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Friday, October 21, 2005
Thursday, October 20, 2005
Wednesday, July 20, 2005
Clinic Inaccessibility leads to ED Overcrowding
Ann Emerg Med. 2005 Jan;45(1):4-12.
Ellen J. Weber, MD in January 2005 Annals of Emergency Medicine found that ED users are similar to nonusers with regard to health insurance and usual source of care but are more likely to be in poor health and have experienced disruptions in regular care. [Suggesting that] the success of efforts to decrease ED use may depend on improving delivery of outpatient care.
In other words, there are no more uninsured patients in the ED than anywhere else in the hosptial or medical clinics. A more important factor in ED overcrowding is that many ED patients go the ED because they cannot get an appointment to see their primary care physician.
Some medical practice groups assign someone to be on-call at all times or to evaluate and treat same-day appointments for the entire group. Patients with urgent concerns or problems can then be seen immediately by someone who has access to their medical records, recieve prompt treatment, or be directly admitted to the hospital never having to set foot in an ED.
Ellen J. Weber, MD in January 2005 Annals of Emergency Medicine found that ED users are similar to nonusers with regard to health insurance and usual source of care but are more likely to be in poor health and have experienced disruptions in regular care. [Suggesting that] the success of efforts to decrease ED use may depend on improving delivery of outpatient care.
In other words, there are no more uninsured patients in the ED than anywhere else in the hosptial or medical clinics. A more important factor in ED overcrowding is that many ED patients go the ED because they cannot get an appointment to see their primary care physician.
Some medical practice groups assign someone to be on-call at all times or to evaluate and treat same-day appointments for the entire group. Patients with urgent concerns or problems can then be seen immediately by someone who has access to their medical records, recieve prompt treatment, or be directly admitted to the hospital never having to set foot in an ED.
Friday, April 08, 2005
Should we be talking about ethics?
Is there such thing as right and wrong? This question is at the heart of philosophy and ethics. Ethics is just one of many branches of philosophy. The main branches of philosophy include: Metaphysics (the study of existence and reality), Epistemology (the study of knowledge and knowing), Ethics (the study of proper action), Politics (the study of proper force), Esthetics (the study of art), and Logic (the study of reasoning and argumentation). All branches of philosophy deal with the issue of right and wrong in different ways. Ethics is the formal study of moral standards and conduct. Ethics asks the questions: what is good? What is evil? How should I behave and why? How should I balance my needs against the needs of others? Ethics, like all branches of philosophy, assumes that right and wrong exits. However, it is the defining of right and wrong, good and bad which ethical philosophy focuses.
Is there such thing as right and wrong? This question is at the heart of philosophy and ethics. Ethics is just one of many branches of philosophy. The main branches of philosophy include: Metaphysics (the study of existence and reality), Epistemology (the study of knowledge and knowing), Ethics (the study of proper action), Politics (the study of proper force), Esthetics (the study of art), and Logic (the study of reasoning and argumentation). All branches of philosophy deal with the issue of right and wrong in different ways. Ethics is the formal study of moral standards and conduct. Ethics asks the questions: what is good? What is evil? How should I behave and why? How should I balance my needs against the needs of others? Ethics, like all branches of philosophy, assumes that right and wrong exits. However, it is the defining of right and wrong, good and bad which ethical philosophy focuses.
Ethics can be divided into metaethics and normative ethics. Metaethics is the investigation of the nature of ethical statements. It questions what does "good" and "right" mean, and how we know what is right. Normative ethics, on the other hand, attempts to arrive at practical moral standards that tell us right from wrong, and how to live moral lives. Normative ethics can be divided into the theory of conduct, which addresses standards of morality, or moral codes or rules and theory of value, which addressed how things are deemed to be valuable.
Most ethical arguments fall into several categories. Deontological arguments are based on generalizable statements, rules, or codes; such as, “thou shalt not kill.” A famous deontologic argument asks, “what if everyone did it?” Conversely, utilitarian arguments are outcome-based. This argument asks, “will the outcome of the decision produce the greatest good for the greatest number?” Utilitarian arguments are also referred to as being consequentialist. Other ethical theories include: communitarianism, which focuses on the interests and values of the community, and principle-based theories, which are not absolute or hierarchical. Principle-based theories are based on a set of guidelines where individual guidelines may assume a greater or lesser priority depending on the situation.
A famous example of a principle-based theory is the “Georgetown mantra” by Tom Beauchamp and James Childress (Principles of Biomedical Ethics), which establishes that the following principles of beneficence, non-maleficence, autonomy, and justice should be considered in all ethical decisions. Autonomy requires respect for people’s decisions and values. Beneficence addresses the need to help people. Non-maleficence recognizes the maxim to “first do no harm.” Justice requires that all like cases be treated alike; and benefits and burdens be distributed fairly.
So, why do we need to talk about ethics in medicine? The reason is because ethically difficult decisions arise in medicine everyday where it is not clear what is the best, or right thing to do. Inevitably, there will be differences of opinion, which can result in conflict. Sometimes that conflict cannot be resolved by those involves and requires mediation by a 3rd-party. Some highly publicized cases go to the state or federal courts to be decided. However, state or federal judges are not the best persons to make medical ethics determinations. The United States constitution expects that individuals and institutions regulate themselves. Therefore, hospitals have formed ethics committees to resolve issues as they arise. This way, those involved resolve the conflict and outside courts are not needed. “Self-government” is an ethical principle in which this country was established.
The teaching and discussion of ethics and ethical theories gives doctors tools they can use to recognize and analyze ethical issues as they arise. This approach also provides tools for physicians to use in their practice and prevent conflict over ethical issues. Therefore, we should continue to teach, discuss, and learn about ethical theory because from a deontological viewpoint, “it’s the right thing to do” while from a utilitarian argument, “it’s working.”
Is there such thing as right and wrong? This question is at the heart of philosophy and ethics. Ethics is just one of many branches of philosophy. The main branches of philosophy include: Metaphysics (the study of existence and reality), Epistemology (the study of knowledge and knowing), Ethics (the study of proper action), Politics (the study of proper force), Esthetics (the study of art), and Logic (the study of reasoning and argumentation). All branches of philosophy deal with the issue of right and wrong in different ways. Ethics is the formal study of moral standards and conduct. Ethics asks the questions: what is good? What is evil? How should I behave and why? How should I balance my needs against the needs of others? Ethics, like all branches of philosophy, assumes that right and wrong exits. However, it is the defining of right and wrong, good and bad which ethical philosophy focuses.
Ethics can be divided into metaethics and normative ethics. Metaethics is the investigation of the nature of ethical statements. It questions what does "good" and "right" mean, and how we know what is right. Normative ethics, on the other hand, attempts to arrive at practical moral standards that tell us right from wrong, and how to live moral lives. Normative ethics can be divided into the theory of conduct, which addresses standards of morality, or moral codes or rules and theory of value, which addressed how things are deemed to be valuable.
Most ethical arguments fall into several categories. Deontological arguments are based on generalizable statements, rules, or codes; such as, “thou shalt not kill.” A famous deontologic argument asks, “what if everyone did it?” Conversely, utilitarian arguments are outcome-based. This argument asks, “will the outcome of the decision produce the greatest good for the greatest number?” Utilitarian arguments are also referred to as being consequentialist. Other ethical theories include: communitarianism, which focuses on the interests and values of the community, and principle-based theories, which are not absolute or hierarchical. Principle-based theories are based on a set of guidelines where individual guidelines may assume a greater or lesser priority depending on the situation.
A famous example of a principle-based theory is the “Georgetown mantra” by Tom Beauchamp and James Childress (Principles of Biomedical Ethics), which establishes that the following principles of beneficence, non-maleficence, autonomy, and justice should be considered in all ethical decisions. Autonomy requires respect for people’s decisions and values. Beneficence addresses the need to help people. Non-maleficence recognizes the maxim to “first do no harm.” Justice requires that all like cases be treated alike; and benefits and burdens be distributed fairly.
So, why do we need to talk about ethics in medicine? The reason is because ethically difficult decisions arise in medicine everyday where it is not clear what is the best, or right thing to do. Inevitably, there will be differences of opinion, which can result in conflict. Sometimes that conflict cannot be resolved by those involves and requires mediation by a 3rd-party. Some highly publicized cases go to the state or federal courts to be decided. However, state or federal judges are not the best persons to make medical ethics determinations. The United States constitution expects that individuals and institutions regulate themselves. Therefore, hospitals have formed ethics committees to resolve issues as they arise. This way, those involved resolve the conflict and outside courts are not needed. “Self-government” is an ethical principle in which this country was established.
The teaching and discussion of ethics and ethical theories gives doctors tools they can use to recognize and analyze ethical issues as they arise. This approach also provides tools for physicians to use in their practice and prevent conflict over ethical issues. Therefore, we should continue to teach, discuss, and learn about ethical theory because from a deontological viewpoint, “it’s the right thing to do” while from a utilitarian argument, “it’s working.”
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.
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.
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