Culture of Health Blog

An interview with Renee Hsia, MD, a Robert Wood Johnson Foundation Physician Faculty Scholars program alumna and associate professor of emergency medicine at the University of California, San Francisco. She is the co-author of “Emergency Care: Then, Now and Next,” published in the December 2013 issue of Health Affairs, which focused on the future of emergency medicine. The interview is part of a series of posts featuring RWJF Scholars who authored articles in the issue.

Human Capital Blog: Other than the obvious changes in technology, how are emergency departments (EDs) different today than they were 50 years ago?

Renee Hsia: We’ve had a dramatic transition since the 1950s, in terms of what emergency departments do, and the patient outcomes we expect. We mention in the article, for example, that years ago many emergency departments used funeral hearses to transport patients to the ED. Now transport is usually in vehicles with all sorts of life-saving equipment on board. That’s one reason the mortality rate is a lot lower now than it was then; death is much rarer in the emergency room today.

Another dramatic transition has been the rise of the specialist in emergency medicine. It used to be more common to have physicians trained in other specialties taking turns in the emergency room. You still see that in some rural areas, but it’s far less common. There’s been a gradual movement toward the understanding that we need people who are masters in the acute presentation of illness.

We’ve also seen the beginnings of a system transition, with a growing focus on regionalization. We have to account for the reality that not all community EDs and hospitals are equipped with the same technology as tertiary hospitals, such as a cardiac catheterization lab, for example. We need to be sure that we can get patients “the right care in the right place at the right time,” and that requires close coordination within the larger health care system.

HCB: You discuss the relationship between ED crowding and changes in primary care practice. Could you tell us about that?

Renee Y. Hsia, M.D., M.Sc., is an emergency physician at San Francisco General Hospital and an assistant professor in the Department of Emergency Medicine at the University of California San Francisco. She is a Robert Wood Johnson Foundation Physician Faculty Scholar.

A few weeks ago, my colleague Yu-Chu Shen, Ph.D., and I published the results of a study in the Journal of the American Medical Association (JAMA) (abstract) showing that if you are unlucky enough to have a heart attack on a day that your hospital is busy, you have a higher risk of dying. More specifically, we found that for every 100 patients unfortunate enough to have a heart attack when their emergency rooms are diverting ambulances for long periods of time – a key indicator of a busy ER – there are about three potentially avoidable deaths in the 30 days after patients are admitted to the hospital.

Why might this be? We know ER crowding has become rampant; we’ve all experienced the annoyances (as patients, family members or providers) of hours-long waits to be seen. Many of us have also experienced the panic of worrying that a loved one isn’t getting the best care they could because the ER is crowded.

As an ER doctor at a busy county hospital that’s also a trauma center, I feel the stress of providing care to patients under tense circumstances. It’s a daily – sometimes an hourly – challenge. None of our staff – technicians, pharmacists, nurses and doctors – feel good when we are crowded to the point that we cannot provide the best care possible.