emergency departments

Study: Millions of chronically ill not getting care they need

Anne Zieger — Tue, 05 Aug 2008 10:35:42 -0400

A new study confirms what most in the provider arena already knew--that far too many patients with chronic conditions like diabetes or high blood pressure aren't getting the care they need because they lack health insurance. The study, published in the Annals of Internal Medicine, estimates that roughly one of every three uninsured, working-age adults--or about 11 million people--has been diagnosed with a chronic illness. Researchers concluded that many of these patients seldom see primary care doctors, with some relying instead on emergency rooms for their care.

In their survey, researchers found that almost one-quarter of the uninsured with a chronic illness hadn't visited a health professional within the last year, and about 7 percent said they typically went to an emergency room for care. This puts them at high risk for complications, given that, for example, people with high blood pressure can face catastrophic problems like a stroke if they don't get the right drugs or monitoring.

To learn more about the study:
- read this piece in The New York Times

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SPOTLIGHT: OH health system offers mental health svcs in EDs

Anne Zieger — Wed, 09 Jul 2008 13:49:46 -0400

As FierceHealthcare readers know, mental health patients waiting for care in emergency departments seldom get specialized care while they're waiting for psych evaluations. However, in an unusual move, one Ohio health system has received a grant to do just that. The hope is that such services will help patients stabilize or perhaps even avoid hospitalization. Article

Study: ED patients more satisfied if they know wait times

Anne Zieger — Tue, 17 Jun 2008 12:47:34 -0400

Making sure patients know as much as they can about their wait times is the best thing emergency departments can do to increase patient satisfaction--not managing their pain, or even answering other questions. That's the conclusion drawn by a recent Press Ganey survey of more than 1.5 million patients in more than 1,600 EDs. Press Ganey found that while satisfaction went down the longer patients waited, helpful, consistent communication with ED staff still made patients happier. Patients ranked "how well they were informed about delays" as their top factor in satisfaction, followed by control of pain, how much nurses cared about them and how well they were informed of treatment. Interestingly, total wait time ranked last. Patients who waited more than four hours to see a doctor, but felt well-informed about the delay, scored more than twice as high on overall satisfaction as those who waited just an hour but considered communication to be "very poor."

To learn more about the study:
- read this Washington Post article

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EMTALA flexibility proposed to relieve on-call MD shortages

Wed, 11 Jun 2008 06:59:58 -0400

In a new Medicare hospital payment rule released in late April, CMS included a proposal clarifying its on-call policies under EMTALA. If finalized, the proposal would let a group of hospitals in a region designate one of them as the on-call site for a specific time period or service, rather than each struggling to keep up on-call coverage. For example, two hospitals could agree that for half of the month, one hospital would be the official on-call facility, while the other would serve that role for the second half.

In making such a proposal, CMS hopes to address the steadily worsening problem hospitals face with finding adequate on-call coverage by specialists. In 2005, the most recent year for which survey data was available, 73 percent of ED directors reported to the American College of Emergency Physicians that they were having trouble making on-call arrangements.

Regardless of what arrangements they made, individual hospitals with emergency departments would still be required to do a standard medical screening exam and have a plan for how to proceed if an on-call physician wasn't available. CMS wouldn't give preapproval to plans, but would review each plan if EMTALA violations arose after those plans were put in place. (The lack of pre-approval seems to me like a glaring problem--everyone wants a safe harbor determination in place when weighty federal violations may be in the offing-but we'll see, I suppose.)

To learn more about the EMTALA plan:
- read this AMNews article

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Case study:Houston hires tele-nurses to boost 911 dispatch

Tue, 10 Jun 2008 06:59:55 -0400

Far too often, 911 operators are forced to dispatch ambulance crews who later find out that their services weren't really needed. Now, in an effort to cut down on such wasted calls, the Houston City Council has voted to hire tele-nurses to work with dispatchers. A minimum of two nurses will work around the clock, helping dispatchers give first-aid advice and suggestions on how to find a doctor for callers not experiencing true medical emergencies.

Over the next five years, the city will pay the non-profit Harris County Healthcare Alliance $6.8 million to find the nurses, who will be hired through subcontractor CareNet of San Antonio. The two entities will carry liability insurance offering protection of up to $3 million per claim to cover the exposure in assisting the 911 line.

Houston officials expect the program to save money as well as reducing the strain on local emergency departments. Right now, one 2006 study estimated that the city spends $50 million annually responding to non-emergency 911 calls.

To find out more about the program:
- read this Texas Healthflash item

A physician's perspective on why the ED model is stuck

Fri, 06 Jun 2008 06:59:59 -0400

As some you will recall, in a recent column I looked at the issue of how EDs handle patients with non-critical but acute illnesses. (I'd suggested that some form of step-down care, probably in the form of an on-site urgent care clinic, would make a lot of sense.)

However, when I ran my argument past a veteran emergency physician with decades of experience in California EDs, he told me a different story, one that made me sit back and think about whether my suggestion was practical, given the culture of the ED as it stands.

'Why,' I asked him, 'should acutely but not critically ill patients be booted to the curb, rather than cared for via a different track (as happens in some re-worked emergency departments)?'

Here's his reasons why you're not likely to integrate urgent care with ED care anytime soon:

* Culture: Emergency physicians choose the specialty and do the residencies to deal with emergencies.

* Process design: EDs, by and large, are not designed for anything but emergency evaluations.

* Health system stresses: The failure of primary and specialty care to meet demand; having that demand forced into the ED limits how flexible ED staffers can be.

* External pressures: The fact that most EDs and emergency physicians are pressured to produce at greater than 2-3 patients per hour makes it unlikely that that they could adjust to a partially urgent-care-based model. ("You can't do semi-elective workups with that degree of pressure," he notes.)

* Financial credential concerns: "We are profiled by insurers, and do not want to be the outlier" by investing extra resources in patients who aren't in serious trouble, he says.

* Managed care standards: "Length-of-stay and other ED metrics are driving the industry now--and a protracted workup in the ED skews the LOS and may make you an outlier," he says.

* Reimbursement models: Investing more resources in the less-critical patient can be particularly difficult if health plan incentives discourage it. "Where I'm at, with 95 percent capitation," there would be tremendous resistance to have "workups" occur in different cost silos," he notes.

It sounds to me as if integrating critical care and urgent care in the ED setting would be one hell of a challenge, at best. Still, with some hospitals managing to create separate tracks for the critically and acutely ill, it must be possible.

What do you think would need to happen to turn your emergency room into a system that had distinct workflows (other than basic triage) for sick patients versus mortally ill patients? Do you think it would even be a good idea to try and make this happen? Tell me what you think! - Anne

Case study: TX trauma hospital faces neurosurgery crisis

Fri, 09 May 2008 06:59:54 -0400

In a situation echoed in emergency departments around the country, the ED at Harris Methodist Fort Worth Hospital has been turning away patients with brain and spine injuries for months due to a shortage of neurosurgeons. Worse, the neurosurgeons who remain have been threatening to leave, tired of being overworked because of the shortage. Harris would like to recruit as many as five additional neurosurgeons, but national shortages have made this extremely difficult.

The hospital, a level 2 trauma center, has just four neurosurgeons available, covering every other day. Right now, ambulances must frequently take those with serious injuries to publicly-funded John Peter Smith, which is nearby. The neurosurgeons at JPS have seen their workload grow 84 percent, to 794 consultations last year. Meanwhile, the number of trauma patients admitted to Harris dropped 7 percent from 2006 to 2007.

To learn more about Harris' issues:
- read this Fort Worth Star-Telegram article

Related Article:
Trend: On-call shortage closing trauma departments

NYC will prep possible organ donors prior to consent

Thu, 08 May 2008 06:59:56 -0400

Here's a program bound to raise some hackles, despite the potential for helping patients waiting for donor organs. New York City has announced plans to dispatch the country's first ambulance designed to preserve the newly dead so that families have time to consider organ donations. What makes it controversial is that the crews would perform preservation procedures on the corpse without consent, just enough to keep it viable, until the family decided whether or not to give consent for organ removal/donation. The team wouldn't take any organs unless that consent was given.

The Rapid Organ Recovery Ambulance program, which has federal funding, was actually created because of complaints from families who were angry that the loved one couldn't donate as per his or her wishes, because they died outside of a hospital. In fact, about 22,000 people a year die from cardiac arrest outside of a hospital and aren't considered for organ donation. Emergency departments and transplant teams across the country are watching carefully to see how this scheme works out.

To learn more about the program (including what procedures are performed by the organ recovery team):

- read this USA Today article

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Trend: More free-standing EDs opening

Fri, 25 Apr 2008 06:59:56 -0400

In recent years, the number of freestanding emergency departments has grown dramatically, climbing 23 percent from 2005 to 2006, according to the American Hospital Association. These EDs treat many of the minor conditions typically addressed by urgent care centers, but unlike urgent care centers, are open 24/7. With 179 already in existence, and a dozen or more in the planning stages across the U.S., these independent EDs are an increasingly popular alternative to crowded EDs.

The question, critics say, is whether they're good for the health system as a whole. For one thing, they skim off such patients from medical practices and urgent care, both of which typically charge less. This could raise health system costs overall, analysts say. Also, patients who need additional help--such as surgery or cardiac procedures--still need to be rushed to traditional EDs, a delay which could prove to be harmful, some emergency care providers suggest.

To learn more about this trend:
- read this USA Today article

Related Articles:
Congress takes on ED overcrowding.
Case study: AZ hospital posts ED wait times on website.
EDs seeing more affluent patients, less uninsured.
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SPOTLIGHT: CA faces specialist flight from EDs

Fri, 25 Apr 2008 06:59:52 -0400

Specialists are becoming an increasingly precious commodity in emergency departments across the U.S. But even by national standards, things are particularly bad in California, whose Medi-Cal program has some of the lowest retention rates in the country. These low rates, combined with other forces giving specialists the ability to refuse on-call schedules, are creating a crisis in the state's EDs. Article