Five challenges facing emergency medicine

Health care reform has touched everything from payment structures to the delivery of care.

The rise of ambulatory and urgent care centers, as well as initiatives to reduce hospital admissions, has led to process changes within emergency departments.

As these dramatic shifts continue, here are five challenges currently facing emergency medicine.

1. Capacity

The greatest challenge is and has always been emergency department capacity. As the population has aged, more people are functioning with chronic disease. Emergency departments are treating more complex illnesses successfully, but that means allotting more time to each patient. Ambulatory and urgent care networks have increased ED referrals and volume.

Population health has also played a factor. Emergency medicine physicians often don’t have all the information they need — background, medical history and social factors. Following a patient post-discharge is nearly impossible and has been an Achilles heel. Better connectivity is necessary to navigate a patient to wellness.

2. Length of stay

Hospitals have consistently looked at ways to improve emergency department traffic flow. One particular model — known as split-flow — has become popular. EDs think in terms of minutes and hours, not hospital days. Shaving precious minutes off a patient encounter can vastly improve patient experiences.

Split-flow utilizes a physician at the door, replacing traditional triage by allowing for early assessment and initial point of care. Patients see the intake doctor and are then funneled to the appropriate level of treatment. This model has helped reduce the time a patient is in the ED. Regardless how rapid the response, though, if a hospital’s capacity is full, the admitted patient (about 25 percent of ED patients) has no choice but to remain in the emergency department (sometimes hours) until a bed opens.

3. Declining reimbursements

Declining reimbursement poses many issues. Health systems and emergency departments are forced to work with thinner margins, do more with less and try to not let it affect quality. Due to reimbursement reduction, expanding regulations and insurance denials, the financial environment is tougher each year. 

Hospitals should and are mandated to treat anyone who shows up at the ED door. It’s the right thing to do. But treating self-pay, no-pay or underinsured patients adds to the financial pressures.

4. Staffing

In a market where there is ongoing need for qualified physicians, physician assistants, nurse practitioners and other health care professionals, recruitment and retention is very challenging. The attractiveness of urgent care centers and unattractiveness of New York’s high cost of living makes hiring qualified emergency medicine professionals difficult. Optimizing strategies for staff retention is crucial.

Emergency departments are opened 168 hours a week/365 days a year. Demanding schedules and a fast pace environment (hard to take a 30-minute lunch and unwind) requires attention to the work-life balance of our staff to avoid burnout.

5. Technology

Technology is good…it will be better. Emergency medical records are still early in development and have not improved efficiency. Actually, it has added time to the patient-doctor encounter.

EMRs evolved dramatically the past two years, but a significant amount of them are still isolated. Better communication between technology systems will streamline care and manage patient flow.

John D’Angelo, MD, is senior vice president and executive director of Northwell Health’s Emergency Medicine Services and oversees all of the health system’s emergency departments. An emergency medicine physician for 16 years, Dr. D’Angelo was instrumental in the health system’s sepsis initiative and he served as clinical sponsor for the Allscripts Emergency Department Information Systems (EDIS) project.