Improve Emergency Care? Pandemic Helps Point the Way

The pandemic may present an opportunity to reshape the future of emergency medicine.

The coronavirus has already prompted health care leaders to rethink how to deliver care to make the most of available resources, both physical and digital. If the shift to greater use of telemedicine continues after the pandemic, it could reduce reliance on the emergency room, where crowding has long been a problem.

This could happen if telemedicine increases the ability for doctors to see more patients more quickly. A Veterans Health Administration study found that same-day access to primary care was associated with fewer emergency visits for conditions that weren’t true emergencies.

During the pandemic, educational campaigns have tried to raise awareness about telemedicine, offering guidelines on when people should seek immediate attention, and when an online consultation is adequate. And American Medical Association officials are seeking to keep the regulatory flexibility on telemedicine that has been allowed during the pandemic.

Of course, telemedicine isn’t a solution for every health problem. And patients with limited digital fluency and access may get left behind as reliance on telemedicine grows. But the potential payoff is large: A review of medical records of older patients found that 27 percent of emergency room visits could have been replaced with telemedicine.

According to the American College of Emergency Physicians, more than 90 percent of emergency departments are routinely crowded, which has long been recognized as problematic.

On average, a patient visiting an emergency room will wait about 40 minutes. Although that’s down from about an hour a decade ago, 17 percent of patients visiting an emergency department in 2017 waited over an hour. About 2.5 percent waited more than two and a half hours.

As many studies have documented, longer wait times can be harmful. For some conditions, a systematic review in 2018 found, longer waits are associated with lower-quality care and adverse health outcomes that include increased mortality. One study found that crowding in the emergency room is associated with a longer wait for antibiotics for pneumonia patients.

“Early antibiotics are critical for a number of common and serious conditions treated in the E.D., including pneumonia,” said Dr. Laura Burke, an emergency physician with the Beth Israel Deaconess Medical Center in Boston. “Patients who have delays in antibiotic treatment have higher death rates.”

Another study of nearly 200 California hospitals in 2007 found crowded emergency departments were associated with longer hospital stays, higher costs and a greater chance of death.

This crowding and its adverse consequences are problems in other countries, too. A 2018 National Bureau of Economic Research working paper examined emergency department wait times in England. Beginning in 2004, a policy penalized hospitals if their emergency departments did not complete treatment for the vast majority of patients within four hours, admitting them to the hospital if necessary for subsequent care. Large fines were imposed for failing to meet this target and, in some cases, hospital managers lost their jobs.

The study found that the policy reduced the time a patient spent in the emergency department by 19 minutes, on average, or about 8 percent. It also found a reduction in 30-day mortality of 14 percent and in one-year mortality of 3 percent.

Longer waits can also increase costs, according to a study published last year in Economic Inquiry. A 10-minute-longer wait increases the cost to care for patients with true emergencies by an average of 6 percent. The study took advantage of the fact that emergency department triage nurses make different decisions about how quickly to treat similar patients, which inserts a degree of randomness into their waiting times.

“The longer patients wait, the more their conditions can deteriorate,” said the study author, Lindsey Woodworth, an economist with the University of South Carolina. “Sicker patients cost more to treat.”

A big contributor to crowding, Dr. Burke said, is that some types of patients — in particular those needing behavioral health care — are hard to move out of the emergency department, even when they no longer need to be there. “Many hospitals do not reserve enough beds for behavioral health patients,” she said. “These patients often wait days in the E.D. for definitive care and, by taking up space in the E.D., they delay the E.D. care for other patients.”

Because the bottleneck in this case is the need for more hospital beds for patients with mental health conditions, this is not necessarily a problem that telemedicine can address.

Additionally, many people end up waiting in the emergency department on the advice of other medical providers, though they may not need to. Their problems could be handled elsewhere. Although estimates vary, some studies suggest up to a third of E.D. visits are avoidable.

Although health care coverage has grown since passage of the Affordable Care Act, newly insured people tend not to have a regular source of care like a primary care physician. When health problems arise, those newly insured tend to visit the emergency department, just as they might have before they were covered.

In situations that aren’t true emergencies, urgent care centers or retail clinics may provide faster care. But sometimes the only source of help available in the middle of the night is an emergency room. One study found that when urgent care centers close, emergency room volume increases. It’s worth mentioning that lower-income patients or those without coverage may be unable to afford care at these centers.

Once the pandemic fades, the momentum from telemedicine may continue, with the possibility of making progress on a problem that shouldn’t wait.

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