Friday, April 08, 2005

ER: Saftey net of US health care system

Due to EMTALA legislation, the ED has been set up as the safety net for the US healthcare system. The following list details various health care populations who fall into the ER safety net: 1. EMS ground/air 2. Uninsured 3. Patient dumping (other hospitals) 4. After hours 5. Nursing homes 6. Disaster response 7. Prisons/Jails 8. Clinic overflow 9. Homeless 10. Psychiatric Crisis 11. Access to medical specialists. 12. Hospital admission.

Since September 11th, Emergency Room overcrowding has taken on new significance. ERs operate as the safety net for the US health care system not only for the 44 million uninsured in the US, but also serve a major role in US disaster preparedness. As more US emergency departments (ED) continue to operate at critical census, not only has the quality of medical care provided in the ED slipped, but also when the next disaster or terrorist attack occurs, US ED’s may not be ready to respond.

ED overcrowding is caused by several factors. First, EMTALA legislation mandates that ERs see and treat any and all patients. No other physicians in the US have such a requirement to treat all patients who come in their doors. Additionally, with increases in the numbers of uninsured and decreases in federal and private reimbursement, ERs are losing money while treating more patients than ever before. In fact, US ED utilization rose by more than 14% from 1992 to 1999, increasing to over 100 million annual patient visits. Currently, 80% of ERs in the US are running at capacity.

Inadequate inpatient capacity is another factor, which contributes to ED overcrowding. The greatest impediment to ED patient outflow has been the lack of inpatient hospital beds for acutely ill patients. Although hospitals may physically have extra rooms and beds, because of a national nursing shortage and cuts in funding, hospitals lack nurses and support staff for those beds. Many metropolitan trauma centers routinely divert EMS patients to other hospitals for lack of ICU beds.

Another factor is the higher severity of illness. Because of the aging and worsening health of the US population, the number of critically ill patients presenting to California EDs from 1990 to 1999 increased by 59%. ED patients with multiple chronic health issues routinely require complicated and time-intensive workups before they are admitted. Additionally, this sharp rise in critical patients, coupled with a markedly decreased inpatient capacity, forces EDs to act as "pseudo-ICUs". Ill patients routinely board in the ED for as much as 24 hours or longer until admission.

Due to EMTALA legislation, the ED has been set up as the safety net for the US healthcare system. The following list details various health care populations who fall into the ER safety net: 1. EMS ground/air 2. Uninsured 3. Patient dumping (other hospitals) 4. After hours 5. Nursing homes 6. Disaster response 7. Prisons/Jails 8. Clinic overflow 9. Homeless 10. Psychiatric Crisis 11. Access to medical specialists. 12. Hospital admission.

A new study in the Annals of Emergency Medicine in January 2005 reports that 83.2% of patients visiting ED’s had a usual source of healthcare other than the ED, and were as likely as non-ED patients to have insurance. However, the study found that patients visiting the ED were more likely to be sicker and to have some disruption in their usual source of healthcare; for instance not being able to get an appointment to see their primary care physician.

So, what can be done to make a difference? This latest study published in Annals of Emergency medicine suggest that improvement in ED overcrowding may be achieved by developing strategies to improve delivery of outpatient care. I think every American has had difficulty at one time or another getting an appointment with their doctor. Most physician clinic schedules are filled 6 months into the future. Consequently, patient needing to see their physician that day or within 24 hours are routinely directed to ED. Strategies to rectify this are for physicians to leave room in their schedules for same-day appointments.

Another method would be to designate a different member of physician group each day to handle same-day appointments for the whole group. The designated physician may schedule half or full day to treat same-day appointments or even respond to pages from home depending on demand. Using this system, the same-day physician may not know the patient, but he will likely have access to that patient’s medical records and be able to consult with the patient’s personal physician. This is much better situation than what an ED physician will have.

It could be argued that if ED’s are required to see any patient that comes through the door, than physicians groups should be required to evaluate, treat, refer, and/or direct admit all their established patients who seek urgent same-day medical care.

In conclusion, strategies which help patients obtain health care from their usual source of care will help ED overcrowding. Also, increases in funding and support for nursing and support staffing in the hospitals will make more beds available for critically ill patients who are often required to board in the ED. Less overcrowding ED overcrowding will likely improve patient care, decrease medical mistakes, decrease racial/ethnic disparities in care, and assure that ED’s will be ready to respond to any future disasters or emergencies.

1. S Trzeciak and E P Rivers. Emergency department overcrowding in the United States: an emerging threat to patient safety and public health. Emerg Med J 2003; 20:402-405

2. J Weber, J Showstack, K Hunt, D Colby, and M Callaham. Does lack of a usual source of care or health insurance increase the likelihood of an emergency department visit? Results of a national population-based study. Annals of Emg Med 2005; 1: 4-12.

1 comment:

BRoz said...

Since September 11th, Emergency Room overcrowding has taken on new significance. ERs operate as the safety net for the US health care system not only for the 44 million uninsured in the US, but also serve a major role in US disaster preparedness. As more US emergency departments (ED) continue to operate at critical census, not only has the quality of medical care provided in the ED slipped, but also when the next disaster or terrorist attack occurs, US ED’s may not be ready to respond.

ED overcrowding is caused by several factors. First, EMTALA legislation mandates that ERs see and treat any and all patients. No other physicians in the US have such a requirement to treat all patients who come in their doors. Additionally, with increases in the numbers of uninsured and decreases in federal and private reimbursement, ERs are losing money while treating more patients than ever before. In fact, US ED utilization rose by more than 14% from 1992 to 1999, increasing to over 100 million annual patient visits. Currently, 80% of ERs in the US are running at capacity.

Inadequate inpatient capacity is another factor, which contributes to ED overcrowding. The greatest impediment to ED patient outflow has been the lack of inpatient hospital beds for acutely ill patients. Although hospitals may physically have extra rooms and beds, because of a national nursing shortage and cuts in funding, hospitals lack nurses and support staff for those beds. Many metropolitan trauma centers routinely divert EMS patients to other hospitals for lack of ICU beds.

Another factor is the higher severity of illness. Because of the aging and worsening health of the US population, the number of critically ill patients presenting to California EDs from 1990 to 1999 increased by 59%. ED patients with multiple chronic health issues routinely require complicated and time-intensive workups before they are admitted. Additionally, this sharp rise in critical patients, coupled with a markedly decreased inpatient capacity, forces EDs to act as "pseudo-ICUs". Ill patients routinely board in the ED for as much as 24 hours or longer until admission.

Due to EMTALA legislation, the ED has been set up as the safety net for the US healthcare system. The following list details various health care populations who fall into the ER safety net: 1. EMS ground/air 2. Uninsured 3. Patient dumping (other hospitals) 4. After hours 5. Nursing homes 6. Disaster response 7. Prisons/Jails 8. Clinic overflow 9. Homeless 10. Psychiatric Crisis 11. Access to medical specialists. 12. Hospital admission.

A new study in the Annals of Emergency Medicine in January 2005 reports that 83.2% of patients visiting ED’s had a usual source of healthcare other than the ED, and were as likely as non-ED patients to have insurance. However, the study found that patients visiting the ED were more likely to be sicker and to have some disruption in their usual source of healthcare; for instance not being able to get an appointment to see their primary care physician.

So, what can be done to make a difference? This latest study published in Annals of Emergency medicine suggest that improvement in ED overcrowding may be achieved by developing strategies to improve delivery of outpatient care. I think every American has had difficulty at one time or another getting an appointment with their doctor. Most physician clinic schedules are filled 6 months into the future. Consequently, patient needing to see their physician that day or within 24 hours are routinely directed to ED. Strategies to rectify this are for physicians to leave room in their schedules for same-day appointments.

Another method would be to designate a different member of physician group each day to handle same-day appointments for the whole group. The designated physician may schedule half or full day to treat same-day appointments or even respond to pages from home depending on demand. Using this system, the same-day physician may not know the patient, but he will likely have access to that patient’s medical records and be able to consult with the patient’s personal physician. This is much better situation than what an ED physician will have.

It could be argued that if ED’s are required to see any patient that comes through the door, than physicians groups should be required to evaluate, treat, refer, and/or direct admit all their established patients who seek urgent same-day medical care.

In conclusion, strategies which help patients obtain health care from their usual source of care will help ED overcrowding. Also, increases in funding and support for nursing and support staffing in the hospitals will make more beds available for critically ill patients who are often required to board in the ED. Less overcrowding ED overcrowding will likely improve patient care, decrease medical mistakes, decrease racial/ethnic disparities in care, and assure that ED’s will be ready to respond to any future disasters or emergencies.

1. S Trzeciak and E P Rivers. Emergency department overcrowding in the United States: an emerging threat to patient safety and public health. Emerg Med J 2003; 20:402-405

2. J Weber, J Showstack, K Hunt, D Colby, and M Callaham. Does lack of a usual source of care or health insurance increase the likelihood of an emergency department visit? Results of a national population-based study. Annals of Emg Med 2005; 1: 4-12.