Emergency healthcare worker well-being in Atlanta.
The last several years have been a challenging time to be an emergency healthcare worker (EHCW) which includes emergency physicians, associate providers, nurses and staff. Prior to the COVID-19 pandemic, EHCW burnout rates were already higher than those in other specialties or care environments, with rates ranging from 2% in emergency nurses to 76% in resident physicians.1,2
In the past three years, however, a combination of global, national and local challenges have pushed many Atlanta EHCWs to their breaking point. Given the current climate of emergency medicine, now is an ideal time to reflect and strategize ways to improve the well-being and professional fulfillment of our local emergency department workforce.
The impacts of the COVID-19 pandemic on EHCWs are well-documented and include increased rates of burnout, worry, anxiety, fear and perceived stress.3,4,5 Emergency departments (EDs) were one of the few healthcare elements whose services remained uninterrupted during the initial phase of the pandemic.
On a daily basis, EHCWs exposed themselves to an increased risk of infection with a poorly understood virus, along with the potential of passing it to their loved ones.6,7 As the pandemic progressed, the ED became the front line of tragedy, including terminal intubations and facilitating patients’ final phone calls to families. The working conditions were difficult, and many felt unsupported.7,8 This led many EHCWs to experience high moral distress during this time.7
Pre-existing nursing shortages were amplified during the pandemic.9,10 EDs saw an exodus of nursing and ancillary professionals, leaving patient care areas poorly staffed despite an increase in patient volumes back to pre-pandemic levels and beyond. This problem persists today as hospitals navigate an acute-on-chronic nursing shortage. Remaining staff continue to do more with fewer resources and less assistance.
Other pre-existing issues in emergency departments have escalated since the onset of the pandemic, including overcrowding, boarding and violence. As a result of overcrowding and boarding, ED waiting room times are increasing, and care for new or lower acuity patients are now in hallway beds and other improvised locations.11
This limits an EHCW’s ability to adequately examine and care for their patients.12 In some EDs, “waiting room medicine,” the practice of seeing and treating patients – even sick ones – from the waiting room, has become common practice. Additionally, violence against ED workers, already a well-recognized national problem, increased as the pandemic continued and our societal conversation evolved.13,14,15 The ED became the flashpoint of misinformed patients and families who believed they were being misled by the healthcare system in response to their COVID-19 diagnosis or treatment options.16
In Georgia, EDs have experienced additional stresses on top of the national trends discussed above. As one of the few remaining states to avoid implementing an expansion of Medicaid eligibility, Georgia continues to have a higher-than-average rate of residents without health insurance.17,18 For the uninsured population, few options exist to obtain healthcare – even for routine problems – outside of the ED.
Compounding this problem locally, the 2022 closures of Atlanta Medical Center (AMC) and Atlanta Medical Center South (AMC South) have resulted in a significant number of patients without a medical home. These closures represent a loss of over 650 inpatient beds serving high-need areas within the city.19,20 As a result, there have been significant increases in the medical, psychiatric and trauma volumes for the remaining EDs in metro Atlanta, which were already above capacity.
The closure of AMC in the Old Fourth Ward leaves Grady Memorial Hospital as the only Level I trauma center in Atlanta. Grady experienced a 30%-50% increase in trauma volume last year and saw more than 10,000 trauma activations in 2022, making it one of the busiest trauma centers in the country.
The EDs of AMC and AMC South served a predominantly Black population (67.3%), and over half (51.5%) were Medicare or Medicaid recipients.19 Health disparities by race and structural racism within the healthcare system are a public health crisis in the United States, and these closures have worsened the situation locally.21,22,23
In response to the closure of both AMC campuses, Governor Brian Kemp pledged $130 million of federal funds allocated to Georgia to go to Grady Memorial Hospital to add about 185 beds, and additional funding to Grady was provided by local governments.19,24
Finally, consistent with national trends, Atlanta has experienced an increase in interpersonal violence (including homicide, rape and aggravated assault) over the past several years.25 Such violence results in an additional increase in ED and trauma center visits, and victims’ injuries often result in critical illness, chronic disabilities or prolonged recoveries that may lead to additional ED visits.
The question remains: How do we improve EHCW wellness and professional satisfaction? Fortunately, there are systems-level interventions that have been shown to reduce burnout. As an organizational blueprint for improving healthcare worker burnout, Shanafelt and Noseworthy propose nine areas of focus for organizations.26 1) Acknowledge and assess the problem, 2) harness the power of leadership, 3) develop and implement targeted work unit interventions, 4) cultivate community at work, 5) use rewards and incentives wisely, 6) align values and strengthen culture, 7) promote flexibility and work-life integration, 8) provide resources to promote resilience and self-care, 9) facilitate and fund organizational science.26 While individual self-care is vital for EHCWs to maintain health and professional fulfillment, these types of organizational improvements will ultimately create the environment for people to thrive at work and stay engaged.
When developing well-being efforts, a multifaceted and multimodal approach are important. There are many national (American Academy of Emergency Medicine, American College of Emergency Physicians and Society for Academic Emergency Medicine)27,28,29 and regional (Georgia Professionals Health Program)30 resources that are available to EHCWs that should be utilized while local resources are still being cultivated. At Emory, well-being is multifaceted, and we are fortunate to benefit from programming and resources that come from Emory University, Emory University School of Medicine, Emory Healthcare and the Grady Health System.
In the spirit of organizational change, Emory has created a Chief Wellness Officer position/s and founded a new Office of Well-Being (EmWELL) to lead the design, direction and implementation of well-being programs that address the current environmental stressors among clinicians, health professionals, faculty and staff. The goals of the office include facilitating system-wide changes that enable team members to effectively practice in a culture that prioritizes and promotes professional fulfillment in addition to establishing a robust well-being research foundation. This, coupled with the Emory School of Medicine’s Wellness Working group, is led by an emergency physician and includes physicians from multiple specialties, allowing them to build capacity and serving as a forum for effective practices.
The work from this group focuses on developing work unit interventions, cultivating community at work and aligning values with EmWell. Innovations have included wellness newsletters that share accomplishments of individuals and work units, wellness events to foster community outside of the workplace, and highlighting university and healthcare programs that are of interest. The groups build physician committees to give feedback to the organization on the design of healthier schedules, promoting regular time to strengthen social bonds between co-workers and demonstrating leadership buy-in to building a healthier work culture.
Creating positions such as Chief Wellness Officers and Directors of Well-Being, Equity, Diversity and Inclusion are all positive efforts to tackle the problems facing EM in Atlanta. Furthermore, a positive focus on building engagement and fostering resilience and professional development rather than a negative focus on burnout is key.
Organizations that provide care to underserved patients are also impacted by decisions to limit or expand Medicare, as this funding is vital to both patient care and indirectly the care of EHCWs themselves. We must advocate for local change to improve the work environment in EDs. Locally, we need to partner with physicians in other specialties to ensure appropriate referrals are made to the ED. Hospitals should look at increased outpatient support and access to care for their patients. Exploring and implementing solutions to decrease ED boarding and improve ED throughput are paramount in creating a safe and fulfilling workplace.
At the state level, the expansion of Medicaid would provide increased revenues to hospitals and would mitigate some of the financial burden in caring for patients who are uninsured or underinsured. The metro-area counties outside of Fulton and DeKalb need improved resources for uninsured patients and provision of indigent care.
The Emory EM residency visits the state capital annually to meet with local lawmakers to discuss issues impacting the EDs across the state. As physicians, our voice is heard by our policymakers. We all have a role in advocacy and should feel empowered to reach out to our lawmakers to advocate for our patients, prehospital systems and EDs.
EHCWs are resilient and dedicated practitioners. As the landscape of emergency medical care is changing, now is the ideal time to strategize, innovate and implement to improve the working environment in EDs across the country.
- Adriaenssens J, De Gucht V, Maes S. Determinants and prevalence of burnout in emergency nurses: a systematic review of 25 years of research. Int J Nurs Stud. 2015 Feb;52(2):649–61.
- Lin M, Battaglioli N, Melamed M, Mott SE, Chung AS, Robinson DW. High Prevalence of Burnout Among US Emergency Medicine Residents: Results From the 2017 National Emergency Medicine Wellness Survey. Ann Emerg Med. 2019 Nov;74(5):682–90.
- Kelker H, Yoder K, Musey P Jr, Harris M, Johnson O, Sarmiento E, Vyas P, Henderson B, Adams Z, Welch J. Prospective study of emergency medicine provider wellness across ten academic and community hospitals during the initial surge of the COVID-19 pandemic. BMC Emerg Med. 2021 Mar 24;21(1):36. doi: 10.1186/s12873-021-00425-3. PMID: 33761876; PMCID: PMC7988634.
- Rodriguez RM, Medak AJ, Baumann BM, Lim S, Chinnock B, Frazier R, Cooper RJ. Academic Emergency Medicine Physicians’ Anxiety Levels, Stressors, and Potential Stress Mitigation Measures During the Acceleration Phase of the COVID-19 Pandemic. Acad Emerg Med. 2020 Aug;27(8):700-707. doi: 10.1111/acem.14065. Epub 2020 Jul 21. PMID: 32569419; PMCID: PMC7361565.
- Nguyen J, Liu A, McKenney M, Liu H, Ang D, Elkbuli A. Impacts and challenges of the COVID-19 pandemic on emergency medicine physicians in the United States. Am J Emerg Med. 2021 Oct;48:38-47. doi: 10.1016/j.ajem.2021.03.088. Epub 2021 Apr 2. PMID: 33836387; PMCID: PMC8016733.
- Nguyen LH, Drew DA, Graham MS, Joshi AD, Guo CG, Ma W, Mehta RS, Warner ET, Sikavi DR, Lo CH, Kwon S, Song M, Mucci LA, Stampfer MJ, Willett WC, Eliassen AH, Hart JE, Chavarro JE, Rich-Edwards JW, Davies R, Capdevila J, Lee KA, Lochlainn MN, Varsavsky T, Sudre CH, Cardoso MJ, Wolf J, Spector TD, Ourselin S, Steves CJ, Chan AT; COronavirus Pandemic Epidemiology Consortium. Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study. Lancet Public Health. 2020 Sep;5(9):e475-e483. doi: 10.1016/S2468-2667(20)30164-X. Epub 2020 Jul 31. PMID: 32745512; PMCID: PMC7491202.
- Blanchard J, Messman AM, Bentley SK, Lall MD, Liu YT, Merritt R, Sorge R, Warchol JM, Greene C, Diercks DB, Griffith J, Manfredi RA, McCarthy M. In their own words: Experiences of emergency health care workers during the COVID-19 pandemic. Acad Emerg Med. 2022 Aug;29(8):974-986. doi: 10.1111/acem.14490. Epub 2022 May 22. PMID: 35332615; PMCID: PMC9111302.
- Plouffe RA, Nazarov A, Forchuk CA, Gargala D, Deda E, Le T, Bourret-Gheysen J, Jackson B, Soares V, Hosseiny F, Smith P, Roth M, MacDougall AG, Marlborough M, Jetly R, Heber A, Albuquerque J, Lanius R, Balderson K, Dupuis G, Mehta V, Richardson JD. Impacts of morally distressing experiences on the mental health of Canadian health care workers during the COVID-19 pandemic. Eur J Psychotraumatol. 2021 Nov 10;12(1):1984667. doi: 10.1080/20008198.2021.1984667. PMID: 34777712; PMCID: PMC8583841.
- Gorman VL. Future Emergency Nursing Workforce: What the Evidence Is Telling Us. J Emerg Nurs. 2019 Mar;45(2):132-136. doi: 10.1016/j.jen.2018.09.009. Epub 2018 Oct 24. PMID: 30529292.
- Castner J, Bell SA, Castner M, Couig MP. National Estimates of the Reserve Capacity of Registered Nurses Not Currently Employed in Nursing and Emergency Nursing Job Mobility in the United States. Ann Emerg Med. 2021 Aug;78(2):201-211. doi: 10.1016/j.annemergmed.2021.03.006. Epub 2021 Jun 12. PMID: 34127308; PMCID: PMC8555063.
- Smalley CM, Simon EL, Meldon SW, Muir MR, Briskin I, Crane S, Delgado F, Borden BL, Fertel BS. The impact of hospital boarding on the emergency department waiting room. J Am Coll Emerg Physicians Open. 2020 May 23;1(5):1052-1059. doi: 10.1002/emp2.12100. PMID: 33145557; PMCID: PMC7593429.
- Laam LA, Wary AA, Strony RS, Fitzpatrick MH, Kraus CK. Quantifying the impact of patient boarding on emergency department length of stay: All admitted patients are negatively affected by boarding. J Am Coll Emerg Physicians Open. 2021 Mar 2;2(2):e12401. doi: 10.1002/emp2.12401. PMID: 33718931; PMCID: PMC7926013.
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- Bin Naeem S, Kamel Boulos MN. COVID-19 Misinformation Online and Health Literacy: A Brief Overview. Int J Environ Res Public Health. 2021 Jul 30;18(15):8091. doi: 10.3390/ijerph18158091. PMID: 34360384; PMCID: PMC8345771.
- Rudowitz R, Drake P, Tolbert J, Damico A. How Many Uninsured Are in the Coverage Gap and How Many Could be Eligible if All States Adopted the Medicaid Expansion? https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/ (Accessed April 6, 2023)
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- Thomas DJ. After weeks of drama, disappointment, Atlanta Medical Center to close. The Atlanta Journal-Consititution. https://www.ajc.com/news/atlanta-news/after-weeks-of-drama-disappointment-atlanta-medical-center-to-close/WCORMLKD7FEEJAD3NA4XI3KY7A/ (Accessed April 6, 2023)
- Hart A. South Fulton to lose only full care hospital. The Atlanta Journal-Constitution. https://www.ajc.com/news/coronavirus/south-fulton-to-lose-only-full-care-hospital/DSYSEJ6KLJF7VAAWKOJGQDNKZY/ (Accessed April 6, 2023)
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- Bluestein G and Landergan K. New details: financial rescue planned for Grady Health System. The Atlanta Journal-Constitution. https://www.ajc.com/news/atlanta-news/new-details-financial-rescue-planned-for-grady-health-system/PXZSG5EDDFAVDBRMGDLEEJZG6Q/ (Accessed April 6, 2023)
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