Emergency Medicine Advocacy Handbook

Ch. 16. Emergency Medicine Outside the ED

Jose Reyes, MD; Adnan Hussain, MD

Chapter 16. Emergency Medicine Outside the ED

Recorded by Neena Joy, DO | Morristown Medical Center/Atlantic Health

For the past 20 years, emergency departments have been faced with increasing patient volumes and overcrowding, leading to poorer outcomes for patients and worsening work environments for physicians and staff. Many emergency physicians are now looking outside of the physical emergency department in order to alleviate stress on our EDs while providing high-quality care to patients.

We must find ways to provide acute, emergent, and urgent care without sacrificing access for the vulnerable populations we serve. Expanding the methods and locations by which we show up for patients, 24/7/365, must be a priority.

Why It Matters to EM and ME

The specialty of emergency medicine was born of the need for highly trained physicians with expertise in the diagnosis and treatment of undifferentiated acute problems and threats to life and limb. To assure this care is provided, emergency departments need access to specialized equipment and 24-7 diagnostics. We will always need hospital-based brick-and-mortar EDs, but the current climate of health care – particularly for emergency medicine – means it’s also time to examine how we can bring our skills beyond the four walls.

How We Got to This Point

Before the 1960s, patients seeking care for unscheduled, emergent issues were seen in hospital rooms staffed by a variety of physicians in different stages of training in any type of medicine, from pathology to surgery.¹ Additionally, and importantly, pre-hospital care was unorganized and unregulated, with many funeral homes providing medical transport with the assistance of untrained staff. The 1960s saw a confluence of events that led to the rise of emergency medicine as a specialty and for prehospital care standards, set by the Federal Highway Safety Act, along with the innovation of CPR as a resuscitative measure.¹ With the implementation of EMTALA in the 1980s, hospital-based emergency departments evolved into the safety net for our society; the place where doctors serve “anyone, anything, anytime.” From 1997 to 2016, emergency department visits increased by 60%.²

Before the COVID-19 pandemic, our EDs and our specialty were already at a breaking point, with 50% of emergency departments experiencing overcrowding in 2015 and one-third having to divert ambulances.³ It was in this state that we found ourselves entering the COVID-19 pandemic. Meanwhile, the U.S. population is aging, which means EDs are frequently seeing a larger portion of older and more medically complex patients,1 along with people who – because of a broken insurance system, financial hardship, or lack of primary care access – simply forgo care until a crisis event.

Current State of the Issue

Just as a confluence of factors led to the creation of EM as a specialty, a confluence of factors is gathering to add “anywhere” as a fourth tenet of EM.

Many emergency physicians experience the strain on emergency departments firsthand. From evaluating ill-appearing patients in hallways to examining, treating, and discharging patients from the waiting room, our current system is often not conducive to efficient and effective care of patients. Before and during the pandemic, 50-60% of hospitals experienced overcrowding.^3,4 The effects on patients are apparent: delays in assessment and care, increased rate of patients leaving without being seen, and increased mortality.⁵ Less apparent are the systemic effects, such as increased inpatient length of stay beyond the already prolonged emergency department length of stay, which then further worsens crowding. Constantly dealing with these challenging working conditions is burning out dedicated emergency physicians. Change is needed now to minimize deleterious effects on both patients and staff. Ours is a specialty founded in and molded by the gaps left in the medical system, and it is through our innate flexibility that our field can further adapt to meet the changing needs of our patients.

Emergency physicians are the experts in acute care, but how we deliver that care is evolving. From providing acute care in different settings to providing pre- and post-acute care, the expansion of our practice will not only increase access to care but simultaneously decrease strain on hospital-based brick-and-mortar EDs. This could affect future practice in one of two ways. For some, this may serve to diversify a physician’s work. The ED is a physically and cognitively demanding workplace. Instead of working solely in the emergency department, some physicians may be able to split their work between standard ED shifts and novel settings, such as telehealth, mobile clinics or hospices. For others wanting to work exclusively in a traditional ED setting, they will interact with patients who may have access to emergency physicians before and after an ED visit, broadening the methods by which patients can receive acute care.

The purpose of innovating the practice of emergency medicine is to increase access to acute care while also offering practice models that provide new venues for accessing the expertise of emergency physicians. Community paramedicine is one such example. Using this model, paramedics can assess, refer, and educate patients at-home or in residential facilities, often with remote support from emergency physicians.⁶ Studies evaluating community paramedicine have demonstrated improved health outcomes and decreased emergency department visits, with patients experiencing better diabetic and hypertensive control while also decreasing transport to EDs up to 78%.⁶ Patients who were transported by community paramedicine providers had higher rates of admission compared to those transported by traditional paramedics and were admitted more frequently, indicating community paramedics can accurately identify patients needing a higher level of care, without increased mortality or a subsequent visit to the ED within 7 days of evaluation. In a separate study focused on targeting high ED utilizers comprised of elderly patients with multiple comorbidities, ED transports and 911 calls decreased by nearly half.⁷

Telehealth, or the use of audio-video technology to remotely assess patients, allows emergency physicians to provide remote care, either through direct connection with patients or by supporting nonphysicians providing care in remote or out-of-hospital settings. Acute care telehealth may simply allow physicians to recommend transport to an emergency department, but with appropriate resources, can also allow physicians to order tests and subsequently follow up to discuss the results with appropriately selected patients.² One prospective study found that 3 in 4 patients who utilized telehealth for acute problems had their concerns resolved in one visit while simultaneously decreasing costs, serving as a proof of concept for the utility of the service.⁸ Additionally, other EMS systems have investigated the use of audio-video conferencing for patients being evaluated by paramedics responding to an emergency services call.⁹ While traditional payment models for EMS require transportation to the hospital for the EMS agency to be paid, alternative payment models are now being piloted such as the CMS Emergency Triage, Treat and Transport (ET3) to still provide payment in the absence of transport.¹⁰ For higher acuity patients requiring transport, this can serve as a real-time method to provide improved treatment en route and ideally shorten ED wait times for those who do require further emergency department evaluation and treatment.

Beyond providing care at home, emergency medicine can benefit from emphasizing and prioritizing the development of urgent care and mobile facilities to broaden the access to care for lower acuity complaints, particularly in underserved communities. In one study, proximity to an urgent care center was shown to reduce patient presentation to academic emergency departments.¹¹ An urgent care center within 1 mile of patients reduced presentations for low-acuity complaints to academic emergency department, and that effect compounded by 1% for each month the urgent care was open over a 2-year period.¹¹ As the specialists in acute unscheduled care, emergency physicians are uniquely suited to practice in urgent cares as well as other environments where unscheduled care is delivered, such as on cruise ships, at events and in disasters.

In recent years, the medical community has focused on increased access to care for the underserved, studying street medicine and mobile clinic solutions. Street medicine is the practice of providing clinic to provide care for unsheltered individuals, whether in a mobile or permanent clinic.¹³ Mobile clinics can also serve other groups struggling with access to care, such as recent immigrants or the uninsured. In one study, homeless patients who utilized dedicated clinics for the unsheltered had an 8% reduction in inappropriate use compared to those who used hospital-based clinics; they were also less likely to require admission, indicating an improvement in clinical outcomes in addition to being less likely to present for social needs such as food or housing.¹⁴ Mobile clinics’ patient-centered focus and utilization of community health workers has been shown to improve outcomes by fostering trust and more shared decision-making among patients.¹⁴ One mobile clinic in Southern California focused only on serving children with asthma in underserved communities; it decreased ED visits, while also increasing symptom-free days for patients, suggesting utility beyond simply managing acute exacerbations of illness.¹⁵ Due to the breadth of our training and our familiarity with treating underserved patients, emergency physicians are well-suited to practice in these settings and may find the new environment to be uniquely fulfilling.

Rural populations also struggle with health care access. In the early 2000s, legislation was passed to prevent the closure of rural hospitals by providing the designation of “Critical Access Hospital.” This designation appropriated increased funding to rural hospitals with 24/7 access to emergency services. Despite receiving additional funding, many rural hospitals have nonetheless closed, leading to a gap in the availability of emergency services by EM-trained physicians.¹⁶ One proposed model of providing emergency services is by promoting the development of free-standing emergency departments, believed to be a more cost-effective manner of providing emergency care.

As the U.S. population ages, the medical complexity and average acuity level of emergency visits is increasing.¹⁷ Even with mobile medicine, complex patients with acute needs are likely to require intensive treatment and stabilization. One method by which our care delivery can evolve for them is by emergency physicians providing home-based care for these patients. Two specific examples include hospital-at-home care and home hospice care.

Hospital-at-home, per the American Hospital Association, is a care delivery model that enables “some patients who need acute-level care to receive care in their homes, rather than in a hospital. This care delivery model has been shown to reduce costs, improve outcomes and enhance the patient experience.”¹⁸ Hospital-at-home interventions keep inpatient beds open without sacrificing outcomes for those with chronic illnesses. In these programs, patients with acute needs are closely monitored at home with remote monitoring equipment and home visits by nurses and physicians; in some cases, the physicians may evaluate the patient using telemedicine. In a recent meta-analysis, hospital-at-home programs did require a longer treatment time but were associated with fewer readmissions and decreased need for long-term care, a common complication of in-hospital admissions.¹⁹ In addition to emergency physicians managing acute illness at home, emergency physicians are becoming more engaged in palliative care as a method of decreasing emergency department visits for patients with multiple comorbidities in the later stages of life.²⁰ Palliative care fellowships now are open to EM-trained physicians,²¹ as ED-initiated palliative care can result in better outcomes and decreased emergency department visits. Many emergency physicians find palliative care and hospice care to be a gratifying and meaningful way to expand their practice.

Moving Forward

Emergency medicine fills gaps left by an often antiquated health care system by evaluating and treating all comers to our emergency departments. Crowding and boarding are breaking the safety net that is the ED. To accommodate the needs of our patients without compromising the longevity of emergency department staff, it is evident we must change the way we practice emergency medicine.

With many mobile clinics and street medicine-based initiatives operating solely on philanthropy or grants, we should advocate for funding and compensation from payers for care provided through these programs. Telemedicine, another way to expand coverage, would benefit from multistate telehealth licensure to allow for emergency physicians to provide care across state lines.²² Standardized regulations for freestanding EDs also could increase the safety net while offering a different practice model for physicians.²³ All of these goals require advocacy at the institutional, state, and federal levels.

We also must advocate within the health care system (and academic medicine) to promote the benefits of broadening care beyond the four walls of our EDs. From increasing education on palliative care to broadening awareness of EMS-based interventions such as community paramedicine, we can strengthen the knowledge of graduating physicians and physicians in leadership roles to promote programs that can improve quality of life for patients while simultaneously resulting in less utilization of the ED itself.

We must find ways to provide acute, emergent, and urgent care without sacrificing access for the vulnerable populations we serve. Expanding the methods and locations by which we show up for patients, 24/7/365, must be a priority.

• The future of emergency medicine will involve emergency physicians practicing outside of the traditional hospital-based brick-and-mortar ED.
• 50-60% of emergency departments are faced with overcrowding, leading to poorer outcomes for patients, higher health care costs, and increased burnout for medical providers.
• More elderly and medically complex patients lead to strain on emergency departments, indicating interventions beyond increased access to primary care are necessary to relieve the current strain.
• Initiatives that increase access to care for vulnerable populations have been proven to safely decrease non-emergent ED visits.
• Emergency physicians are well suited to provide care to patients in their homes through ED-initiated hospice care or hospital-at-home treatments, leading to better quality of life for patients while avoiding the complications associated with hospital admissions and keeping inpatient beds available.
• Advocacy on legislation improving physician compensation for novel initiatives is necessary to allow for widening of the safety net emergency medicine provides.
• Promoting education on these initiatives is necessary to have a physician workforce prepared to engage and thrive in the new face of acute care.

References

1. Suter RE. Emergency medicine in the United States: a systemic review. World J Emerg Med. 2012;3(1):5-10.
2. Kelen G, Wolfe R, D-Onofrio G, et al. Emergency Department Crowding: The Canary in the Health Care System. NEJM Catalyst. 2021;5(2).
3. Salway RJ, Valenzuela R, Shoenberger JM, Mallon WK, Viccellio A. Emergency Department (ED) Overcrowding: Evidenced-Based Answers to Frequently Asked Questions. Revista Médica Clínica Las Condes. 2017;28(2):213-219.
4. Bouillon-Minois JB, Raconnat J, Clinchamps M, Schmidt J, Dutheil F. Emergency Department and Overcrowding During COVID-19 Outbreak; a Letter to Editor. Arch Acad Emerg Med. 2021;9(1):e28.
5. Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: A systematic review of causes, consequences and solutions. PloS one. 2018;13(8):e0203316.
6. van Vuuren J, Thomas B, Agarwal G, et al. Reshaping healthcare delivery for elderly patients: the role of community paramedicine; a systematic review. BMC Health Serv Research. 2021;21(1):29.
7. Adio O, Ikuma L, Wiley S. Management of frequent ED users by community paramedics improves patient experiences and reduces EMS utilization. Patient Experience Journal. 2020;7:174-188.
8. Nord G, Rising KL, Band RA, Carr BG, Hollander JE. On-demand synchronous audio video telemedicine visits are cost effective. Am J Emerg Med. 2019;37(5):890-894.
9. O’Sullivan SF, Schneider H. Developing telemedicine in Emergency Medical Services: A low-cost solution and practical approach connecting interfaces in emergency medicine. J Med Access. 2022;6:27550834221084656.
10. Centers for Medicare & Medicaid Services. Emergency Triage, Treat, and Transport (ET3) Model. Updated January 2023.
11. Carlson LC, Raja AS, Dworkis DA, et al. Impact of Urgent Care Openings on Emergency Department Visits to Two Academic Medical Centers Within an Integrated Health Care System. Ann Emerg Med. 2020;75(3):382-391.
12. Jaramillo C. Reducing low-acuity preventable emergency room visits by utilizing urgent care center services via mobile health unit diversion program. J Urgent Care Med. 2022;16(6):35-37.
13. Montgomery D. The homeless get sick; ‘street medicine’ is there for them. Stateline. Sept. 18, 2018.
14. Holmes CT, Holmes KA, MacDonald A, et al. Dedicated homeless clinics reduce inappropriate emergency department utilization. JACEP Open. 2020;1(5):829-836.
15. Yu SWY, Hill C, Ricks ML, Bennet J, Oriol NE. The scope and impact of mobile health clinics in the United States: a literature review. Int J Equity Health. 2017;16(1):178.
16. Dayton MDFFJ, Md H. Does the Conversion of Critical Access Hospitals into Freestanding Emergency Departments Represent a Financially Viable Way to Maintain Rural Access to Emergency Care? J Freestanding Emerg Med. 2015;2.
17. Emergency Department Benchmarking Alliance. Accessed at https://www.edbenchmarking.org/about-us.
18. American Hospital Association. Hospital-at-home. Accessed at https://www.aha.org/hospitalathome.
19. Arsenault-Lapierre G, Henein M, Gaid D, Le Berre M, Gore G, Vedel I. Hospital-at-Home Interventions vs In-Hospital Stay for Patients With Chronic Disease Who Present to the Emergency Department: A Systematic Review and Meta-analysis. JAMA Netw Open. 2021;4(6):e2111568-e2111568.
20. George N, Bowman J, Aaronson E, Ouchi K. Past, present, and future of palliative care in emergency medicine in the USA. Acute Med Surg. 2020;7(1):e497.
21. EMRA Match for Fellowships. Updated 2022.
22. Gajarawala SN, Pelkowski JN. Telehealth Benefits and Barriers. JNP. 2021;17(2):218-221.
23. Gutierrez C, Lindor RA, Baker O, Cutler D, Schuur JD. State Regulation Of Freestanding Emergency Departments Varies Widely, Affecting Location, Growth, And Services Provided. Health Aff (Project Hope). 2016;35(10):1857-1866.