Open encounters in crowded ERs

Sarina Lalla is a medical student in class of 2020 at McMaster University.

 

 

 

When I was on an emergency medicine rotation, I asked for a room to tell a patient news about an X-ray. I was told that this was not a common practice given the scarcity of private rooms. It was advised that I inform them in the waiting room where other strangers sat nearby. I was also told to present cases to staff in small spaces in earshot of patients. This was unsettling to me, and pushed me to reflect on confidentiality and privacy breaches in the ED.

Canadian EDs are well-known to be overcrowded. With limited resources and a high patient volume, the space of a department is used to house a maximum of patients. Sometimes thin curtains are separating patients, or nothing is separating them at all. Often, they are placed in hallways and close to workstations where healthcare staff outside of their circle of care are working. Moreover, when a physician is on the go and managing many ill patients at once, a team member speaking to them can feel pressured to discuss a case in inconvenient open spaces.  This means that people who are not involved in the circle of care can hear or witness confidential details of medical encounters in many different ways.

The implications of this can be concerning. What if this was a small community and the patient whose privacy was breached knew other patients in the ER? What if those people were their boss or a co-worker? What if there was a concern or a condition that could jeopardize personal and professional relationships if known to others?

Confidentiality is one of the pillars of medical ethics, law and practice. It is essential to maintain in order to preserve a physician-patient relationship of trust, allowing for full honesty and complete details in order to get an accurate history and physical. This is crucial in issues that may be extremely stigmatizing like obstetrical and gynecological health, mental health, and infectious diseases.

When confidentiality is jeopardized in such situations, there is sacrifice of justice, beneficence and non-maleficence for the purpose of practicality. Given that practicality is not a pillar of medical ethics, this shows that the practice of sharing medical information in the open ER is unethical. Yet, it remains common in a situation where resources are stretched thin.

A study done in a university hospital ED showed that more than half of the patients had confidentiality and privacy breaches, most commonly occurring in the triage and waiting areas, in rooms close to the workstations, and curtained rooms.

What can we do about this practice? It is known where patients are most vulnerable to privacy breaches in ED, and targeting those areas is an effective first step.  An Irish study showed that a refurbishing of a maternity emergency department through from curtained cubicles to walled cubicles, making encounters a bit more private, dramatically improved a patient’s perception of preserving their privacy and confidentiality, which lead them to feel more at ease in their physician-patient relationship.

Monetary investments aside, there are some simple ways that I feel that we can avoid confidentiality breach. Those include speaking in more secure workstations out of earshot of patients, and making efforts to place patients in secure, closed off rooms for all discussions with the healthcare team while those who are not being addressed are placed in a separate waiting room.

As long as we remain in a shortage of primary care physicians, this issue is likely to persist as we prioritize addressing increased demand. It will also continue to raise ethical implications.  Therefore, healthcare workers in the ED should continue to talk about this issue for all to hear.

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