One of the most significant causes of our current workforce dilemma deemed by my MBA team is a toxic work environment. This has been experienced firsthand by our team members who are currently working in the emergency department and inpatient hospital setting. The contributors to this toxic work environment are multifactorial. Specifically, they include growing physician and other healthcare provider burnout, increased work demands such as a constant push to meet quality metrics that do not inherently translate to improved health outcomes or patient experience, more violence in the workplace, and underappreciation of all team members.
One strategy to address factors such as burnout would be to address current misalignment in financial incentives that compel hospitals to keep high inpatient census levels, which often preferences high-margin patients and yields inefficiency. Consequently, as inpatient capacity is finite and limited, an inevitable back-up of inpatient admissions accumulates in the emergency department where providers are neither trained in hospital medicine nor have the resources to practice hospital medicine. Pressure is ultimately placed on individual providers, such as physicians, to continue serving patients in a high-risk environment and a toxic work environment is produced when health care providers are forced to work in a dysfunctional system while still being held liable for adverse outcomes.
A proposed solution by the authors in the recent NEJM Commentary Emergency Department Crowding: The Canary in the Health Care System is to “realign health care financing to allow hospitals to keep inpatient capacity below a critical threshold of 90%”. The negative impact of crowding in emergency departments has become even more pertinent during the COVID-19 pandemic. Many hospitals have returned to their pre-pandemic volumes whereas some, such as mine, are seeing record high numbers of patients in the emergency department within almost the past decade. However, our COVID-19 prevalence rates are concurrently rising, and as the commentary authors point out, “highly restrictive but necessary infection controls remain in place, limiting hospital and ED functions”.
Cost-shifting will be required to make this proposed solution financially feasible. Specifically, hiring greater ancillary staff and keeping the facility open for longer periods of time would facilitate maximizing the number of surgeries and elective procedures done at the hospital, which in turn would bring greater revenue to the hospital. Maintaining longer hours would prevent a bolus of patients requiring inpatient beds and help smooth out ED throughput curves to minimize crowding. There is already substantial evidence demonstrating how ED crowding contributes to worsening rates of morbidity, mortality, staff burnout, medical error, and excessive cost. The pandemic has made it difficult to ignore this any longer.
Tehreem Rehman, MD MPH 