Why We Don't Rank Emergency Room Care

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Perhaps ranking the care is not appropriate, but having a routine evaluation of practice, review of emergency records, and evaluation of appropriateness of discharge to home, Adult Family Home, or an Assisted Living Facility would be beneficial; at least for hospital training.
I have been a registered nurse for 20+ years and my biggest frustration is dealing with emergency room staff. I have worked in geriatrics for 18 years and I have a great deal of concern about how the elderly patients are evaluated in the E.R. . Nurses in Skilled Nursing Facilities (nursing homes) can accept and care for almost everyone returning from an emergency room visit. Staff in Adult Family Homes and Assisted Living Facilities cannot. Too often I have sent a resident back to the Emergency Room due to continued decline, uncontrolled pain, or a complaint of increased or persistent symptoms not addressed or resolved by emergency room physicians. On several occassions the resident has gone back to the E.R. 2 or 3 times in 48 hours before they are admitted.
The E.R. staff does not send complete notes regarding the care the elderly person received while in the emergency department. A generic computer print out of the diagnosis and a few lines about when to contact the primary M.D. is all we get.
More often than not, there is not even a phone call letting staff know the resident is returning. If a call is received it is usually from a social worker and the transfer report is sketchy at best.
I feel that if there is not going to be some sort of review, evaluation, or assessment of emergency room practices, there should at least be more education requirements for emergency room staff and discharge planners about safe discharges and the differenceslong term care facilities and the services they provide..

Donna of WA 3:14PM June 23, 2008

Avery, you note persuasive arguments for not measuring ED quality, all applicable to the ED alone. However, there are quality monitors that can be placed on ED service that will indicate the efficiency and quality of care of the ED as a component of the host hospital. There are also significant monitors that indicate ED quality alone.
Here are some quality monitors I've analyzed as a former hospital administrator and in my present work as a risk manager and healthcare compliance officer working with professional liability insurance companies.
1. Time of presentation in ED to Triage.
How long does it take an ED to register a patient and put them in appropriate triage? Hospitals should be able to tell the actual time a patient presents in the ED and when they were seen.
2. Triage to treatment.
Once triage has occurred, how long does it take to initiate treatment?
3. Throughput time.
How long does it take an ED and hospital to move a patient from the ED to the appropriate inpatient setting? Some hospitals 'store' patients in the ED as long as 48 hours or more, waiting for an inpatient bed. Many times these delays result in poor care. ED's are designed to diagnose and refer - not as inpatient wards.
Hospitals can tell you how long it takes to move a patient from treatment at the ED to the inpatient registration process, but many 'doctor' the numbers.
4. Internal ED monitors could include:
Test time. How long does it take to get test results back from radiology or laboratory once ordered?
Staffing ratios. How many MD's to patients? How many Nurses in Triage? How many nurses managing active ED patients?
AMA. How many patients leave against medical advice because they are fed up with wait times?
Left without Treatment. How many patients leave without being treated?
Physician response time. How long does it take on-call Physicians called to the ED to respond?
Even assuming all ED's are equally effective in treating patients (which they are not) these monitors can help separate the good from the best ED's.
Regards,
Scott Jones