Emergency Care – Marginalized Patients Face Priority Issues

Patients are admitted to emergency care departments (EDs) in the majority of the United States in accordance with the urgency of their conditions and the order in which they arrived. However, a recent study from Yale University found that over 29% of ED patients are cut in line, with patients from marginalized groups—such as those with lower incomes, patients who are not white, and patients who do not speak English—more likely to experience this.

According to the experts, this phenomenon can impact patient outcomes and emphasizes the necessity for consistent practices.

JAMA Network Open published the study.

Whether a patient arrives at the emergency room on foot or by ambulance, a triage team often gives them an initial assessment and assigns them a score based on their level of medical need. The emergency severity index, which has a scale of one to five, provided that score. The most urgent events—like cardiac arrest—are given a number of “one,” while the least urgent things—like prescription refills—are given a value of “five.”

If two patients arrive at the same moment, the one with the higher severe score will receive treatment first, according to this approach. The patient who arrived earlier will be treated first if two patients with the same score.

However, this isn’t always the case. Between July 2017 and February 2020, researchers examined electronic health record data from two busy emergency rooms and discovered that 28.8% of patients were ignored at least once in favor of those with lower severity scores or later-arriving patients with the same severity score.

Compared to patients with private insurance, patients having Medicaid as their primary insurance were more likely to be queue-jumped. Spanish-speaking patients were more likely to have English-speaking patients jump the queue than were Black or Hispanic patients, who were also more likely to be passed over than white patients.

“Some of these queue jumps may, in fact, be appropriate, as patients do get sicker and their severity levels do change,” said Dr. Rohit Sangal, assistant professor of emergency medicine at Yale School of Medicine and lead author of the study. “But not all of these jumps are justified.”

Additionally, the patients who were jumped over were more likely to depart before receiving full care and more likely to be placed in a hallway than a room, according to the study.

“That limits how well we can perform an exam,” said Sangal. “We have to ask sensitive questions, which is harder to do with people walking by. And doing bedside procedures in a way that maintains a patient’s privacy is very difficult if not impossible.”

The discrepancies found in the study may be influenced by racism and classism, according to the researchers. According to them, finding effective remedies would depend on examining how discrimination manifests itself at all levels of the health care system, even though some instances of bias may occur during interpersonal contacts in emergency rooms.

“There may be an assumption that patients are being discriminated against by whoever’s doing the triage,” said Dr. Hazar Khidir, an instructor of emergency medicine at Yale School of Medicine and co-author of the study. “But the key here is, this is a structural issue.”

For instance, marginalized patients might not have as much access to outpatient care generally, which would leave less data in their medical records, according to Khidir. This can cause triage teams in emergency rooms to overestimate the severity of the patient’s sickness. Patients who already receive routine outpatient care may gain from their provider’s advocacy and advance up the line.

According to the researchers, addressing these several levels of unfairness will necessitate a broad range of interventions, which may include updated queueing rules, novel triage strategies, and a more diverse medical workforce that more closely resembles the patient community.

When the study’s researchers evaluated patients with the highest scores, such as those who had suffered a stroke or trauma, they found no difference in line jumping.

“In those cases, there are clear protocols for what we do regarding treatment,” Sangal said. “And that this disparity goes away with this group of patients speaks to how well-defined protocols may help close these gaps.”

After actions have been done to resolve the issue, the researchers think it will be crucial to reevaluate queuing and patient outcomes. They propose that reviewing big datasets of complex data with input from doctors who directly face the difficulties will help researchers gauge their success.

“After emergency departments make changes, we can then measure if anything has improved,” said Lesley Meng, assistant professor of operations management at Yale School of Management and co-author of the study. “If not, we can tweak the approach. But if it is, then we can disseminate the intervention to other medical centers and share best practices more broadly.”

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