Providing courage, balance and humanity in the emergency services

Nacho Vallejo
 

@varelalaf

Urgency is a unique environment in healthcare. It works intending to deal with situations that can put the person's life at risk, but it’s also a "safety net" or, as we have defined it on some occasion in this blog, "a refugee camp of the health system". The care for people in this field of health isn’t only due to pathological and physiological disorders, but sometimes those who go to the emergency room do so as a consequence of dysfunction of our healthcare system that manifests itself with "collateral damage" derived from poor accessibility and, in other cases, from an excess of activity.

As a result of the increasingly frequent use of this healthcare resource, healthcare professionals working in this environment have less time for patients, which usually translates into more tests and less listening, exhaustion, safety problems and increased costs. Unfortunately, many of us who work in this area, or have contact with it, have succumbed to algorithms and clinical practise guidelines by practising the “cookbook” medicine that Jordi Varela spoke about in a previous post. Clinical reasoning has been replaced by “take a look and ask for a CT scan”, obviating the realization of open questions that allow an understanding of the patients' report and facilitate their involvement in the diagnostic processes that affect them.

The Right Care Alliance (RCA) organization is a United States-based entity where patients and healthcare professionals address systemic healthcare issues. RCA is a project created by the Lown Institute, founded by cardiologist and Nobel laureate Bernard Lown (died last week at age 99) Unlike the Choosing Wisely campaign, specifically focused on promoting the reduction of the excessive use of resources, the Lown Institute also promotes healthcare adapted to the needs and values of people. The Alliance consists of a dozen groups of specialists in different areas, called councils, which include one for emergency medicine. As a result of his work, the Emergency Medicine Journal has recently published ten recommendations for healthcare professionals to bring “value, balance and humanization to emergency services”.

This Top ten was born in 2016 thanks to the analysis of each of the RCA boards. By consensus, using the Delphi method, the most relevant suggestions were voted based on the importance of the recommendation for patients, its potential positive impact, and its usefulness in highlighting and improving the deficiencies in emergency healthcare.

The list of recommendations, grouped into eight points, is:

1) Avoid performing additional tests in patients at low risk for acute coronary syndrome or pulmonary embolism. If the initial evaluation of the patient suggests a minimal risk of these clinical entities, further testing can lead to an unnecessary cascade of harm and additional costs. Doctors must be empowered not to test for a disease that we don’t suspect.

2) Avoid routine laboratory tests if there is no clinical suspicion of a specific medical condition or the test is unlikely to contribute to a change in the treatment plan. Be judicious in the use of imaging techniques, particularly in trauma patients. Instead of routine "scan imaging", clinicians should develop a more judicious approach based on history and physical examination findings, particularly in patients who maintain a good level of consciousness that allows them to be evaluated and observed.

3) Be aware that there are non-medical reasons for a patient to go to an emergency department. Health problems can often be caused by factors such as mental health, poverty, violence, or social conditions such as housing, food, etc. The emergency services alone will not be able to solve these problems, but interdisciplinary teamwork with social workers or with the available long-term resources can help to get to the root of chronic health problems and connect the patients with the health and social resources of their community.

4) Tailor the intensity of care to the patient's goals. We often assume that patients in the ED "want everything done to them," but this isn’t necessarily true. Furthermore, it’s often unclear what “everything” implies for the people served. Setting healthcare goals early during an emergency department visit can help avoid further tests and treatments that patients don’t want, which are especially important in serious illnesses.

5) Use shared decision making. In circumstances where several treatment options are similar and none are superior, use shared decision making to support the patient in making a decision based on the best available evidence and her values and preferences. Shared decision making can also be useful in emergencies to reduce low-value care while respecting the autonomy of the patient.

6) Adapt the discharge recommendations and follow-up indications to each patient. Discharge instructions are an essential component in the communication of the professional with the patient. In the emergency services they are often incomplete, rapid and standardized, which means that at the end of the care process many patients don’t understand their diagnosis, plan care, follow-up or what to do if your condition changes, deteriorates or doesn’t improve. The discharge instructions are a fundamental part of the visit to the emergency services and must be adapted to the patient to guarantee adequate communication between the patient and the professional.

7) When prescribing a recommendation or a treatment, make an effort to ensure that the patient is capable of doing what is proposed. Many factors influence the ability of patients to adhere to treatment plans, but most discharge processes in the emergency services don’t recognize this and many recommendations are not reasonable and sometimes not even possible, at least from the perspective of some patients. We should ask actively and in advance about the barriers that may make it tricky to adhere to our instructions.

8) The emergency services should cooperate with community health and social services. The development of strategies and care circuits that promote proactive teamwork and the empowerment of patients and their families is a tool that emergency care professionals must use in order to avoid further fragmentation of the healthcare system and improve people's health.

This list of recommendations is an opportunity to optimize health care in emergency services and can also serve as a starting point to understand the vital context of patients outside of this care setting. Although some problems of attention in this environment are large and probably difficult to solve, it’s possible to make small modifications in our daily practice that can have an impact. Healthcare professionals who work in emergency services or are in contact with them must participate in this change. Listening more and requesting tests more carefully can be a good start.