Thanks as always to Dr. Mike Silverman, Chair of the Department of Emergency Medicine at the Virginia Hospital Center in Arlington, for these superb updates!
Friday Night Update from the ER in Arlington, VA
I was talking to a friend earlier this week about the impact the Omicron surge had on his Christmas party last year. Effectively, a big party (appropriately) turned into just a few people. COVID cases continue to trend up in the ER. We’re actually seeing more cases each week than this time last year. Of course, Omicron started to surge 51 weeks ago so we’ll see what happens over the next couple of weeks as people increase their holiday gatherings and see if we have another surge this winter.
We introduced a new COVID test into the ER this week and my daily data report is running a few days behind. (The query needed to be edited). With that said, we still had an uptick in cases for the week and a higher percent positive rate. Where the new test impacted my data the most this past week was on the “symptomatic patients” where we ran about 70 tests less than a typical week. The new test looks at COVID, Flu A and B, and also tests for RSV at the same time. Therefore, I think some symptomatic patients who normally would have been captured with our previous covid/flu test, were not captured with the new test. Previously, we did a second swab for RSV antigen when we thought it needed to be tested for. This was a rapid and cost appropriate test but was only appropriate for those under age 5. We also have a much broader viral panel which is very expensive, takes longer to run, and is generally not appropriate for patients being discharged. So now, with one swab, I can get a relatively rapid result on our symptomatic patients of all ages. Anyway, by next week, I expect the data to be up to date. And even with not capturing all of the tests, we still had more positives than previous weeks.
I got asked a great question last week that I’m going to try to answer. The question basically boiled down to what percent of the patients that we see in an ER can be seen in other venues—PCP, urgent care, etc…It’s a really complicated question and the answer will in some respect vary from ER to ER (access to care, insurance mix, number of patients without PCP’s etc). I gave a lecture about 20 years ago and showed a headline from the Washington Post that said about 50% of ER visits were “urgent care.” What we’ve seen in the last 20 years is a proliferation of urgent cares (follow the money—insured patients with stuff that’s generally pretty easy for us to manage with good reimbursement). Much of what emergency physicians would call the easy, urgent care population has disappeared from the ERs. We still see lacerations and extremity injuries (sprains to fractures) but we do actually see less now than we used to. The super easy “bit by a tick,” poison ivy patient, or “fishhook got stuck in my hand” have disappeared.
Emergency departments nationally triage patients on a 1-5 scale based on the Emergency Severity Index. The level a patient is assigned is based on a variety of indicators including chief complaint, vital signs, and the expected number of nursing resources the patient will need. An ESI 1 is a patient in cardiac or respiratory arrest, or near death. A 5 is a patient who requires no nursing resources (no labs, IV, meds, etc…). Most of the patients we see in the ER are ESI 3’s, all of whom are truly appropriate for the ER. We track each of these levels very closely and have seen a real drop in the percentage of lower acuity patients we’re seeing each year. Whereas our ESI 4’s and 5’s (5’s are really rare in most ERs), used to be 30+% even a few years ago, now we’re running in the 20% range. And honestly, for many/most of these patients, the ER is the right place for them—head injuries (so we can assess if they need a CT scan which urgent care’s don’t usually have access to), extremity injuries so we can manage the fracture, etc…Recent data suggests that <4% of visits are non-urgent.
The ER has become the place to diagnose patients. We have access to labs and radiology testing and even some specialists if needed. I will admit that I don’t know what percent of the day a typical PCP keeps available to evaluate their patients who have acute problems. I do know that ERs get a lot of patients that are appropriately referred to the ER to evaluate their acute condition. My take is that the old days of going to your doctor’s office for an evaluation of abdominal pain or a headache is generally not how medicine is done anymore. The ER is where acute problems are taken care of. The PCPs office is for management of routine health issues and follow up on other issues. The PCPs I talk to are really busy, and typically don’t have the ability to save appointment slots for same day appointments. Often times, people seen in the ER still require further testing to better define their problems once a life-threatening emergency condition has been ruled out so the PCPs are still doing some work to treat a different conditions.
The biggest exception to this is the pediatrics patient. Pediatricians have always been great at evaluating sick children in their office. Most kids don’t need fancy testing and the pediatricians’ offices have adapted to check for strep, flu, covid, etc…And the pandemic made them provide even more access to care for their patients. (Also, I need to give credit to many of the PCPs who figured out a way to assess acute issues via telemedicine, saving some patients from coming to the ER. This was a really important way to evaluate so many patients with positive home COVID tests who then needed consideration of further treatment).
I don’t do a lot of primary care in the ER. I did do more in Baltimore when more of my patients lacked insurance and didn’t have access to a PCP. But even those patients who came in for diabetes or hypertension and thought they just needed medication refills, were really coming in for complications of their disease and not having the medication—elevated blood sugars and/or elevated blood pressures. The volume growth ERs experience isn’t related to primary care or even urgent care type patients. However, it is definitely related to an aging population that has higher ED utilization needs than younger people, recognizing that patient evaluations and work ups can typically be done quickly in the ER if there was a time sensitive diagnosis to make, and to some extent increasing mental health and substance abuse needs.
Some of you will remember the episode of the TV show ER, where Dr Green went out to the packed waiting room and basically said, “if you have a fever and muscle aches, you have the flu. Go home. You don’t need to be here.” And while some of us have dreamed about doing that, it’s actually against the Federal EMTALA law. With that said, many flu patients don’t need an ER visit. But COVID is a bit of a game changer because there is an unpredictable subset of people who get very sick. And there is a patient population who appropriately or not, are very afraid of dying or having another complication if they get COVID. But part of our patient volume growth is related to COVID and other respiratory viruses.
Our bread and butter patient population is abdominal pain (which has a number of true emergency conditions we’re evaluating people for), chest pain (obviously concerned for heart issues but also blood clots in the lung and even issues related to the aorta, like what caused the death of the reporter Grant Wahl during the World Cup), first trimester pregnancy related issues (miscarriage and tubal pregnancy), sepsis (the biggest killer of hospitalized patients in the hospital), neurological issues (stroke, confusion, headache), and injury (represents about 27% of ER cases nationally).
Walking into the ER as a patient is expensive and with more people choosing high deductible health plans, I think many very carefully make the decision to come to an ER versus using another option. Very rarely I’ll get a patient who literally is only coming in for a pregnancy test and I think that maybe $20 at CVS can give you the answer, rather than potentially thousands of dollars at the ER, but really what many patients with low acuity complaints need is access to care or someone addressing another underlying concern. I think I’ve said this before but a former boss used to say that emergency physicians are in the reassurance business. The patient seeking a pregnancy test may be very worried about a tubal pregnancy or having a miscarriage. The patient with a headache may be worried about a brain tumor. And the patient with abdominal pain and bloody bowel movements may be worried about cancer.
I went into emergency medicine to take care of everyone. Twenty years ago when I would present the slide to residents in training that 50% of our patients were not emergencies, that was to reset expectations as to what the job looks like on a day to day basis. Interestingly enough, over the last several years, our patients have been sicker than ever, and most of us would gladly welcome back the occasional urgent care or lower acuity patient that are now going to stand alone urgent cares.
Get your COVID tests now. The Biden administration is again partnering with the USPS to allow people to order four free covid tests online. You’ll recall that last winter, it was extremely challenging to find rapid covid tests at your pharmacy. In preparation for what is expected to be higher demand for testing, this move is much appreciated by all of us who work in the ER and saw patients for routine testing last winter. You can order your tests at covidtests.gov I ordered mine this morning and it took less than 30 seconds.
The WHO estimates that nearly “15 million people have likely died as a result of the COVID-19 pandemic (worldwide) in 2020 and 2021, nearly three times more than previously reported.” Published in the journal Nature, the data was based on excess deaths reported above baseline. Heart disease was the leading cause of worldwide deaths in 2019, with nearly 9 million deaths.
I suspect most people who read these posts have gotten their vaccines. I know there’s some non-believers out there, but the data continue to support the benefits of the vaccine. 80% of the US population has received at least one dose. I got my first dose two years ago today. Published in the Commonwealth Fund this week, the authors (conservatively) found that “the COVID-19 vaccines have kept more than 18.5 million people in the US out of the hospital and saved more than 3.2 million lives.” The authors “found that without COVID-19 vaccines, the nation would have had 1.5 times more infections, 3.8 times more hospitalizations, and 4.1 times more deaths than it did between December 2020 and November 2022.” There are also financial benefits to improved health, saving the US “more than $1 trillion.”
Coronavirus is not quite done with us yet.
Science matters. Get vaccinated (or your booster). Keep a mask handy.