In Chief

The unconscionable extended ED boarding of acutely ill psychiatric patients in need of inpatient care was the subject of one of the most requested recent EM editorials. Tragically, in the 2 years since “A Wintry Mix of Patients” first appeared (March 2013), little has changed.

An August 7, 2014 Washington State Supreme Court decision prohibiting the use of EDs to board acutely ill psychiatric patients may be one step in the right direction. But it offers no alternatives for actually providing the care. A week after the ruling, ACEP’s president expressed concern that EPs could be caught in the middle of conflicting federal and state mandates, and medical liability risks.

Throughout the United States this winter, admitted patients and their families waited hours to days in emergency departments for inpatient beds. Few waited longer or suffered more than those waiting for a psychiatric bed. The number of patients needing hospitalization for acute psychiatric conditions and behavioral disturbances frequently exceeds the capacity of psychiatric services to admit them and increasingly exceeds the capacity of psychiatric EDs to provide continued care until beds become available. When psychiatric patients are boarded in surrounding medical EDs that were never designed for this purpose, emergency physicians, nurses, and security officers must try to provide a safe and secure environment of care for both the displaced psychiatric patients and nearby medical and surgical patients.

In a January 22, 2013, article, Washington Post reporter Olga Khazan describes the plight of a 15-year-old girl with Asperger’s syndrome and an anxiety disorder who spent 2 days on stretchers in two EDs waiting for an inpatient bed. The article attributes the nationwide bed shortage to cutbacks after “28 states and the District [of Columbia] reduced their mental health funding by a total of $1.6 billion” between 2009 and 2012.

Similarly, in a July 2012 report, “No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals,” the nonprofit Treatment Advocacy Center (TAC) points out that the total number of state psychiatric beds in this country decreased by 14% from 2005 to 2010, dropping the per-capita bed ratio to the same level it was in 1850, the year that our country began to provide more humane care by hospitalizing the most severely mentally ill patients. The TAC report also notes that, in the absence of needed psychiatric treatment and care, people in acute or chronic crises gravitate to hospital EDs, jails, prisons, or the streets, and are partly responsible for higher rates of violent crimes.

At the same time that state-supported psychiatric beds are disappearing at an alarming rate, a desperate need for more med/surg beds is leading many general hospitals to convert psychiatric beds to nonpsychiatric beds. But a lack of inpatient beds is not the only factor responsible for this crisis in care. Health insurance providers are much more selective with respect to which inpatient psychiatric services they will pay for, and often will not cover an available inpatient bed nearby. Why is there a difference between psychiatric and nonpsychiatric inpatient coverage, and why do states permit the difference? This practice adds to the misery and delays the care of all patients, as emergency psychiatrists and social workers must spend hours or days arranging for covered inpatient stays.

All inpatient care, including psychiatric care, can be expensive, but how much money does the elimination of psychiatric services really save if you add in the cost of extra prison capacity, the loss of income by family members waiting in the ED with an ill relative, or the loss of productivity by victims of violent crimes committed by nonhospitalized mentally ill patients? Psychiatrists utilizing potent modern medications have made incredible strides in treatment, but treating an illness is not the same as curing it, and patients who stop taking their medications after their prescriptions run out often end up back in the ED—sometimes repeatedly. Such episodic ED care also adds to the overall costs and, more important, hurts many people in the process.

For more than 150 years, states have assumed major responsibility for providing a safe therapeutic environment for those suffering from severe mental illness. Now is not the time to abandon this responsibility. As a nation, if we cannot recognize the seriousness of this problem and if we do nothing to fix it immediately, lack of beds is not the only lack of capacity from which we suffer.

The unconscionable extended ED boarding of acutely ill psychiatric patients in need of inpatient care was the subject of one of the most requested recent EM editorials. Tragically, in the 2 years since “A Wintry Mix of Patients” first appeared (March 2013), little has changed.

An August 7, 2014 Washington State Supreme Court decision prohibiting the use of EDs to board acutely ill psychiatric patients may be one step in the right direction. But it offers no alternatives for actually providing the care. A week after the ruling, ACEP’s president expressed concern that EPs could be caught in the middle of conflicting federal and state mandates, and medical liability risks.

Throughout the United States this winter, admitted patients and their families waited hours to days in emergency departments for inpatient beds. Few waited longer or suffered more than those waiting for a psychiatric bed. The number of patients needing hospitalization for acute psychiatric conditions and behavioral disturbances frequently exceeds the capacity of psychiatric services to admit them and increasingly exceeds the capacity of psychiatric EDs to provide continued care until beds become available. When psychiatric patients are boarded in surrounding medical EDs that were never designed for this purpose, emergency physicians, nurses, and security officers must try to provide a safe and secure environment of care for both the displaced psychiatric patients and nearby medical and surgical patients.

In a January 22, 2013, article, Washington Post reporter Olga Khazan describes the plight of a 15-year-old girl with Asperger’s syndrome and an anxiety disorder who spent 2 days on stretchers in two EDs waiting for an inpatient bed. The article attributes the nationwide bed shortage to cutbacks after “28 states and the District [of Columbia] reduced their mental health funding by a total of $1.6 billion” between 2009 and 2012.

Similarly, in a July 2012 report, “No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals,” the nonprofit Treatment Advocacy Center (TAC) points out that the total number of state psychiatric beds in this country decreased by 14% from 2005 to 2010, dropping the per-capita bed ratio to the same level it was in 1850, the year that our country began to provide more humane care by hospitalizing the most severely mentally ill patients. The TAC report also notes that, in the absence of needed psychiatric treatment and care, people in acute or chronic crises gravitate to hospital EDs, jails, prisons, or the streets, and are partly responsible for higher rates of violent crimes.

At the same time that state-supported psychiatric beds are disappearing at an alarming rate, a desperate need for more med/surg beds is leading many general hospitals to convert psychiatric beds to nonpsychiatric beds. But a lack of inpatient beds is not the only factor responsible for this crisis in care. Health insurance providers are much more selective with respect to which inpatient psychiatric services they will pay for, and often will not cover an available inpatient bed nearby. Why is there a difference between psychiatric and nonpsychiatric inpatient coverage, and why do states permit the difference? This practice adds to the misery and delays the care of all patients, as emergency psychiatrists and social workers must spend hours or days arranging for covered inpatient stays.

All inpatient care, including psychiatric care, can be expensive, but how much money does the elimination of psychiatric services really save if you add in the cost of extra prison capacity, the loss of income by family members waiting in the ED with an ill relative, or the loss of productivity by victims of violent crimes committed by nonhospitalized mentally ill patients? Psychiatrists utilizing potent modern medications have made incredible strides in treatment, but treating an illness is not the same as curing it, and patients who stop taking their medications after their prescriptions run out often end up back in the ED—sometimes repeatedly. Such episodic ED care also adds to the overall costs and, more important, hurts many people in the process.

For more than 150 years, states have assumed major responsibility for providing a safe therapeutic environment for those suffering from severe mental illness. Now is not the time to abandon this responsibility. As a nation, if we cannot recognize the seriousness of this problem and if we do nothing to fix it immediately, lack of beds is not the only lack of capacity from which we suffer.

The unconscionable extended ED boarding of acutely ill psychiatric patients in need of inpatient care was the subject of one of the most requested recent EM editorials. Tragically, in the 2 years since “A Wintry Mix of Patients” first appeared (March 2013), little has changed.

An August 7, 2014 Washington State Supreme Court decision prohibiting the use of EDs to board acutely ill psychiatric patients may be one step in the right direction. But it offers no alternatives for actually providing the care. A week after the ruling, ACEP’s president expressed concern that EPs could be caught in the middle of conflicting federal and state mandates, and medical liability risks.

Throughout the United States this winter, admitted patients and their families waited hours to days in emergency departments for inpatient beds. Few waited longer or suffered more than those waiting for a psychiatric bed. The number of patients needing hospitalization for acute psychiatric conditions and behavioral disturbances frequently exceeds the capacity of psychiatric services to admit them and increasingly exceeds the capacity of psychiatric EDs to provide continued care until beds become available. When psychiatric patients are boarded in surrounding medical EDs that were never designed for this purpose, emergency physicians, nurses, and security officers must try to provide a safe and secure environment of care for both the displaced psychiatric patients and nearby medical and surgical patients.

In a January 22, 2013, article, Washington Post reporter Olga Khazan describes the plight of a 15-year-old girl with Asperger’s syndrome and an anxiety disorder who spent 2 days on stretchers in two EDs waiting for an inpatient bed. The article attributes the nationwide bed shortage to cutbacks after “28 states and the District [of Columbia] reduced their mental health funding by a total of $1.6 billion” between 2009 and 2012.

Similarly, in a July 2012 report, “No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals,” the nonprofit Treatment Advocacy Center (TAC) points out that the total number of state psychiatric beds in this country decreased by 14% from 2005 to 2010, dropping the per-capita bed ratio to the same level it was in 1850, the year that our country began to provide more humane care by hospitalizing the most severely mentally ill patients. The TAC report also notes that, in the absence of needed psychiatric treatment and care, people in acute or chronic crises gravitate to hospital EDs, jails, prisons, or the streets, and are partly responsible for higher rates of violent crimes.

At the same time that state-supported psychiatric beds are disappearing at an alarming rate, a desperate need for more med/surg beds is leading many general hospitals to convert psychiatric beds to nonpsychiatric beds. But a lack of inpatient beds is not the only factor responsible for this crisis in care. Health insurance providers are much more selective with respect to which inpatient psychiatric services they will pay for, and often will not cover an available inpatient bed nearby. Why is there a difference between psychiatric and nonpsychiatric inpatient coverage, and why do states permit the difference? This practice adds to the misery and delays the care of all patients, as emergency psychiatrists and social workers must spend hours or days arranging for covered inpatient stays.

All inpatient care, including psychiatric care, can be expensive, but how much money does the elimination of psychiatric services really save if you add in the cost of extra prison capacity, the loss of income by family members waiting in the ED with an ill relative, or the loss of productivity by victims of violent crimes committed by nonhospitalized mentally ill patients? Psychiatrists utilizing potent modern medications have made incredible strides in treatment, but treating an illness is not the same as curing it, and patients who stop taking their medications after their prescriptions run out often end up back in the ED—sometimes repeatedly. Such episodic ED care also adds to the overall costs and, more important, hurts many people in the process.

For more than 150 years, states have assumed major responsibility for providing a safe therapeutic environment for those suffering from severe mental illness. Now is not the time to abandon this responsibility. As a nation, if we cannot recognize the seriousness of this problem and if we do nothing to fix it immediately, lack of beds is not the only lack of capacity from which we suffer.

If an emergency department is considered the “front door” to the hospital, how do we regard a free-standing emergency department (FSED) with no hospital attached to it? Until recently, FSEDs were most commonly located in rural areas lacking hospitals and primary care providers. But fueled by recent hospital closures in the face of steadily increasing demands for emergency care, FSEDs are now appearing in previously well-served urban areas, too. In the past 6 months, three new FSEDs have opened in New York City on the sites of recently closed hospitals. What do FSEDs mean for emergency medicine and emergency physicians, and are they safe alternatives to traditional hospital based EDs?

Newer technologies and treatments, coupled with steadily increasing pressures to reduce inpatient stays, razor-thin hospital operating margins, and the refusal of state and local governments to bail out financially failing hospitals, have created a disconnect between the increasing need for emergency care and the decreasing number of inpatient beds.

On one end of the EM patient care spectrum, urgent care centers and retail pharmacy clinics—collectively referred to as “convenient care” centers—are rapidly proliferating to offer care to those with urgent, episodic, and relatively minor medical and surgical problems (see last month’s editorial, “Urgent Care and the Urgent Need for Care”). With little or no regulatory oversight, convenient care centers staffed by EPs, family practitioners, internists, NPs, and PAs, offer extended hour care—but not 24/7 care—to anyone with adequate health insurance or the ability to pay for the care.

On the other end of the EM patient care spectrum are the FSEDs, now divided into two types: satellite EDs of nearby hospitals, and “FS”-FSEDS with no direct hospital connections. Almost all FSEDs receive 911 ambulances, are staffed at all times by trained and certified EPs and RNs, provide acute care and stabilization consistent with the standards for hospital-based EDs, and are open 24/7 – a hallmark that distinguishes EDs from UCCs. FSEDs code and bill both for facility and provider services in the same way hospital-based EDs do. Although organized emergency medicine has enthusiastically embraced, and recently endorsed FSEDs, its position on UCC’s has been decidedly mixed.

Are FSEDs safe for patients requiring emergency care? The lack of uniform definitions and federal and state regulatory requirements make it difficult to gather and interpret meaningful clinical data on FSEDs and convenient care centers. But a well-equipped FSED, served by state-of-the-art pre- and inter-facility ambulances, and staffed by qualified EPs and RNs, should provide a safe alternative to hospital-based EDs for almost all patients in need of emergency care—especially when no hospital-based ED is available.

Specialty designations of qualifying area hospitals such as “Level I Trauma Center” will minimize but not completely eliminate bad outcomes of cases where even seconds may make the difference between life and death. In the end though, the real question may be is an FSED better than no ED at all?

Ideally, a hospital-based ED should be the epicenter of a network of both satellite convenient care centers and FSEDs, coordinating services, providing management and staffing for all parts of the network, and arranging safe, appropriate intranetwork ambulance transport.

Although many hospitals are less interested in offsite convenient care centers than they are in FSEDs that can supply more inpatients, EM cannot afford to ignore any of the alternatives being offered to hospital-based ED care, and should immediately embrace all of them before other specialties begin helping themselves to slices of a pie that EM has worked hard to bake to perfection for almost half a century.  

If an emergency department is considered the “front door” to the hospital, how do we regard a free-standing emergency department (FSED) with no hospital attached to it? Until recently, FSEDs were most commonly located in rural areas lacking hospitals and primary care providers. But fueled by recent hospital closures in the face of steadily increasing demands for emergency care, FSEDs are now appearing in previously well-served urban areas, too. In the past 6 months, three new FSEDs have opened in New York City on the sites of recently closed hospitals. What do FSEDs mean for emergency medicine and emergency physicians, and are they safe alternatives to traditional hospital based EDs?

Newer technologies and treatments, coupled with steadily increasing pressures to reduce inpatient stays, razor-thin hospital operating margins, and the refusal of state and local governments to bail out financially failing hospitals, have created a disconnect between the increasing need for emergency care and the decreasing number of inpatient beds.

On one end of the EM patient care spectrum, urgent care centers and retail pharmacy clinics—collectively referred to as “convenient care” centers—are rapidly proliferating to offer care to those with urgent, episodic, and relatively minor medical and surgical problems (see last month’s editorial, “Urgent Care and the Urgent Need for Care”). With little or no regulatory oversight, convenient care centers staffed by EPs, family practitioners, internists, NPs, and PAs, offer extended hour care—but not 24/7 care—to anyone with adequate health insurance or the ability to pay for the care.

On the other end of the EM patient care spectrum are the FSEDs, now divided into two types: satellite EDs of nearby hospitals, and “FS”-FSEDS with no direct hospital connections. Almost all FSEDs receive 911 ambulances, are staffed at all times by trained and certified EPs and RNs, provide acute care and stabilization consistent with the standards for hospital-based EDs, and are open 24/7 – a hallmark that distinguishes EDs from UCCs. FSEDs code and bill both for facility and provider services in the same way hospital-based EDs do. Although organized emergency medicine has enthusiastically embraced, and recently endorsed FSEDs, its position on UCC’s has been decidedly mixed.

Are FSEDs safe for patients requiring emergency care? The lack of uniform definitions and federal and state regulatory requirements make it difficult to gather and interpret meaningful clinical data on FSEDs and convenient care centers. But a well-equipped FSED, served by state-of-the-art pre- and inter-facility ambulances, and staffed by qualified EPs and RNs, should provide a safe alternative to hospital-based EDs for almost all patients in need of emergency care—especially when no hospital-based ED is available.

Specialty designations of qualifying area hospitals such as “Level I Trauma Center” will minimize but not completely eliminate bad outcomes of cases where even seconds may make the difference between life and death. In the end though, the real question may be is an FSED better than no ED at all?

Ideally, a hospital-based ED should be the epicenter of a network of both satellite convenient care centers and FSEDs, coordinating services, providing management and staffing for all parts of the network, and arranging safe, appropriate intranetwork ambulance transport.

Although many hospitals are less interested in offsite convenient care centers than they are in FSEDs that can supply more inpatients, EM cannot afford to ignore any of the alternatives being offered to hospital-based ED care, and should immediately embrace all of them before other specialties begin helping themselves to slices of a pie that EM has worked hard to bake to perfection for almost half a century.  

If an emergency department is considered the “front door” to the hospital, how do we regard a free-standing emergency department (FSED) with no hospital attached to it? Until recently, FSEDs were most commonly located in rural areas lacking hospitals and primary care providers. But fueled by recent hospital closures in the face of steadily increasing demands for emergency care, FSEDs are now appearing in previously well-served urban areas, too. In the past 6 months, three new FSEDs have opened in New York City on the sites of recently closed hospitals. What do FSEDs mean for emergency medicine and emergency physicians, and are they safe alternatives to traditional hospital based EDs?

Newer technologies and treatments, coupled with steadily increasing pressures to reduce inpatient stays, razor-thin hospital operating margins, and the refusal of state and local governments to bail out financially failing hospitals, have created a disconnect between the increasing need for emergency care and the decreasing number of inpatient beds.

On one end of the EM patient care spectrum, urgent care centers and retail pharmacy clinics—collectively referred to as “convenient care” centers—are rapidly proliferating to offer care to those with urgent, episodic, and relatively minor medical and surgical problems (see last month’s editorial, “Urgent Care and the Urgent Need for Care”). With little or no regulatory oversight, convenient care centers staffed by EPs, family practitioners, internists, NPs, and PAs, offer extended hour care—but not 24/7 care—to anyone with adequate health insurance or the ability to pay for the care.

On the other end of the EM patient care spectrum are the FSEDs, now divided into two types: satellite EDs of nearby hospitals, and “FS”-FSEDS with no direct hospital connections. Almost all FSEDs receive 911 ambulances, are staffed at all times by trained and certified EPs and RNs, provide acute care and stabilization consistent with the standards for hospital-based EDs, and are open 24/7 – a hallmark that distinguishes EDs from UCCs. FSEDs code and bill both for facility and provider services in the same way hospital-based EDs do. Although organized emergency medicine has enthusiastically embraced, and recently endorsed FSEDs, its position on UCC’s has been decidedly mixed.

Are FSEDs safe for patients requiring emergency care? The lack of uniform definitions and federal and state regulatory requirements make it difficult to gather and interpret meaningful clinical data on FSEDs and convenient care centers. But a well-equipped FSED, served by state-of-the-art pre- and inter-facility ambulances, and staffed by qualified EPs and RNs, should provide a safe alternative to hospital-based EDs for almost all patients in need of emergency care—especially when no hospital-based ED is available.

Specialty designations of qualifying area hospitals such as “Level I Trauma Center” will minimize but not completely eliminate bad outcomes of cases where even seconds may make the difference between life and death. In the end though, the real question may be is an FSED better than no ED at all?

Ideally, a hospital-based ED should be the epicenter of a network of both satellite convenient care centers and FSEDs, coordinating services, providing management and staffing for all parts of the network, and arranging safe, appropriate intranetwork ambulance transport.

Although many hospitals are less interested in offsite convenient care centers than they are in FSEDs that can supply more inpatients, EM cannot afford to ignore any of the alternatives being offered to hospital-based ED care, and should immediately embrace all of them before other specialties begin helping themselves to slices of a pie that EM has worked hard to bake to perfection for almost half a century.  

The proliferation of urgent care centers (UCCs) in many urban areas during the past few years is beginning to significantly affect the practice of emergency medicine in both anticipated and unanticipated ways. The demand for rapid care of minor but urgent medical problems along with the diminishing availability of primary care providers, continued hospital closings, and overcrowded EDs make efficient, conveniently-located UCCs that accept most forms of insurance an attractive and profitable way to deliver needed health care.

In some areas, UCCs located in close proximity to hospital-based EDs are relieving the burden to divert resources from the care of seriously ill and injured patients to those with relatively minor emergencies. In other areas, however, UCCs are competing with EDs for patients who are relatively easy to care for and are a source of income that mitigates the financial burden of providing costly and poorly reimbursed care for other patients.

Freed of the need to comply with federal and state regulatory requirements imposed on hospital-based EDs -- particularly the obligation to evaluate and stabilize everyone who comes to an ED for care -- UCCs can offer less expensive care that is attractive to patients and third party payers alike. Many health insurers are now encouraging their patients to utilize UCCs instead of EDs by listing on their insurance cards lower co-payments for UCC visits directly next to those for EDs.

Many, if not most, health care providers who staff and frequently own UCCs are residency-trained, board certified emergency physicians, which undoubtedly offers prospective patients reassurance that the care provided in a store-front UCC is of the highest quality. Alternatives to UCC and ED care, such as retail pharmacy walk-in “clinics” staffed by NPs or PA’s, do not offer their self-triaging patients the safety of stabilization or treatment by trained EPs prior to transfer to a nearby ED, should the patient’s condition turn out to be life threatening or more serious than initially thought.

None of the foregoing is necessarily bad for the specialty of emergency medicine. For those who worry about the “fragmentation” of EM into subspecialty areas such as pediatric emergency medicine and now urgent care, it is worth recalling Heraclitus’ observation that change is the only thing that is constant, and that the scope and practice of EM has been expanding, not shrinking, to now include the evaluation and possible admission of many more patients referred by PMDs (See the 2012 Rand report, “The Evolving Role of Emergency Departments in the United States”), and to the provision of observation services for patients who require short hospital stays. Nor is it bad that UCCs are providing another venue for EPs to practice emergency medicine outside of EDs, i.e. to be emergency physicians instead of “emergency room doctors”

But in some cases, UCCs are beginning to jeopardize the future financial viability of hospital EDs — a shaky situation to begin with, based on a poor national model of attributing all costs, but only a small percentage of revenues to the ED. Moreover, a truly worrisome unanticipated consequence of the rapid proliferation of independent UCCs is the drain on the number of emergency physicians available to staff EDs, including many young EPs who opt for UCC positions offering higher compensation and no night duty, upon completing their residencies.

Should these trends continue, the ability to adequately staff the nation’s EDs with well-trained emergency physicians will become a severe problem. Ironically, the survival of all of the alternative venues to EDs, including UCCs and pharmacy-based walk-in clinics, depends on having well-functioning EDs to refer seriously ill patients to. This impending EP shortage should be addressed now by adjusting compensation formulas for hospital-based EPs where necessary to compete successfully with those of UCCs, and by increasing the number of available emergency medicine residency positions.

The proliferation of urgent care centers (UCCs) in many urban areas during the past few years is beginning to significantly affect the practice of emergency medicine in both anticipated and unanticipated ways. The demand for rapid care of minor but urgent medical problems along with the diminishing availability of primary care providers, continued hospital closings, and overcrowded EDs make efficient, conveniently-located UCCs that accept most forms of insurance an attractive and profitable way to deliver needed health care.

In some areas, UCCs located in close proximity to hospital-based EDs are relieving the burden to divert resources from the care of seriously ill and injured patients to those with relatively minor emergencies. In other areas, however, UCCs are competing with EDs for patients who are relatively easy to care for and are a source of income that mitigates the financial burden of providing costly and poorly reimbursed care for other patients.

Freed of the need to comply with federal and state regulatory requirements imposed on hospital-based EDs -- particularly the obligation to evaluate and stabilize everyone who comes to an ED for care -- UCCs can offer less expensive care that is attractive to patients and third party payers alike. Many health insurers are now encouraging their patients to utilize UCCs instead of EDs by listing on their insurance cards lower co-payments for UCC visits directly next to those for EDs.

Many, if not most, health care providers who staff and frequently own UCCs are residency-trained, board certified emergency physicians, which undoubtedly offers prospective patients reassurance that the care provided in a store-front UCC is of the highest quality. Alternatives to UCC and ED care, such as retail pharmacy walk-in “clinics” staffed by NPs or PA’s, do not offer their self-triaging patients the safety of stabilization or treatment by trained EPs prior to transfer to a nearby ED, should the patient’s condition turn out to be life threatening or more serious than initially thought.

None of the foregoing is necessarily bad for the specialty of emergency medicine. For those who worry about the “fragmentation” of EM into subspecialty areas such as pediatric emergency medicine and now urgent care, it is worth recalling Heraclitus’ observation that change is the only thing that is constant, and that the scope and practice of EM has been expanding, not shrinking, to now include the evaluation and possible admission of many more patients referred by PMDs (See the 2012 Rand report, “The Evolving Role of Emergency Departments in the United States”), and to the provision of observation services for patients who require short hospital stays. Nor is it bad that UCCs are providing another venue for EPs to practice emergency medicine outside of EDs, i.e. to be emergency physicians instead of “emergency room doctors”

But in some cases, UCCs are beginning to jeopardize the future financial viability of hospital EDs — a shaky situation to begin with, based on a poor national model of attributing all costs, but only a small percentage of revenues to the ED. Moreover, a truly worrisome unanticipated consequence of the rapid proliferation of independent UCCs is the drain on the number of emergency physicians available to staff EDs, including many young EPs who opt for UCC positions offering higher compensation and no night duty, upon completing their residencies.

Should these trends continue, the ability to adequately staff the nation’s EDs with well-trained emergency physicians will become a severe problem. Ironically, the survival of all of the alternative venues to EDs, including UCCs and pharmacy-based walk-in clinics, depends on having well-functioning EDs to refer seriously ill patients to. This impending EP shortage should be addressed now by adjusting compensation formulas for hospital-based EPs where necessary to compete successfully with those of UCCs, and by increasing the number of available emergency medicine residency positions.

The proliferation of urgent care centers (UCCs) in many urban areas during the past few years is beginning to significantly affect the practice of emergency medicine in both anticipated and unanticipated ways. The demand for rapid care of minor but urgent medical problems along with the diminishing availability of primary care providers, continued hospital closings, and overcrowded EDs make efficient, conveniently-located UCCs that accept most forms of insurance an attractive and profitable way to deliver needed health care.

In some areas, UCCs located in close proximity to hospital-based EDs are relieving the burden to divert resources from the care of seriously ill and injured patients to those with relatively minor emergencies. In other areas, however, UCCs are competing with EDs for patients who are relatively easy to care for and are a source of income that mitigates the financial burden of providing costly and poorly reimbursed care for other patients.

Freed of the need to comply with federal and state regulatory requirements imposed on hospital-based EDs -- particularly the obligation to evaluate and stabilize everyone who comes to an ED for care -- UCCs can offer less expensive care that is attractive to patients and third party payers alike. Many health insurers are now encouraging their patients to utilize UCCs instead of EDs by listing on their insurance cards lower co-payments for UCC visits directly next to those for EDs.

Many, if not most, health care providers who staff and frequently own UCCs are residency-trained, board certified emergency physicians, which undoubtedly offers prospective patients reassurance that the care provided in a store-front UCC is of the highest quality. Alternatives to UCC and ED care, such as retail pharmacy walk-in “clinics” staffed by NPs or PA’s, do not offer their self-triaging patients the safety of stabilization or treatment by trained EPs prior to transfer to a nearby ED, should the patient’s condition turn out to be life threatening or more serious than initially thought.

None of the foregoing is necessarily bad for the specialty of emergency medicine. For those who worry about the “fragmentation” of EM into subspecialty areas such as pediatric emergency medicine and now urgent care, it is worth recalling Heraclitus’ observation that change is the only thing that is constant, and that the scope and practice of EM has been expanding, not shrinking, to now include the evaluation and possible admission of many more patients referred by PMDs (See the 2012 Rand report, “The Evolving Role of Emergency Departments in the United States”), and to the provision of observation services for patients who require short hospital stays. Nor is it bad that UCCs are providing another venue for EPs to practice emergency medicine outside of EDs, i.e. to be emergency physicians instead of “emergency room doctors”

But in some cases, UCCs are beginning to jeopardize the future financial viability of hospital EDs — a shaky situation to begin with, based on a poor national model of attributing all costs, but only a small percentage of revenues to the ED. Moreover, a truly worrisome unanticipated consequence of the rapid proliferation of independent UCCs is the drain on the number of emergency physicians available to staff EDs, including many young EPs who opt for UCC positions offering higher compensation and no night duty, upon completing their residencies.

Should these trends continue, the ability to adequately staff the nation’s EDs with well-trained emergency physicians will become a severe problem. Ironically, the survival of all of the alternative venues to EDs, including UCCs and pharmacy-based walk-in clinics, depends on having well-functioning EDs to refer seriously ill patients to. This impending EP shortage should be addressed now by adjusting compensation formulas for hospital-based EPs where necessary to compete successfully with those of UCCs, and by increasing the number of available emergency medicine residency positions.

Would you be able to diagnose the first case of Ebola in a febrile patient who has no travel history and presents to an ED during flu season?  Could you distinguish the lesion of cutaneous anthrax early in a bioterrorist attack from that of a brown recluse spider bite? Could you recognize the initial signs of botulism compared to those of stroke, myasthenia gravis, or Bell’s palsy?

In the 1940s, University of Maryland Professor Theodore Woodward advised his medical house staff that “when you hear hoofbeats, think of horses, not zebras.” Though directed at internists who are also trained to think of rare or esoteric illnesses in their patients’ differential diagnoses, the zebra aphorism is also applicable in a variety of medical settings including the emergency department and ED triage. In a busy ED, ruling out zebras every time hoofbeats are heard would waste an enormous amount of diagnostic resources while causing extensive delays in caring for all who come to the ED.

On the other hand, focusing exclusively on the most common or obvious explanations for patients’ presenting complaints risks missing serious, potentially fatal illnesses at a time when lifesaving interventions may still be possible. Even worse, not considering unexpected or atypical illnesses in patients when they first present may result in exposing others to danger and potential health care disasters. For example, a patient who has meningococcal meningitis requires prompt diagnosis, effective treatment, and isolation, along with the identification, evaluation, and prophylactic treatment of everyone who came into close contact with the patient.

Sometimes the first patient or “index” case presenting to an ED is a victim of a source of illness that may also affect many others. Common sources include food and drink, drugs and poisons, and the air we breathe. It is more difficult to identify the true source of a patient’s illness that may affect many when there are other plausible explanations and when nonspecific ED treatments such as fluids, oxygen, antipyretics, and pain meds alleviate the presenting signs and symptoms allowing the patient to be discharged home with follow-up care.

Determining when hoofbeats are caused by a horse and when they are caused by a zebra is one of the most difficult challenges of emergency medicine.This time of year, I am reminded of a young restaurant kitchen worker who several decades ago had been brought to the ED after being found unconscious on the floor of a restaurant men’s room. The ED “drug screen” revealed the presence of several drugs of abuse, and after a few hours of IV hydration, nasal O_², and “psych clearance,” the patient was discharged home. The next day, a middle-aged male customer of the restaurant was found dead on the floor of the same men’s room. Only then was carbon monoxide poisoning from a faulty heater identified as the true cause of both illnesses. This time of year, too, home cooking and food preparation for the holidays may become sources of serious foodborne bacterial, viral, and parasitic illnesses affecting large numbers of people.

Determining when hoofbeats are caused by a horse and when they are caused by a zebra is one of the most difficult challenges of emergency medicine. Successfully addressing this dilemma requires scrupulous attention to all of the information obtained at triage—especially initial vital signs—and not trying to force a patient’s presentation into a diagnosis when it is less than a perfect fit. Some illnesses may be more common certain times of the year, but critical thinking is never out of season. 

Would you be able to diagnose the first case of Ebola in a febrile patient who has no travel history and presents to an ED during flu season?  Could you distinguish the lesion of cutaneous anthrax early in a bioterrorist attack from that of a brown recluse spider bite? Could you recognize the initial signs of botulism compared to those of stroke, myasthenia gravis, or Bell’s palsy?

In the 1940s, University of Maryland Professor Theodore Woodward advised his medical house staff that “when you hear hoofbeats, think of horses, not zebras.” Though directed at internists who are also trained to think of rare or esoteric illnesses in their patients’ differential diagnoses, the zebra aphorism is also applicable in a variety of medical settings including the emergency department and ED triage. In a busy ED, ruling out zebras every time hoofbeats are heard would waste an enormous amount of diagnostic resources while causing extensive delays in caring for all who come to the ED.

On the other hand, focusing exclusively on the most common or obvious explanations for patients’ presenting complaints risks missing serious, potentially fatal illnesses at a time when lifesaving interventions may still be possible. Even worse, not considering unexpected or atypical illnesses in patients when they first present may result in exposing others to danger and potential health care disasters. For example, a patient who has meningococcal meningitis requires prompt diagnosis, effective treatment, and isolation, along with the identification, evaluation, and prophylactic treatment of everyone who came into close contact with the patient.

Sometimes the first patient or “index” case presenting to an ED is a victim of a source of illness that may also affect many others. Common sources include food and drink, drugs and poisons, and the air we breathe. It is more difficult to identify the true source of a patient’s illness that may affect many when there are other plausible explanations and when nonspecific ED treatments such as fluids, oxygen, antipyretics, and pain meds alleviate the presenting signs and symptoms allowing the patient to be discharged home with follow-up care.

Determining when hoofbeats are caused by a horse and when they are caused by a zebra is one of the most difficult challenges of emergency medicine.This time of year, I am reminded of a young restaurant kitchen worker who several decades ago had been brought to the ED after being found unconscious on the floor of a restaurant men’s room. The ED “drug screen” revealed the presence of several drugs of abuse, and after a few hours of IV hydration, nasal O_², and “psych clearance,” the patient was discharged home. The next day, a middle-aged male customer of the restaurant was found dead on the floor of the same men’s room. Only then was carbon monoxide poisoning from a faulty heater identified as the true cause of both illnesses. This time of year, too, home cooking and food preparation for the holidays may become sources of serious foodborne bacterial, viral, and parasitic illnesses affecting large numbers of people.

Determining when hoofbeats are caused by a horse and when they are caused by a zebra is one of the most difficult challenges of emergency medicine. Successfully addressing this dilemma requires scrupulous attention to all of the information obtained at triage—especially initial vital signs—and not trying to force a patient’s presentation into a diagnosis when it is less than a perfect fit. Some illnesses may be more common certain times of the year, but critical thinking is never out of season. 

Would you be able to diagnose the first case of Ebola in a febrile patient who has no travel history and presents to an ED during flu season?  Could you distinguish the lesion of cutaneous anthrax early in a bioterrorist attack from that of a brown recluse spider bite? Could you recognize the initial signs of botulism compared to those of stroke, myasthenia gravis, or Bell’s palsy?

In the 1940s, University of Maryland Professor Theodore Woodward advised his medical house staff that “when you hear hoofbeats, think of horses, not zebras.” Though directed at internists who are also trained to think of rare or esoteric illnesses in their patients’ differential diagnoses, the zebra aphorism is also applicable in a variety of medical settings including the emergency department and ED triage. In a busy ED, ruling out zebras every time hoofbeats are heard would waste an enormous amount of diagnostic resources while causing extensive delays in caring for all who come to the ED.

On the other hand, focusing exclusively on the most common or obvious explanations for patients’ presenting complaints risks missing serious, potentially fatal illnesses at a time when lifesaving interventions may still be possible. Even worse, not considering unexpected or atypical illnesses in patients when they first present may result in exposing others to danger and potential health care disasters. For example, a patient who has meningococcal meningitis requires prompt diagnosis, effective treatment, and isolation, along with the identification, evaluation, and prophylactic treatment of everyone who came into close contact with the patient.

Sometimes the first patient or “index” case presenting to an ED is a victim of a source of illness that may also affect many others. Common sources include food and drink, drugs and poisons, and the air we breathe. It is more difficult to identify the true source of a patient’s illness that may affect many when there are other plausible explanations and when nonspecific ED treatments such as fluids, oxygen, antipyretics, and pain meds alleviate the presenting signs and symptoms allowing the patient to be discharged home with follow-up care.

Determining when hoofbeats are caused by a horse and when they are caused by a zebra is one of the most difficult challenges of emergency medicine.This time of year, I am reminded of a young restaurant kitchen worker who several decades ago had been brought to the ED after being found unconscious on the floor of a restaurant men’s room. The ED “drug screen” revealed the presence of several drugs of abuse, and after a few hours of IV hydration, nasal O_², and “psych clearance,” the patient was discharged home. The next day, a middle-aged male customer of the restaurant was found dead on the floor of the same men’s room. Only then was carbon monoxide poisoning from a faulty heater identified as the true cause of both illnesses. This time of year, too, home cooking and food preparation for the holidays may become sources of serious foodborne bacterial, viral, and parasitic illnesses affecting large numbers of people.

Determining when hoofbeats are caused by a horse and when they are caused by a zebra is one of the most difficult challenges of emergency medicine. Successfully addressing this dilemma requires scrupulous attention to all of the information obtained at triage—especially initial vital signs—and not trying to force a patient’s presentation into a diagnosis when it is less than a perfect fit. Some illnesses may be more common certain times of the year, but critical thinking is never out of season. 

The words “disaster preparedness” have been used so many times in the past several years that their mere mention now makes some people’s eyes glaze over. But as much as the drums have been beaten for preparing for natural and manmade calamities, the far more common health care disasters that affect people on a daily basis still go largely unaddressed. Among them is the cycle of over-crowding, ambulance diversions, and admission delays that compromise care in the majority of emergency departments in this country.

Since the fall of 2001, every talk I’ve given about disasters has included a picture of the September 10, 2001, cover of U.S. News & World Report that proclaimed: “Crisis in the ER—Turnaways and Huge Delays Are a Sure-fire Recipe for Disaster.” This striking background for 9/11 was also noted by the Institute of Medicine in its 2006 report, “Hospital-Based Emergency Care: At the Breaking Point.”

If the goal of preparing for an un-anticipated major disaster is to save as many people as possible and minimize the harm to those who survive, why aren’t we willing to devote the same degree of attention and re-sources to our daily disasters? When added together, over the course of a year, these disasters affect more lives and result in more harm to more people than most single mass-casualty events. Is it rational to devote so many resources that hopefully will never be needed while at the same time ignoring what actually happens day after day?

For at least 10 months prior to 9/11, there was a nationwide shortage of tetanus diphtheria (Td) toxoid. Then, late in the afternoon of September 11, our hospital’s apothecary-in-chief called to ask me how many doses of the Td vaccine we would like delivered to the ED. The federal disaster “push packs” had arrived in the New York City area and the supplies they contained (including 50,000 doses of Td) were being distributed to hospitals dealing with the aftermath of the terrorist attack.

Were they important and necessary for a mass-casualty disaster? Absolutely. But no less important for treating the tens of thousands of contaminated wound exposures that people sustained in the months leading up to 9/11.

During disaster drills at our hospital, I make it a practice to “disappear” in order to let the lead attending physician gain the experience of running the ED portion of the exercise. If I were in the ED, participants from every department would inevitably come up to me to ask what was needed, and it would be delivered immediately. This is what happens during actual disasters—what needs to happen happens. Patients in the ED are instantly transferred upstairs to beds that seemingly didn’t exist moments before. House officers, attending physicians, and consultants from all other departments appear in the ED, ready to assist for as long as necessary, often before their presence is even requested.

But why are there no state and federal officials asking during our daily disasters what else is needed in order to quickly care for everyone waiting to be seen? And where are the resources needed to expand the nation’s EDs to accommodate all who seek care there? Why is one type of disaster less important than the other? This seeming oversight is perhaps best expressed in the words of the late comedian George Carlin: “I’m not concerned about all hell breaking loose, but that a part of hell will break loose. It will be much harder to detect.”

Our article on Ebola this month was expanded in response to the diagnosis of the first case in the United States. “Update: Current Management of HIV/AIDs in the Emergency Department” by Sarah Battistich, MD, originally scheduled for this issue will appear instead in the November issue.

The words “disaster preparedness” have been used so many times in the past several years that their mere mention now makes some people’s eyes glaze over. But as much as the drums have been beaten for preparing for natural and manmade calamities, the far more common health care disasters that affect people on a daily basis still go largely unaddressed. Among them is the cycle of over-crowding, ambulance diversions, and admission delays that compromise care in the majority of emergency departments in this country.

Since the fall of 2001, every talk I’ve given about disasters has included a picture of the September 10, 2001, cover of U.S. News & World Report that proclaimed: “Crisis in the ER—Turnaways and Huge Delays Are a Sure-fire Recipe for Disaster.” This striking background for 9/11 was also noted by the Institute of Medicine in its 2006 report, “Hospital-Based Emergency Care: At the Breaking Point.”

If the goal of preparing for an un-anticipated major disaster is to save as many people as possible and minimize the harm to those who survive, why aren’t we willing to devote the same degree of attention and re-sources to our daily disasters? When added together, over the course of a year, these disasters affect more lives and result in more harm to more people than most single mass-casualty events. Is it rational to devote so many resources that hopefully will never be needed while at the same time ignoring what actually happens day after day?

For at least 10 months prior to 9/11, there was a nationwide shortage of tetanus diphtheria (Td) toxoid. Then, late in the afternoon of September 11, our hospital’s apothecary-in-chief called to ask me how many doses of the Td vaccine we would like delivered to the ED. The federal disaster “push packs” had arrived in the New York City area and the supplies they contained (including 50,000 doses of Td) were being distributed to hospitals dealing with the aftermath of the terrorist attack.

Were they important and necessary for a mass-casualty disaster? Absolutely. But no less important for treating the tens of thousands of contaminated wound exposures that people sustained in the months leading up to 9/11.

During disaster drills at our hospital, I make it a practice to “disappear” in order to let the lead attending physician gain the experience of running the ED portion of the exercise. If I were in the ED, participants from every department would inevitably come up to me to ask what was needed, and it would be delivered immediately. This is what happens during actual disasters—what needs to happen happens. Patients in the ED are instantly transferred upstairs to beds that seemingly didn’t exist moments before. House officers, attending physicians, and consultants from all other departments appear in the ED, ready to assist for as long as necessary, often before their presence is even requested.

But why are there no state and federal officials asking during our daily disasters what else is needed in order to quickly care for everyone waiting to be seen? And where are the resources needed to expand the nation’s EDs to accommodate all who seek care there? Why is one type of disaster less important than the other? This seeming oversight is perhaps best expressed in the words of the late comedian George Carlin: “I’m not concerned about all hell breaking loose, but that a part of hell will break loose. It will be much harder to detect.”

Our article on Ebola this month was expanded in response to the diagnosis of the first case in the United States. “Update: Current Management of HIV/AIDs in the Emergency Department” by Sarah Battistich, MD, originally scheduled for this issue will appear instead in the November issue.

The words “disaster preparedness” have been used so many times in the past several years that their mere mention now makes some people’s eyes glaze over. But as much as the drums have been beaten for preparing for natural and manmade calamities, the far more common health care disasters that affect people on a daily basis still go largely unaddressed. Among them is the cycle of over-crowding, ambulance diversions, and admission delays that compromise care in the majority of emergency departments in this country.

Since the fall of 2001, every talk I’ve given about disasters has included a picture of the September 10, 2001, cover of U.S. News & World Report that proclaimed: “Crisis in the ER—Turnaways and Huge Delays Are a Sure-fire Recipe for Disaster.” This striking background for 9/11 was also noted by the Institute of Medicine in its 2006 report, “Hospital-Based Emergency Care: At the Breaking Point.”

If the goal of preparing for an un-anticipated major disaster is to save as many people as possible and minimize the harm to those who survive, why aren’t we willing to devote the same degree of attention and re-sources to our daily disasters? When added together, over the course of a year, these disasters affect more lives and result in more harm to more people than most single mass-casualty events. Is it rational to devote so many resources that hopefully will never be needed while at the same time ignoring what actually happens day after day?

For at least 10 months prior to 9/11, there was a nationwide shortage of tetanus diphtheria (Td) toxoid. Then, late in the afternoon of September 11, our hospital’s apothecary-in-chief called to ask me how many doses of the Td vaccine we would like delivered to the ED. The federal disaster “push packs” had arrived in the New York City area and the supplies they contained (including 50,000 doses of Td) were being distributed to hospitals dealing with the aftermath of the terrorist attack.

Were they important and necessary for a mass-casualty disaster? Absolutely. But no less important for treating the tens of thousands of contaminated wound exposures that people sustained in the months leading up to 9/11.

During disaster drills at our hospital, I make it a practice to “disappear” in order to let the lead attending physician gain the experience of running the ED portion of the exercise. If I were in the ED, participants from every department would inevitably come up to me to ask what was needed, and it would be delivered immediately. This is what happens during actual disasters—what needs to happen happens. Patients in the ED are instantly transferred upstairs to beds that seemingly didn’t exist moments before. House officers, attending physicians, and consultants from all other departments appear in the ED, ready to assist for as long as necessary, often before their presence is even requested.

But why are there no state and federal officials asking during our daily disasters what else is needed in order to quickly care for everyone waiting to be seen? And where are the resources needed to expand the nation’s EDs to accommodate all who seek care there? Why is one type of disaster less important than the other? This seeming oversight is perhaps best expressed in the words of the late comedian George Carlin: “I’m not concerned about all hell breaking loose, but that a part of hell will break loose. It will be much harder to detect.”

Our article on Ebola this month was expanded in response to the diagnosis of the first case in the United States. “Update: Current Management of HIV/AIDs in the Emergency Department” by Sarah Battistich, MD, originally scheduled for this issue will appear instead in the November issue.