Stress cripples HCWs in emergency department
Stress cripples HCWs in emergency department
IOM report calls for protections
The nation's emergency care system is in crisis, and the solution must include protections for the health care workers who struggle to make it work, according to an Institute of Medicine report, "Hospital-Based Emergency Care: At the Breaking Point."
"You can't build a better emergency care system without a healthy and safe work environment and a strong work force," says IOM panel member Brent R. Asplin, MD, MPH, medical director of Regions Hospital emergency department (ED) and department head of emergency medicine at Health Partners Group and Clinics in St. Paul, MN. "The emergency care system rests on the foundation of all the dedicated individuals, from pre-hospital care [of first responders] to the variety of specialists who support the emergency department."
The ED poses higher risks of stress, violence, and infectious disease than other units in the hospital, notes Asplin. Those workers are the backbone of emergency care and need support, he says.
"Much of the progress that is occurring in the ED today is because the professionals working in it refuse to let it fail, despite, in some circumstances, overwhelming odds," says Asplin, who also is vice chair of emergency medicine at the University of Minnesota in St. Paul.
The vulnerability of workers became clear in the SARS epidemic in Canada, which began with an outbreak in the ED of a Toronto hospital. An elderly woman became ill and died at home after a visit to Hong Kong. Her son, who had cared for her, was admitted to the ED with pneumonia.
The close proximity of patients in the ED contributed to nosocomial spread. Ultimately, 128 cases were linked to the initial ED case, including 47 infected health care workers.1
"In most emergency departments, by the time a truly potentially dangerous airborne pathogen like SARS or smallpox or [pandemic] influenza was identified, the likelihood would be that the whole emergency department would essentially be contaminated," Asplin says.
Improving the ED through redesign
Redesign of the emergency department — both physical structure and processes — actually can relieve some of the stress and hazards, says Asplin.
For example, delays in patient flow create stress for ED workers and increase the risk of infectious disease transmission. The IOM report cites a study showing that 91% of the nation's EDs report overcrowding as a problem. Often, patients have received the care they need from the ED but are waiting for an available inpatient bed, says Asplin.
The IOM panel urged the Joint Commission on Accreditation of Healthcare Organizations to establish a standard to address ED overcrowding and the "boarding" of patients in the ED.
The IOM also recommended that "hospitals adopt robust information and communications systems to improve the safety and quality of emergency care and enhance hospital efficiency." An electronic medical record can give ED personnel quick access to patient information and reduce the paperwork burden, Asplin says.
In fact, ED operations should be evaluated overall to improve efficiency. Can registration take place at the bedside? Can some minor care occur during triage? Are all the required tasks still necessary and providing value? "Focus on tasks that add value and take away tasks that don't," says Asplin.
At Harbor-UCLA Medical Center in Torrance, CA, ED physicians meet monthly to discuss ED issues. To address the physical stress of night shifts, the physicians decided to shorten the shift by one hour, from 11 p.m. to 7 a.m. to midnight to 7 a.m., says Marianne Gausche-Hill, MD, director of pre-hospital care and a member of the IOM panel.
The medical center is constructing a new ED — with ceiling lifts, she says. Technology reduces stress, from software that tracks patient flow to lift devices and gurneys that are easier to push, says Gausche-Hill, who also is a clinical professor of medicine at the University of California at Los Angeles.
Redesigning the ED can protect workers and patients elsewhere in the hospital. The airflow of an ED should be separate and distinct, Asplin advises. "One mistake we've made in emergency care systems is not treating our emergency departments as essentially airborne isolation units," he says.
Security is another major concern for emergency departments. ED personnel sometimes treat rival gang members side by side, or care for a gunshot victim while worrying that the perpetrator may come by to finish the job, says Gausche-Hill.
The IOM panel suggests assigning multiple caregivers to a violent-prone patient and/or having two entry points to ED exam rooms.
It is commonplace for EDs to have security guards. Some also have metal detectors and surveillance cameras. At Regions Hospital, employees and physicians carry devices that allow them to communicate with colleagues in the department — and push a panic button if they need immediate help.
Sufficient staffing and adequate patient flow also can create a better environment for patients and staff, says Asplin.
"You're never going to take the stress out of emergency care. If you did, a lot of people who are working in the emergency care system wouldn't be interested in it. It does attract people who are interested in a high-paced and sometimes high-stress environment," he says, but adds, "We've met and exceeded the stress threshold for many of the workers, and it is time to reduce it."
Reference
1. Varia M, Wilson S, Sarwal S, et al. Investigation of a nosocomial outbreak of Severe Acute Respiratory Syndrome (SARS) in Toronto, Canada. CMAJ 2003; 169:285-292.
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