The Non-Crisis in America’s Emergency Departments: The Death of Triage

Staying Power

I suppose the only good thing about my patient’s twelve-hour wait in the Emergency Department waiting room before he even made it into a room, and his subsequent two-hour wait before he finally saw me, was that the results of the basic lab work ordered in triage where immediately available and, as his chest xray had been done (also out of triage) ten hours previously, it was a matter of five minutes to diagnose him with a fairly serious case of pneumonia for which he was easily admitted. I spent more than five minutes with him of course. When you wait that long, especially with the degree of patience and good humor exhibited by this most excellent gentleman, you deserve some of your doctor’s time, your moment in the sun, whether you need it or not and even if all you want to do is complain (which he didn’t). His total time in the department was about 21 hours because, although quickly admitted, there is such a backlog of patients in our hospital that he didn’t actually go upstairs until almost the end of my shift.

Most patients don’t have to wait that long to be seen. Some days are busier than others and occasionally we get a big run of traumas or critical patients which slows the flow of less-urgent patients to a crawl but twelve-hour waits are the exception, not the rule. Four, five, or six-hour waits are not unusual however, nor is it uncommon for me to admit a patient and find them still in their room (albeit in a more comfortable hospital bed in place of the Emergency Department folding slab) when I come in for my next shift. And occasionally a patient is admitted, receives his definitive treatment, and is discharged from the emergency department.

It can get busy. It has gotten busier lately because my hospital has just opened its new Emergency Department, a huge, modern facility with all the bells and whistles which, because there is such a severe crisis in Emergency Medicine they advertised the hell out of and are now reaping a bountiful crop of patients. So many in fact that the waiting room can take the appearance of a disaster zone with patients draped over every available piece of furniture, fitfully sleeping under hospital blankets while the late arrivals spill into our brand-new architectural gem of a lobby; regrettably confounding the best computer rendered images of its architects who depicted it with smart, well dressed people sitting in casual conversation and not full of three-hundred pound asthmatics crouching amid the greasy detritus of their extended wait. It was so crowded on a recent shift that our sardonic Charge Nurse asked to set up some kind of MASH-like field hospital to start treating the small minority of patients who really needed to be seen sooner than we were getting to them. Maybe an eighty year-old-man incontinent of urine and leaving puddles on the waiting room chairs need to be seen a little more quicky than we are otherwise able, especially as the majority of patients who we see have minor complaints that probably don’t need to be seen by a doctor at all.

Apparently there are some fairly serious complaints waiting for hours at a time which may or may not turn out to be anything but used to be an almost automatic free pass through triage. I’d like to think that our triage system is working but sometimes it gets so busy that even if your chief complaint is chest pain, the only way you’re getting back quickly is if you have EKG findings. Patients with cardiac and pulmonary complaints get an EKG which is shown to a physician who can then decide whether to jump the line and bring the person back. Unfortunately, the word has leaked out that we take chest pain seriously so many less than scrupulous patients work a little chest pain into their chief complaint, muddying the waters and subverting the triage process. But whatever the complaint, it cannot be denied that our Emergency Department along with many others is being deluged with patients.

Many reasons for this are proposed. The mythical 47-million uninsured Americans are dragged in as handy scapegoats. While there may be 47-million people in the United States without health insurance, the majority of our patients have insurance of one form or another. Almost every child we see in our new Pediatric Emergency Department has at least Medicaid (CHIP), to reap the bonanza of which they built the thing in the first place, as do many of the conveyor-belt mothers who bring them in. The elderly who make up the largest segment of our patient population have Medicare and are not shy about using as much medical care as they possibly can. Additionally, while the auto industry is struggling in our state, almost every other patient not in the first two categories seems to have medical insurance courtesy of your car note, not to mention that many private employers still provide comprehensive medical insurance. Our uninsured population is small, as a total percentage of patients, and is mostly illegal or recent immigrants, the working poor, and most especially the young who are invincible and even if they could afford it, wouldn’t dream of spending a dime of their disposable income for anything as prosaic, as non-trendy, as medical care. (In fact, the battle cry of Generation “Y” or whatever they are called nowadays might as well be, “A Thousand Bucks for my Tatoos but Not One Penny For My Doctor.”)

It is also true that many of our patients wade into the morass of our waiting room because even if they have a primary care doctor, not necessarily a given even if you are insured, the waiting time for an appointment can be weeks or even months and any testing or studies beyond basic lab work will be done in a disjointed manner over the course of several visits and referrals with no definitive resolution in a timely manner. There is an understanding in the community that while you may have to wait with winos and hookers, once you get into the department studies and tests will fly thick and fast, allowing those with worrisome but let’s just say less-than-emergent problems to usurp the traditional deliberative slowness of primary care medicine. In this we are perhaps victims of our own success. Many of our attendings are somewhat old-school and are not shy about discharging patients to follow-up with their own doctor but many are not and we find ourselves working up the damndest things. I mean, I’m as interested in uterine fibroids as the next guy but maybe it’s not going to make much of difference if the patient has to wait an extra week to be given the bad news.

Primary care doctors, for their part, take advantage of this and have been known, by the bye, to send a patient or two to the Emergency Department with the expectation that they will get a rapid work-up. Not to mention that as primary care doctors are extremely busy nowadays and are not generally paid enough to make the prospect of late night house calls appealing, the default advice whenever you call your doctor is, “Go to the Emergency Room.” I ask almost every parent who brings in their child at 2AM with what is nothing more than a cold why they hauled the family out of the house and braved the snowy roads of our wintery state to bring the kid in. The inevitable reply is that they called their pediatrician (or whoever was on call) and were instructed to come in.

As a factor contributing to long wait times in the Emergency Department, neither can it be denied that the relative scarcity of not only hospital beds but hospital beds of the required type leads to admitted patients langushing in the department for hours if not days, occupying space and nursing time that is unavailable for new patients. (Chest pain patients, for example, no matter how stable or how unlikely they are to have coronary artery disease but who are admitted for an exercise stress test which will be, as sure as the Pope wears funny hats, completely negative, need a telemetry bed. ) The bottleneck in the department is not real estate per se, you understand. We can always put patients in hall beds, something we aren’t supposed to be doing but which is often unavoidable, but as there is a finite supply of both nurses and doctors there is an upper limit to the number of patients that can be safely managed at one time. It’s not as if we can forget about the admitted patient either, many of whom are actually quite sick and demand a lot of their nurse’s time. How many patients can a nurse realistically be expected to follow anyway? Five? Six? If you think they can handle more you don’t know the amount of work involved in nursing.

As for doctors, we can follow more than that because we’re not actually doing much of the actual patient care (with the exception of invasive procedures) but even we have an upper limit. My attendings can follow a fair number at one time but even they will tell you that past twenty or so, which they can only do because they have residents working for them, things start to get insane and not a little unsafe. I start getting into trouble at around eight or nine, especially if a few of them are complicated, and past that most of my time is spent spinning my wheels as the inefficiency inherent in breaking my attention into too many little chunks starts to overwhelm my ability to concentrate on new patients.

As cognizant as we are in Emergency Medicine of the need for speed, we cannot just run the patients through like cattle which is what would be required on some nights to meet the hospital’s goal of a thirty minute door-to-doctor time. The paperwork alone on any patient, even a simple one, takes a minimum of ten minutes and that’s rushing it. This is not to say that a simple SOAP note and a couple of orders take that long to write but we also document for billing and liability, both of which greatly magnify the complexity of documention. There are also numerous home-grown paperwork initiatives at our hospital, either thought up de novo by an underworked bureaucrat or an over-reaction to the heavy hand of JCAHO or one of several other hospital accrediting crime families.

At my hospital, because an intern denied washing his hands when asked by a JCAHO consigliere, the residents now have to provide a list of their patients by medical record number for every shift with the initials of the attending or the charge nurse verifying that we did, in fact, wash our hands before we touched the patient. Now, if you think about it, to comply with the spirit of the rule every time we washed our hands we would have to have an attending physician, an individual with a staggering amount of education and impressive medical credentials, stand over us at the sink with a stopwatch timing the lathering. Either that or get the Charge Nurse, a gal with two days worth of work to fit into her 12-hour shift, to do the same. This would take, what? five minutes per patient? Suppose I see 18 patients in a typical shift, that’s an hour and a half of valuable (and billable) patient care time involved in a useless task which is not only humiliating but so stupid that it burns. The ironic thing is that for most of my patients, many of whom have only an indifferent relationship with soap, I cannot wait to wash my hands after I examine them and feel like a leper until I can get to a sink.

What actually happens, as you can guess, is that at the end of the shift we make a hasty list of our patients and the attending or the charge nurse just runs down the list initialling, turning a poorly conceived effort to change behavior into more of joke than it already is and producing in the end just another useless piece of paper to be found by future archaeologists excavating “Stupid Age” ruins. But it is a piece of paper that eats twenty minutes of useful time. It all adds up. I haven’t actually turned one in yet. In a training system that thrives on humiliating residents, this is perhaps the most humiliating thing I have ever been asked to do and I’m not going to do it unless they threaten to fire me in which case I will cave…but I’m going to make my attendings or the charge nurse watch me wash my hands. If we’re going to do it, we’re going to do it right.

I digress a little but this does actually lead me to two points.

First of all, in most of the country there is no real crisis in Emergency Medicine except one that is entirely man-made and entirely correctable if there was a real interest on the part of hospitals and even many in our profession to do so. It is true that there are a lot of patients but the real problem is that as a society, we are terrifically over-doctored and while a fair number of our patients have actual, bona fide medical problems which either need immediate intervention or cannot wait for a leisurely referral and a delayed admission, the majority have relatively minor complaints that are either non-life threatening exacerbations of chronic problems, minor but legitimate medical problems that can wait a bit and would be better and more easily handled by the patient’s primary care doctor, or mostly so trivial and of a self-limiting variety that no medical attention is really needed at all. Consider the first four patients of a recent shift, all with a complaint of “the flu” and all of whom were young, relatively healthy people with what turned out to be minor upper respiratory tract infections. Basically nothing more than colds, maybe bad ones but colds none-the-less. Two of them had been seen the day before for the same complaint but took to heart the boilerplate admonition on their discharge instructions to “Return if not Better” and had dutifully waited four or five hours to be told, once again, that while we can send a man to the moon we have no cure for the common cold. If there was really a crisis in the Emergency Department, these four patients would never have gotten through triage. An experienced nurse would have met them at the door and said, “Are you crazy? Go home. Drink some chicken soup like yer’ granny told you to. We are packed to the gills and there is no way you’re going to occupy a valuable bed and the attention of my nurses for an hour just because you have no common sense and nothing better to do.”

They don’t say this, of course, and the patients are dutifully triaged and eventually may even get a five hundred dollar work up for a cold, something for which most people don’t even go to the doctor or interrupt their day in any manner. I assure you that I have worked with a cold or a severe but self-limiting gastroenteritis many times worse than that of many of my patients but the thought of going to my doctor, let alone the Emergency Department, never crosses my mind. (Residency is like that. You’re overworked, don’t have time to eat right, and are exposed to every virus in town.) It’s just common sense. Or used to be until we decided that absolutely everything was not only a medical problem but an emergency.

The lack of common sense is unfortunately built into the system as a result of the Emergency Medical and Active Labor Treatment Act of 1986 (EMTALA), a law designed to prevent patient dumping but which has also had two major unintended consequences. The first is the inability to refuse treatment to anyone for any reason. Ostensibly the law only requires a screening exam to exclude an emergency medical condition, the absence of which allows a participating hospital (all of them, by default, because they all take Medicare and Medicaid money) to send the patient home without any further treatment. Practically, however, when combined with the dangers of an out-of-control and exceptionally predatory legal system nobody is ever refused treatment for any condition, even the aforementioned minor complaints, which has turned the nation’s Emergency Departments into hyper-expensive Urgent Care Clinics that also dabble in a little Emergency Medicine. Unfortunately, unless you are actively dying, even if you have a legitimate medical complaint you are bound to languish in the department because for every one of you there are five people who really have no business occupying a bed. So sorry. Write your congressman.

The second unintended consequence is to make most Emergency Departments highly lucrative profit centers for their hospitals. To defray the cost of providing the free care quasi-mandated by EMTALA, many departments started to aggresively market their services to paying customers, those with insurance, who would have previously never even dreamed of coming to the Emergency Room, once a fearsome place usually located in the worst part of town with scary parking and close exposure to dangerous-looking people. In this respect our specialty is becoming just another customer service business competing for a piece of the two-trillion dollars we spend every year on medical care. That kind of treasure attracts a lot of desperados and there is now even less of an incentive to exercise a little restraint or to educate the public about the limitations of modern medicine. Unfortunately, the minor complaint is the bread-and-butter of most Emergency Departments. They pay well for the time invested and you can run them in and out quickly.

My second point is that for all the howling about a crisis, very little is done to free up more of the doctor’s and nurse’s time, the real bottleneck in the process. The converse is true as we are, as I have pointed out, continuously subjected to one poorly conceived bureaucratic initiative after another, very few of which have any effect on the patients but serve only to tie up valuable time in non-patient care activities. Most of my time is spent looking at a computer or filling out documentation that, it is hoped, will live up to its promised talismanic powers of legal protection. Not likely, of course. I shudder to think of the treasure trove of hastily written documentation, much if it incomplete and a very poor representation of what actually happened for the patient, waiting like some vast treasure trove to rival Cibola and the other Seven Cities of Gold for the intrepid legal conquistador who first dares land on the shores of this savage and incomprehensible land.

18 thoughts on “The Non-Crisis in America’s Emergency Departments: The Death of Triage

  1. Panda,

    I have been reading your site for years and all I can say is thank you very much. Your insight, thought experiments and such make reading you blog much more enjoyable over doing research into which field of medicine I want to pursue. Thanks and keep at it

  2. “There are also numerous home-grown paperwork initiatives at our hospital, either thought up de novo by an underworked bureaucrat or an over-reaction to the heavy hand of JHACO or one of several other hospital accrediting crime families.”

    Oh, so true. My VA hospital has an upcoming visit from the main gangsters. Guess whose paperwork load has almost instantaneously doubled courtesy of nursing “management” who might do better instead focusing on a core competency of theirs, like say nursing, instead of my documentation.

    Worse, it does zilch, zero, nothing for patient care. In fact, all it does is exhaust me further, making me that much more dangerous to my patients post-call.

  3. I volunteer in an ER by where I live. I just started there a little more than a month ago. I expected to see more weird and crazy stuff there, but most of it is stuff liek what you describe. I also very rarely see any doctors in the admitting part where I work. Almost all the care is done by ARNPs or RNs. Sometimes people get move to other parts of the ER like ER-B, ER-C or the Express section. Is it normal to not really ever see doctors in my section?

  4. Panda – do you think that it would be profitable to hire 1 or 2 people for the purpose of following a doctor around, and just taking dications and filling out forms for him? Would the increase in productivity (after an inital training and adjustment period) make up for the salary that has to be paid?

  5. That was an incredibly powerful and impressive post, both in terms of length and content. For a non-clinician as myself, I found it to be an extremely interesting and readable expose of your workday, and the larger scale issues that surround you. I will be forwarding this to my ED physician friend who is wrapping up her first year as an attending – I’m curious as to how much of this rings true with her as well. Thanks for plenty of dinner conversation next time we get together!

  6. (In fact, the battle cry of Generation “Y” or whatever they are called nowadays might as well be, “A Thousand Bucks for my Tatoos but Not One Penny For My Doctor.”)

    Thank you. I’ve paid around 6000 in Cobra since I’ve graduated college (2005) to maintain continuing coverage while switching jobs and waiting for coverage to begin. Nothing makes me angrier than hearing people my age complain they “can’t afford” health care. I might be able to take them seriously if it weren’t for the expensive handbag and the pictures of their recent trip to Iceland :/

  7. PB,

    fyi, there are some decent studies, (sorry i don’t have links right now) that have shown absolutely no need for telemetry in low risk rule out patients. If you have the time or the inclinication, might be worthwhile to bring this up to your group and see if it would change anything (doubtful, but maybe worth a try.)

    great post.

  8. I’ve spent some time in our local emergency room. My husband has epilepsy and once every couple of years lands in an ER. But the last time was the Friday before New Year’s Eve. I had taken him to our PCP because he was complaining of scrotal swelling. To rule out testicular torsion, the PCP ordered him to the emergency room for an ultrasound (turned out to be epididymitis, which is what we all thought, but we all had to be sure, since even a day would have made a difference if it had been testicular torsion).

    But talk about unnecessary tests — all my husband’s medical records say he has epilepsy, yet the last time he was in the emergency room after a seizure they ran every single test they could on him looking for cocaine, meth, heroin, etc. Umm, hello? Why? I can understand the CT scans of the head, his last MRI shows cortical dysplasia and I guess they just want to make sure there’s nothing else cropping up in his skull. But drug tests? I have not been able to figure that one out.

    Being the one that’s sitting out in the emergency room waiting for him, I’ve observed that a lot of folks waiting just seem to have colds. I’ve seen “sick” kids with enough energy to run and play.

  9. “Consider the first four patients of a recent shift, all with a complaint of “the flu” and all of whom were young, relatively healthy people with what turned out to be minor upper respiratory tract infections.”

    I really don’t understand the people I know who think “the flu” is a serious health condition that requires medical attention. Not to mention that 99% of cases which people call “flu” are actually colds. I think a lot of people have no idea what it’s really like be sick.

    I’m 25 years old and have been to the ER four times in my life. Twice I was taken in an ambulance after car accidents, once when I needed stitches at 2 in the morning after a bar fight, and the last after being referred by my pcp for a condition that ended up requiring emergency surgery. If I have a cold or “the flu” I won’t waste my time going to a doctor to be told what I already know. If I think I have strep, I’ll go to an urgent care clinic.

    I just don’t understand how so many people will go to an ER and wait upwards of 4 hours for such minor concerns. The abject pussiness of people in this country is astounding.

  10. Blacksails-

    You’re talking about ER scribes. They’re rare but they exist in several areas: Texas, Oregon, Virginia, California, etc.

    It really depends on the ED (T-sheets versus dictated notes, average wait times, total visits, acuity of visits, type of EMR, etc) and it likely can only be implemented in a setting that doesn’t have residents, i.e. community EDs. I know of one ED that swears by them, but another one nearby shuttered their program. The former was run by a democratic group that tended to focus on lifestyle but the latter did not want to eat the costs.

    Although, from your description, you already probably have heard of them. Don’t know if you’re asking the PB for advice about them or trying to provoke him :), but I would recommend asking a community ED physician that has worked with them before. I can’t speak for PB (whose writings I enjoy very much) and I mean him no insult, but I think it would be hard for him to give an informed view since he is “just” a resident currently in a strictly academic setting. Although, I bet he would be happy to have somebody do his documentation for him at the end of the night.

    In light of today’s medico-legal environment, I think ER scribes tend to be a boon. Also, it does take advantage of somewhat cheap, very motivated, and, for the most part, intelligent labor: premedical students.

    There is a prominent scribe program in DFW, Texas. Google it for more information.


    Oh, and thank you PB for continuing to take the time, despite the rigors of residency, to write these great blog entries.

  11. Brian –

    You’d be surprised what people are willing to do when the monetary cost to them is essentially zero.

    The craziest thing is the temporal cost- people KNOW they’ll be eating Funyuns and watching Judge Judy re-runs for 4-5 hours, but they do it anyway. Somebody with the time for all that over a simple cold probably isn’t a very productive member of society to start with- ergo, entitlements and handouts and waiting in line for something free was bred into them.

  12. imagine if the copay to those funyun-eaters was just $5 for the ER visit? That’d make a HUGE difference, I say.

    Some of the medicaid managed-care companies in my area institute such a copay for an office visit, and it is a surprisingly effective deterrent to seeing a doctor for a nonsense complaint (e.g. a cold)

    Even with medicaid, if you can afford a cellphone, cable tv, or even funyuns, then shelling out $5 to be seen for something really bothering you shouldn’t be much to ask.

    I think this’d represent a huge cost savings to the gov’t payers. But then, as panda aptly points out, hospitals & industry lose their cut of their easy & profitable stuff. The same can be applied to futile end-of-life care, a TREMENDOUS and growing cost burden.

  13. nola-man,
    No, ive never heard of them, but from what Panda described, it seems to me, that having some pre-med student follow residents and attendings around (remember, pre-meds will do this for free), that the doctors could then focus on patient care. Require a 6 month, or 1 year commitement from the pre-meds, give them a week long training course, and hopefully it reduces the paperwork burden on the doctors. It could have the side effect though of forcing the doctors to review all the paperwork and fix it, taking even more time though.

    Back on topic: In Britain they just instituted a new program – now, for minor complaints (cough, runny nose, itching, and a list of other complaints), pharmacists are now allowed to prescribe medicine without a doctor ever seeing the patient. The GP secretary I talked to told me it really helped ease the burned on the practice, since minor complaints were now sent directly to the pharmacy.

    In America though, this couldnt work. I doubt pharmacists have, or even want, enough malpractice insurance.

    I think its a stupid idea. How is a pharmacist supposed to know when the cough is just a cough vs a giant lung tumor? Or stomach pain is just gas vs the giant long differential that accompanies stomach pain?

  14. You are spot on with your assessment of “overmedicine.” It is not a disease of the ER only (though you guys have the worst of it). I work in a large group and get a handful of calls everyday from patients requesting to be seen (immediately) for: “bleeding mole,” “painful growth,” “rash not getting better.” Many of these patients expect to be added on the same day. Most of them don’t need to see me at all — seborrehic keratosis, dermatofibroma, winter eczema.

    An actual pt this last month: man with dermatitis on his leg. I prescribed topical steroid. He called a few days later saying the rash is worse and he now thinks he has lichen sclerosis because that’s what WebMD says he has. I called and reassured him. A few days later he was added on to my clinic when his primary care physician (a good doc) requested a consult. At the patient’s insistence I biopsied the rash. Dermatitis.

    The next time he calls, I’m sending him to the ER.

  15. In response to BlackSails two postings above regarding pharmacists seeing patients at the pharmacy. Today’s pharmacy graduates are being trained a lot more as clinicians and undergoing many rotations before they graduate and unfortunately few are able to utilize these skills in a community pharmacy. I think they could handle a lot of the cases but they do not carry nearly the amount of liability insurance that physician’s do. I think right now is that most pharmacists don’t have the time and currently would not be reimbursed for this service. If you go into a busy chain pharmacy with a drive-through window (which destroyed any sense of professionalism on our part) then you will notice pharmacists are on the phone trying to straighten out third-party issues primarily or verifying the suspicious Lortab prescription or explaining medications to people who wouldn’t wait around to be counseled properly. I know many would love to utilize their knowlege but time and pharmacy client’s impatience will not allow this. People will go and wait 2 hours to see their PCP or 5 hours at the Emergency Center but 15 minutes to wait for a prescription is the “end of the world” and that is if everything goes as planned. Heaven help us if you need a prior authorization or vacation filling or any of the other road blocks thrown in front of a pharmacist by a PBM in order to not pay the claim. We won’t even get started on that joke of a MediCare prescription plan.

    I’m glad I escaped the rat race and work in a nice urban hospital probably somewhere in Panda’s general geography (at least from what I’ve been able to piece together from his various clues). Hospital pharmacy has its own challenges but nothing like the community area. Panda has lots of readers in my little department and we enjoy every post.

    Keep it up.

    loyal pharmacist reader

  16. this beauracracy (sp) sounds a lot like med school. it’s like the start training us early. i don’t know how much busy work i am continually subjected to, when ultimately, i’d love to spend that time studying (and unlike many students, i do spend that time studying!). well, i guess it’s good to know that my school is mentally preparing me for the worst…

    honestly…the horrors of filling out a handwashing checklist! i shudder at the thought. i would take that stand you are: damn the man.

  17. I dont get the benifit of the scribe theing except for the scribe themselves as a chance to get exposure and experience. I have seen them used. The efficient MD’s did their own documentation and orders and only used scribes in assistive ways like holding kids during exams and relaying information to families. They did enjoy having them to teach because they liked teaching. The lazy attendings who rarely wrote anything down and liked some goodlooking adoring young person to follow them around loved them. The Nurses refused to take any orders from them because its essentially a verbal order transcribed by a unlicensed person and we do not do verbal orders outside a code situation. Its only a time saver for those who dont document and dont take the time to review the scribes documentation done on their behalf.

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