communities
they are there to serve, the problem area of the hospital and
an unfriendly place for both providers and patients. On the other
hand, emergency department personnel can adjust to the increasing
demands and expectations. Some providers have stepped forward
to meet the demands. Administration, nursing, clerical and physician
staffs have studied department processes and implemented more
efficient and productive methods, believing that if the patients
are miserable and unhappy due to the waits and service, the providers
must likewise be working under miserable conditions.
All healthcare providers really want to
satisfy their patients and meet their needs. When registration
is too cumbersome, triage becomes extremely difficult, lab and
x-ray takes too long, and there are delays in getting patients
to the floor when admitted, the litany of system problems makes
the department a bad place for patients and providers alike.
These providers have taken on the daunting
task of changing their systems by forming alliances including
personnel from administration, admitting, medical records, lab,
x-ray, nursing services, ED nurses and ED physicians.
Working together they have found efficiencies
by instituting system changes such as the following:
- Rapid triage and bedside registration.
- ED personnel drawing blood and labs.
- X-ray departments responsible for transport
of patients to and from radiology.
- Having time limit expectations for lab
and x-ray.
- ED personnel taking ownership of patients'
time in the department so that no one falls in the "black
hole" of nothing happening and no one knowing or asking
why.
- Adherence to the idea that patients
are not there for the providers but the providers are there
for the patients.
- Belief that if the department is not
a good place for patients it will never be a good place for
providers.
No one will disagree that the reason they
went into healthcare was to provide quality, compassionate, consistent
medical care to patients. Given the two options above, it is also
clear that the second approach is the only real option. We will
not change the numbers or kinds of patients who seek our services.
It takes the commitment of hospital administration,
nursing services, physicians and all hospital parties involved
to accomplish the higher goal of changing to meet the needs of
our patients and our communities. After all, each one of us is
part of those communities and may one day need the kind of emergency
department where efficient, compassionate service to all patients
is the norm and not the exception.
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