Patient Centered Emergency Care? Nope

In this series, I am exploring the concept of "patient-centered care," a term frequently used in discussions but often understood differently based on one's perspective.

For context, you can refer to the first three newsletters here:

1. Patient Perspective
2. Parent Perspective
3. Primary Care Perspective

Today, let's explore my pediatric ER perspective.

If you consult healthcare experts, they often cite the reduction of emergency room (ER) visits as a primary goal in healthcare. Digital health, convenient care, and urgent care services have all been touted as solutions to decrease ER visits. Paradoxically, however, ER visits continue to rise, and the complexity and severity of patients' conditions have not diminished and healthcare costs increase. As a pediatric emergency physician, the reality of the situation I have seen unfold over the last 30 years is quite remarkable. Lack of attention to the fundamentals of patient centered care, the needs of patients missed while we see increased disruption of accessible continual primary care centered around relationships. Primary care and the fundamentals of patient centered care seems to be fading fast.

Everyone wants patients to visit the ER less, yet we do nothing to really address the real problems.. agree or disagree? Let's explore the basics..

So, let's begin by examining why patients choose to visit the ER.

ChatGPT provides a concise summary of the common responses found in the data universe (in bold):

1. Accessibility: Emergency departments are typically open 24/7 and easily accessible to the public. People turn to the ER when they experience health issues outside regular office hours or struggle to secure immediate appointments with their primary care physicians.

In my experience, patients arrive at the ED throughout the day and night, often referred by schools, daycares, primary care providers, or using various modes of transportation. While health concerns drive some visits, others come for school or work notes or due to pressure from family and friends.

2. Lack of Primary Care Access: Patients may lack a primary care physician or face difficulties accessing primary care services due to long wait times, lack of insurance, or limited availability. Consequently, they rely on the ER as their primary source of healthcare.

In my reality, primary care is becoming less accessible even for those with an assigned primary care provider. Fewer physicians offer sick visits, translation services, or ancillary services like lab and x-ray, making it challenging for patients to secure appointments.

3. Perceived Urgency: Some patients may not fully understand what constitutes a genuine medical emergency, leading them to seek care in the ED for issues that could be managed in a primary care setting. This occurs because they believe their symptoms are more severe or urgent than they actually are.

My experience indicates that patients used to seek nurse advice or counseling from school nurses or their primary care providers. Nowadays, many are simply told to seek care, as primary care often lacks the time and resources for counseling or education.

4. Fear and Anxiety: Medical issues can be anxiety-inducing, prompting some individuals to seek immediate care in the ED, even if their symptoms are not life-threatening.

I have no issue seeing patients with overwhelming fear and anxiety, but what we often miss are delayed care, child abuse, malnutrition, and worsening chronic conditions due to inadequate management.

5. Convenience: EDs offer a one-stop-shop for evaluation, diagnosis, and treatment, including diagnostic tests, imaging, and specialist consultations. This convenience may appeal to patients with complex or undiagnosed conditions.

However, the reality is that EDs are often the second or third stop for families, as they get transferred from less specialized settings like urgent care or ERs without pediatric experience. Patient expectations of convenience are not always met in overcrowded EDs.

6. Non-Urgent Conditions Over Time: Minor complaints may worsen if left untreated, leading patients to seek care initially for what appears to be a minor issue but eventually requiring extensive evaluation or treatment.

The lack of engagement by primary care providers in managing chronic conditions has exacerbated this problem. Fragmented care with specialists too often leaves patients without the medications they need.

7. Lack of Education: Public education on appropriate healthcare utilization is not widespread, and some individuals may be unaware of the availability of urgent care centers or primary care services for non-emergent issues.

Health literacy is a significant challenge, particularly for those without insurance or Medicaid, who often have limited access to care and encounter lengthy wait times for specialty appointments. Education is rarely targeted to those most in need.

What's even more tragic is the impractical suggestions and "innovations" proposed to address this problem. ChatGPT also highlights the common failed approaches:

ChatGPT suggests the following:

To address the issue of EDs seeing many minor complaints, healthcare systems and communities often work to promote better education on when to seek care in the ED versus other healthcare settings. This includes initiatives to improve primary care access, increase public awareness of appropriate healthcare utilization, and establish urgent care centers for non-emergent medical issues. Additionally, some EDs have implemented triage systems to prioritize patients based on the severity of their condition, helping ensure that those with true emergencies receive timely care.

In the weeks ahead, we should focus on real solutions to real problems. The suggestions of ChatGPT continue to fail fast and yet investment of time and resources seems to be doubling down on these failed recommendations.

Workarounds, optimism, education, policy adjustments, disruptive initiatives, and fee-for-service models have all failed to demonstrate meaningful effectiveness. To genuinely address our challenges, a return to a patient-centered approach is imperative. The notion of the emergency department serving as a "safety net" is eroding, and we must focus on addressing upstream issues like primary care, patient engagement, medical homes, continuity, and nurturing relationships if we are to avert the impending healthcare crisis.

Although the data presented in the image above may be somewhat dated, the fundamental concepts and trends likely remain unchanged. With the exception of the pandemic, the patterns of increasing ER visits, less acutely ill patients utilizing the ED, a rising number of Medicaid patients resorting to the ED, and reduced out-of-pocket costs for patients continue to exacerbate the crisis. The emergency department is not a patient-centered solution; it has become a workaround for our faltering primary care system.

https://www.kff.org/medicaid/issue-brief/the-impact-of-the-childrens-health-insurance-program-chip-what-does-the-research-tell-us/

https://www.americanactionforum.org/research/primer-examining-trends-in-emergency-department-utilization-and-costs/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6535998/