Otolaryngology in the ED

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Key Points

• Despite the fact that otologic complaints are commonly treated in the ED, there is a possibility that some otologic conditions are being underdiagnosed and undertreated.
• Very few ED visits for otologic complaints are actually “true” medical emergencies.
• Educating primary care providers as well as patients on what constitutes a true otolaryngology emergency could help lower the number of non-urgent visits to the ED.

Are Specialty Emergency Departments a Viable Solution for Overburdened ERs?

The Institute of Medicine Committee on the Future of Emergency Care has recommended developing a system of emergency care to increase access to specialty care. “Historically, there used to be more dedicated otolaryngologic emergency rooms,” said Elliott D. Kozin, MD, clinical fellow in otolaryngology at the Massachusetts Eye and Ear Infirmary (MEEI)/Harvard Medical School in Boston. “Today, the MEEI has one of the last remaining 24/7 emergency rooms that focuses on otolaryngology and ophthalmology-related complaints. The MEEI emergency room is a unique healthcare provider model that provides direct access to specialists in the acute setting.”

In a study led by clinical fellows at the MEEI aimed at characterizing practice patterns in a dedicated otolaryngology emergency department (ED), researchers concluded that, “While all otolaryngologic complaints often do not require specialist-level care, a regionalized system of expertise, whether a stand-alone ED or a dedicated team focused on otolaryngologic complaints by emergency room and/or otolaryngology providers, may lead to improved care coordination and address many of the concerns previously introduced. Moreover, as the implementation of the Patient Protection and Affordable Care Act nears completion, the anticipated number of common otolaryngologic complaints seen in EDs will likely increase significantly.” (Am J Otolaryngol. 2014:35:758-765)

Otolaryngologists should be actively involved in acute care policy decisions and developing emergency department treatment algorithms.

Of 12,234 patient visits at the MEEI ED between January 2011 and September 2013, 50% of patients came in for auditory and vestibular problems and 92.3% of patients were discharged after their ED visit.

Because many otolaryngologic complaints, such as hearing loss and dizziness, are commonly evaluated in the ED setting, Dr. Kozin said that, at minimum, otolaryngologists should be actively involved in acute care policy decisions and in the development of ED treatment algorithms.

Possible Drawbacks

While weighing in on the feasibility of having an ED dedicated to otolaryngologic complaints, some physicians also see downsides to this model. “One of the major drawbacks of a specialty-specific ED is that ED patients present as undifferentiated patients,” said Torree McGowan, MD, an emergency medicine physician at David Grant Medical Center in Fairfield, Calif. “Emergency physicians are unique in that they consider all systems and specialties in their evaluation, and then narrow the differential diagnosis to the right specialist,” she added. “We evaluate an undifferentiated patient based on their chief complaint, rather than managing a known disease—which is how most specialists operate.”