The financial burden of emergency department congestion and hospital crowding for chest pain patients awaiting admission

Lack of utility of telemetry monitoring during transport to inpatient beds for identification of dysrhythmias for emergency department patients with potential and known acute coronary syndromes

Patients admitted with acute and potential acute coronary syndromes (ACS) frequently required accompaniment by a registered nurse from the emergency department (ED) to inpatient telemetry beds. We tested the hypothesis that telemetry transport monitoring for patients with acute and potential ACS is of limited utility. We conducted a prospective cohort study of patients who were admitted from the ED with acute and potential ACS. Endpoints were life threatening ventricular dysrhythmias requiring intervention and duration of transport time. The setting was an urban tertiary-care emergency department with 55,000 annual visits, and the subjects were adult patients admitted from the ED to inpatient beds (intensive care unit or floor telemetry) with ACS and potential ("rule-out") ACS. Main outcome measures were the development of a life threatening ventricular dysrhythmias during transport, any intervention by the transporting nurse, and the total transport time. Of 315 total admissions involving 310 patients, there were no life threatening ventricular dysrhythmias and interventions during transport [0%; 95% confidence interval 0-0.95%]. The total nurse time out of the ED spent transporting was 13.6 minutes (SD 5.2, range 4-40). The routine use of nurses accompanying patients admitted with acute and potential acute coronary syndromes is of limited utility. Patient transportation without nurses may help alleviate ED overcrowding by saving almost 15 minutes of nursing time currently being used for transport without measurable benefit.

The social, professional, and legal framework for the problem of pain management in emergency medicine

The problem of harmful, unnecessary and neglected pain has been studied extensively in many health care settings over the past decade. Research has documented the incidence of untreated pain, and scholars and advocates have given the problem several names: “public health crisis,” “oligoanalgesia, and “moral failing,” among them. Articles have identified a litany of now familiar “obstacles” or “barriers” to effective pain relief. Each of these individual obstacles or barriers has been the subject of targeted remedial action in at least some context.

The checklist approach to improving care for patients in pain, however, is likely to have only limited effect. What really appears to be operating is a complex ecosystem that supports ambivalence, denial, and even suspicion of the circumstance of patients in pain and efforts to treat them. Pain relief in emergency medicine, a relatively new setting for the study of challenges to treating pain, provides a revealing context for viewing discrete obstacles to effective pain management in medicine as part of an integrated environment into which patients with pain enter for treatment.