During a busy ED shift, my computer signaled the complaint and location of my next patient: a woman in bed 10 flagged with “GI bleed.”  I almost bolted to bed 10 to ensure this patient was stable, but then noticed orders pending, so my urgency eased.

“I see you already saw the patient in 10,” I began, addressing the triage physician.

“Yeah, she’s all set,” he replied, without turning from his computer. “You can go see the next one.”

Confused by what “all set” meant, I pressed for clarification.

“Does that mean you already saw her, and you’re keeping her?”

He turned to face me, his voice ladened with annoyance, as he made a half-hearted attempt to enlighten this simple-minded ER doc about the new ways of emergency medicine. Hadn’t I been to the in-service about the “doc at triage” protocol?

“I said she’s all set. I put orders in on her, so you can see the next patient.”

He abruptly turned back around, redirecting his attention to his unfinished charts.

Facing the back of his head, I wondered how inputting orders in a computer made a thorough evaluation of a GI bleed any less urgent.

The new ways of emergency medicine established by the Center for Medicare and Medicaid Services include a “door to provider” time that ensures maximal reimbursement. Reasons cited for this metric are improved patient safety, reduced left-without-being-seen rates and increased patient satisfaction. Ideally, fully or overstaffed emergency rooms could provide prompt and appropriate care regardless of acuity. However, such fully or overstaffed emergency rooms are scarce.

Putting patients face to face with a medical provider in the allotted thirty minute target time has triggered a frenzy in some departments.  Physicians signing up for multiple patients in the system simultaneously to “stop the clock,” knowing they cannot be seen immediately, is one desperate way emergency rooms are surviving this new world of metrics. A triage board displaying a potpourri of patients with assigned providers gives the impression these patients have been evaluated and are stable.  This misleading visual cue thwarts a triage process that has promoted patient safety for years.

A triage doctor that relinquishes care to a department doctor is safer, but poses two potential problems.  Triage doctors, aware of all the potential diagnoses patients may have for any given complaint, are more likely to over test. They cannot perform a complete physical exam in triage, and they do not reevaluate patients.  Secondly, sicker patients may be at a disadvantage since multiple emergency physicians involved their care increases the possibility of error.

In reality, standardizing door-to-provider times among patients with varying acuities is a practice that invites risk.  A patient with a sore throat may have to wait longer than one with a heart attack, but suffers no long term consequences by doing so.  Spreading resources thin to accommodate low acuity patients with the same urgency as high acuity patients is doing the latter a disservice.  Staff scrambling to beat the thirty-minute door-to-provider time for all patients cannot grant sicker patients the attention required for safe, appropriate and expeditious treatment, opening the door for morbidity and mortality.  That is why the concept of triage was developed in the first place.

Spencer Nam explains in the Paradox of Quality Measures in Healthcare that the manufacturing industry first developed the idea of quality improvement. Steps in manufacturing were analyzed, revealing pertinent metrics.  Conversely, patient care does not follow a uniform, stepwise process.  He writes, “Once a patient is registered at the hospital or at a doctor’s office, that patient follows a unique path of care … relying on metrics when there is no agreement on a standardized process causes some of the patient care decisions to be made on reimbursability, while adding administrative responsibilities to track measures that are irrelevant to patient outcomes.  Instead of improving efficiency and effectiveness, these metrics become extremely burdensome to the system.”

Metrics do not improve a system lacking standardized processes.  Dissimilar diseases and acuities requiring drastically different treatments throw a wrench in the whole concept.

CMS introduced three other benchmarks that influence full reimbursement: median time from ED arrival to ED departure for discharged patients, median time from ED arrival to ED departure for admitted ED patients and admit decision time to ED departure time for admitted patients. Could not hospitals, potentially facing lost revenue, leverage these quality measures against physicians by threatening cut in pay, or even termination, if they do not deliver on metrics?  Physicians, handcuffed by system inefficiencies and staffing shortages, may be forced to make clinical decisions based on job security, not good medical practice.  If patients need a CT scan with oral contrast or a lengthy laceration repair, procedures potentially catapulting them outside of the target evaluation times established by CMS, physicians may opt to forego the scan or cut corners on the repair to preserve his or her livelihood.  These decisions are not based on best patient care.

In a whirlwind attempt to comply with arbitrary guidelines that maximize reimbursement, care is less problem-focused, thereby increasing cost to the system and risk for the patient.  As with any task, when speed is rewarded, quality suffers.   In busy ERs, knee-jerk tests are replacing what patients actually need: appropriate medical evaluations by a qualified individuals. This takes more time than clicking boxes on a computer screen.  CMS aims to streamline care with guidelines for door-to-provider time and other ED metrics, imposing financial penalties for those who don’t make the cut. The ones who will actually pay the price, literally and figuratively, are the patients.

Turning back to the patient in bed 10, as a simple-minded ER doc, seeing hundreds of dollars of tests pending, I felt compelled to evaluate her GI bleed myself.  Arriving bedside, I saw a woman in no distress, connected to IV fluids and a cardiac monitor. A brief history was negative for the usual concerning symptoms of a bleed, and I proceeded to the rectal exam. The dark stool was guaiac negative.

“Interesting,” I thought out loud. “Have you had anything red to eat lately, like beets?”

“Oh yes,” she recalled, amazed at my telepathic abilities, “Yesterday I ate a delicious beet salad!”

I smiled and reassured her that she was OK.

That was one expensive salad.

Aida Cerundolo is an emergency physician.

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