COVID accelerated everything. As did burnout and the nursing shortage. What can we do to help unload us in the emergency department instead of getting tasks added to us? Every time I open up my emails, I see, “Hey, here’s something else that we want y’all to do in the emergency department.”
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ACEP Now: Vol 42 – No 04 – April 2023And again, these might be good things, these might be helpful things, but you also got to show me how the hospital’s trying to, on the backend, unloading tasks instead of giving me new things to do.
Dr. Amy Ho: Are we here for emergencies? Are we the experts in being resuscitation? Or are we actually just availablists?
Dr. Luke LeBas: I like to work. I like medicine. I like taking care of patients. I love working with the ED team. I don’t believe that boarding is an ED problem. I believe it’s a hospital problem. And I think one of the ways to fix this is to get more practicing doctors at the higher levels of the hospital who are able to speak on even footing, that there’s no hierarchy, there’s no, “Well, this person is more important because they generate more money for the hospital.”
Those kinds of issues, I think, need to be put to bed. And there needs to be a hospital-wide response to all of this. And the answer can’t just be laying it on a few people in the emergency department and expect them to do more and more work.
Listen to the full interview online. Click or scan the QR Code to access the podcast.
Dr. Amy Ho: I think you touch on a couple really important things. I think one is the importance of physician leadership. Two is the importance of hospital-wide initiatives, which to me, I think someone’s got to take the first step. And a lot of times it is emergency physician leaders because it’s what we see, it’s what we know extremely well, the waiting room is right there. To me, a lot of times the onus can be on the emergency medicine to take those first steps because the hospitals are our collaborative partners.
They’re not really our adversary. No one wants boarding. No hospital administrator walked around saying, “Wow, I wish I had more boarding hours in my hospital.” And I think the takeaways that I have is to first talk to your administration in the ED about options in the ED, i.e., is there a flex area or kind of a vertical area that you could use to take care of the waiting room patients where it’s appropriate?
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5 Responses to “Pros and Cons: Waiting Room Medicine”
April 16, 2023
John Patrick MD FACEPI was disappointed that there was very little said in the discussion about what is best for our patients
April 16, 2023
Mark Melrose, DO, FACEPDear Dr. Ho-
I come from a similar background as you- EM trained, spent most of my 35 year career in ED Director roles- academic, urban community, suburban community, public hospital, and founder/owner/operator of urgent care practices. I am now back in a purely clinical practice in an urban academic, tertiary care, well resourced specialty hospital. The issues you describe are indeed real world EM concerns, however there is one thing you stated as the basis for your value proposition on WR medicine that is so off base that I had to write this reply. “…But we also know that holding patients as collateral as a way to ransom the hospital into trying to come up with solutions isn’t part of the narrative we want to put out there.” FALSE!!! Patients are indeed held ransom daily by our ED’s, because they have nowhere else to go. In my urgent care practice, people would walk in, and turn right around and go somewhere else if the wait time was too long. It was money out of my pocket, so we made sure people didn’t wait. Our ED’s and ED patients will always be hostages as long as inpatient capacity is a slave to surgical revenue stream, and boarding is an ED problem, not a hospital-wide problem. If WR medicine was “best practice”, inpatient hallway medicine would be a thing, and private rooms would be doubled up, everywhere, everyday.
Yours truly,
Mark Melrose, DO, FACEP
April 16, 2023
GW MDLet’s be honest. This conversation is like the choice of only eating fast food and people arguing whether McDonalds or Burger King is better. Sure, you don’t want to starve. But how about not eating fast food at all.
What are the current interests and motivations of hospital leadership?
Let’s take an auto factory. Imagine one part of the factory has workers and processes with set hours.
In another part of the factory, you can run the workers into the ground, force them to build extra cars at all hours of the night, and they can’t say no.
Would you overwork that other part of the factory? Of course you would.
Want to fix this problem overnight?
1. Claw back the past 5 years of bonuses for the CEO, CNO, CFO, COO if there are more than 5 boarders 30 days of the year.
2. Not allow the CEO, CNO, CFO, COO to leave the hospital if there are any boarders in the ED.
3. Forced firing of all 4 of the above if there are more than 5 boarders 60 days of the year.
I guarantee you, the boarding problem would get fixed very very quickly.
But currently, the financial incentives are to maximize boarding. It’s a win-win for admin whatever they may say.
Elon Musk and Spacex are building self landing rockets. Boarding is just not that difficult. It hasn’t been fixed because the motivations are not to fix it.
And then it’s left to us to have these discussions of whether we should be taking care of patients with +trop’s, appendicitis, and sub arachnoids in the waiting room (yes, we had a SAH we were managing in the waiting room in the recent past).
April 23, 2023
Kevin C Meyer, MD, FACEPYou’re both saying the same thing, one glass half full and the other half empty.
I’ve done both clinical and admin over the years within different systems. Some systems are definitely more metric focused and do a better job than others.
Bottom line is that waiting room medicine (hallways too) is terrible for us and the patients. Fundamentally, hospital CEOs are convinced that a shift from inpatient to outpatient care is the future. I would argue that patients don’t know that. We are the center of the medical universe. Physicians in the outpatient setting cannot keep increasingly complicated patients from the ED, but actually encourage them to go if they are concerned.
We need to focus more staff and money on EDs, observation/respite units, and social workers. Make specialty ED in person consultations normal. Let telehealth and AI be the main stays of outpatient care.
We’re doing it wrong and those in charge are thinking about the future of medicine wrong.
January 12, 2024
N. Newman, MD“I think waiting room medicine, if you do it efficiently, shows our partners that we’re here doing our best.”
The fact that “waiting room medicine” is necessary demonstrates that the ED is not efficient and they system as a whole is functions poorly.