EDITORIAL Neal Flomenbaum, MD, Editor in Chief Acute Department Syndrome

n this issue of Emergency Medicine, care under the Affordable Care Act cern. With some creative approaches Greg Weingart, MD, and Shravan have not been met with a commensu- varying by location and circumstanc- Kumar, MD, guide readers through rate increase in ED capacity. Between es, EPs have generally been able to suc- I the diagnosis, monitoring, and treat- 1990 and 2010, the country’s urban cessfully address the safety issues—so ment of acute compartment syndrome, and suburban areas lost one quarter of far. For example, many years ago, we a relatively uncommon but devastat- their hospital EDs (Hsia RY et al. JAMA. began holding in reserve a small por- ing injury that may affect an extremity 2011;305[19]:1978-1985). In that same tion of our fee-for-service EM revenue following a long bone fracture, deep period, New York City lost 20 hospi- available to supplement the hospital- vein thrombosis, or rhabdomyolysis tals and about 5,000 inpatient beds; provided base salaries. By frequently from crush injuries or high-intensity after 2010, when the state stopped bail- monitoring conditions throughout the exercising. Compartment syndrome oc- ing out financially failing hospitals, day, taking into account rate of regis- curs when increased pressure within four more hospitals closed and were tration in the ED, day of the week, OR a limited anatomic space compresses replaced by three freestanding EDs schedules, etc, we were able to decide the circulation and tissue within that (FSEDs). Though FSEDs may partially before noon whether there was a need space until function becomes impos- fulfill the need for 24/7 emergency care to offer 4, 6, or 8 evening/night hours sible. Even with heightened awareness at their former hospital sites, when pa- at double the hourly sessional rate to of the disastrous sequelae, and with tients in FSEDs require admission, they the first EPs, PAs, and NPs in our group very early pressure monitoring of the must compete with patients in hospi- who responded to the e-mails. The injured compartment, physicians are at tal-based EDs for inpatient beds. hours worked did not earn these “first a loss to effectively intervene to prevent Despite the many and varied sources responders” any additional “RVU” the continuing rise in pressure until a of increasing numbers of patients arriv- credits as, for the most part, they were fasciotomy is required. ing in EDs, by all accounts this influx working closely with the inpatient ser- The disastrous consequences of ris- in and of itself is not the major driver of vices to monitor and supplement the ing pressure in a closed space suggests ED overcrowding. Trained, competent care of admitted patients waiting in what can occur in the severely over- EPs, supported by skilled and highly the ED. This arrangement provided an crowded EDs that now are common in motivated RNs, NPs, and PAs, are ca- additional level of patient safety with every city in this country—EDs with pable of efficiently managing even no additional expense to the hospital. too many patients waiting for treat- frequent surges in patient volume—as But flexible measures to provide ment and inpatient beds. long as the “outflow” is not blocked. patient comfort and ensure safety can- Pressure on the nation’s ED capac- In many cases, this means having ad- not solve the inflexible space issue, ity has been steadily increasing for the equate, timely outpatient follow-up and instituting harsher regulations past three decades. Hospital/ED clos- available to allow for safe discharge. and core measures will only increase ings, demand for preadmission test- But overwhelmingly, it means having the pressures on ED staffs. What is re- ing by managed care and primary care adequate numbers of inpatient beds. quired is a serious look at the national physicians, increasing numbers of doc- The discomfort and loss of privacy model for accruing ED costs, revenues, umented and undocumented people that patients experience from spend- and third-party reimbursements, and seeking care, a rapidly aging popula- ing many hours or days on hallway then adjusting the formulas to address tion with more comorbidities, and in- stretchers are bad enough, but eventu- the current patient care realities before creased numbers of patients seeking ally patient safety also becomes a con- a “fasciotomy” is required. I

Author’s Disclosure Statement: The author reports no actual or potential conflict of interest in relation to this article. DOI: 10.12788/emed.2017.0020

100 EMERGENCY MEDICINE I MARCH 2017 www.emed-journal.com