Making Change in the Emergency Department

Article Outline

• Copyright

To the Editor:

Kudos to Robert L. Wears for “Lost in Translation,” his editorial commenting on why emergency clinicians are “resistant” to adopting many of the practice recommendations suggested by “evidence” and “guidelines.” It's high time that somebody pointed out that the emperor has no clothes.

In a 25-year career as a department director and change agent in emergency medicine, I saw many wonderful advances in emergency medicine become reality: procedural sedation, ankle, knee and spine imaging criteria, proactive analgesia, and many more. I witnessed an equal number of witless time-consuming efforts that did nothing to advance patient care and eventually fell by the wayside: immediate steroids for spinal cord injury and blood cultures in the emergency department (ED) for pneumonia patients being admitted come to mind as 2 “mandates” that turned out to have defective science behind them.

Dr. Wears goes a long way toward explaining why patients are still getting opiates for migraine headaches, antibiotics for viral illnesses, and unnecessary imaging studies. A crucial factor is staff time. Patient education takes time, and conflict with patients takes a lot more time. A busy emergency physician or nurse has very limited time, and until we figure out how to do the patient education ahead of time, we will bump up against the constant need to balance the time needed to do things the old way and the time needed to talk the patient/family/tech/private doc into doing things a better way. And so we had better be sure it really is a better way, and the battles must be fought selectively.

The accompanying paper, on changing from nebulizers to spacers for treatment of children with asthma in the ED, is a perfect example. It turns out that Hospital A eventually achieved this change by having full-time respiratory therapy coverage in the ED. The cost analysis was confined to the equipment, with no mention of the hospital's cost for the extra personnel. The thrust of the article was that maybe by taking into account all the various reasons why Hospital B didn't make the change, they laboriously could succeed in doing it for equivalent results. Nobody asks whether this is a fight worth fighting in an environment where the timely treatment of heart attack victims is getting worse, not better, in our overburdened EDs.

I'm all for evidence-based medicine, but I'd like to see a healthy skepticism toward the latest sure-fire scientific advances, and a careful selection of change efforts emphasizing those that actually improve patient outcomes without demanding time emergency physicians and nurses don't have.