Seven secrets of the emergency room, Medicare, and much more.

From time to time, this blog pauses to look at some of the healthcare and emergency medicine issues buzzing around the web. The past few days have offered some interesting topics to chew on.

We'll start with this breaking news: The Senate voted 62-36 Wednesday to approve a $138 billion bill that would temporarily prevent Medicare payment cuts to doctors as well as extend federal Medicaid assistance and COBRA premium subsidies.

"This week's bill helps those who have been hit the hardest. Among other things, we're going to extend unemployment benefits to those looking for work, cut taxes for families and businesses, and protect Medicaid so low-income families can afford healthcare," Senate Majority Leader Harry Reid (D-Nev.) said in a written statement. The bill now heads back to the House. You can visit modernphysician.com to read the entire story.

And now onto the healthcare reform debate...

President Obama took to the road this week to make the case for a health-care overhaul that still awaits an uncertain fate in Congress. This story originally published in the Washington Post, outlines the White House's strategy of using health insurance company rate increases to rekindle the fire for reform.

If you're wondering what the president is saying out there, you can read excerpts of Mr. Obama's speech, as well as view a brief video here.

And of course in politics, every action has a reaction. To counter the White House's health care efforts, hundreds of business groups have launched a multimillion-dollar ad campaign designed to stop health care legislation and fire back at the president's efforts to win support for a plan Obama says would expand insurance coverage to 31 million people.

On another topic, it's been just about a year since H1N1 arrived in the U.S.  A story in today's Health Leaders Media, "One Year Later: What Have We Learned From H1N1?" does a good job of accessing how our healthcare system responded to the frenzy - and poses the question as to whether our country is prepared for the next pandemic. 

We're all getting older. And now it appears more hospitals across the country are expecting to offer geriatric emergency departments as the nation's 76 million baby boomers reach their senior years. These sites are staffed by doctors and nurses with geriatrics training care. But will they remain viable with Medicare cuts to physician payments, or will hospitals use them to draw in patients for more profitable procedures? St. Joseph's Regional Medical Center in Paterson New Jersey has become one of the first hospitals in the nation to open a geriatric emergency department. It seems to be working well - you can read about it here.

If you work in emergency medicine, you know the ins and outs of life in the ER. The New York Times has posted an interesting article on the "seven secrets of the emergency room".  Perhaps you recognize them - or maybe you have some secrets of your own you'd like to share??

Have a comment?  Please feel free to share!

Does Patient Centered Care add to ER Overcrowding?

By Prentice Tom, MD

In a recent issue of Health Affairs, (28, 4, 2009: w555-w565), Dr. Don Berwick makes an argument for Patient Centered Care, where physicians rely on patients to make informed decisions regarding diagnosis and treatment plans.  He states:

"Evidence-based medicine sometimes must take a back seat. First, leaving choice ultimately up to the patient and family means that evidence-based medicine may sometimes take a back seat. Should patient ‘wants' override professional judgment about whether an MRI is needed?  My answer is, basically, ‘Yes.'  On the whole, I prefer that we take the risk of overuse along with the burden of giving real meaning to the phrase ‘a fully informed patient.'"

I agree with the concept that it is critically important to have patients involved in their care and be part of the decision making process. And as physicians, we need to strongly encourage patients to take an active role in their health maintenance and disease management.  Over the last twenty plus years of practice, I have found that by informing and educating patients and their families regarding their medical condition, diagnostic and treatment options, and by seeking their input regarding their health goals and their expectations, I am much better able to serve and care for my patients.

Still, there are times - especially in the emergency department - when this approach may not be in the patient's best interest, nor the best interests of overall patient care.  Unfortunately, in the emergency department, where time and resources may be severely limited, the emergency physician may be required to provide care in a manner that most efficiently utilizes resources and maximizes patient outcome, even though the patient may want a test that is not necessary for treatment or the physician may not have had the opportunity to fully explain his/her decision.

In a physician's office, clinic, or in-patient ward, care that's truly patient-centered considers patients' cultural traditions, personal preferences and values, family situations, and lifestyles.  But in the emergency department where beds are scarce, resources are limited and the patient has no prior relationship with the physician, we need to balance patient education and demand for limited resources with overall patient flow, and the type of patient-centered care that Dr. Berwick describes may not be the best solution.

It is likely that every emergency physician can recall seeing a patient similar to the one that Dr. Berwick describes:  Doctor, I have a headache, and I want an MRI.  Access to an MRI can take multiple hours in a busy hospital, and even explaining why we can't offer such testing can take many minutes.  In principle, I agree with Dr. Berwick.   But in a system where the patient may not bear any financial responsibility, and where resources and time are limited, Such a practice may not always be in the best interests of overall patient care.  I only wished I lived in a world where emergency physicians had the time and resource availability to provide patient centered care to all our patients.

I would appreciate your thoughts or experiences with Patient Centered Care in the emergency department.

 

Why emergency physicians make great leaders outside the ER

By Wesley A. Curry, MD

A crucible is defined as a vessel made of material which does not melt easily, and is used for high temperature chemical reactions.  It's an easy analogy to make the case that the ER has served as a crucible to forge many emergency physicians into outstanding leaders and managers outside the emergency department.

The numbers of emergency physicians in top healthcare positions in hospital administration, medical group management, medical insurance companies-even politics, continues to expand.

In a recent article published by ACEP on physician leadership, an excellent case was made for future areas of emergency physician involvement in hospital and healthcare system leadership. It inspired me to think about why I believe many emergency physicians have the potential to become great leaders.

Warren Bennis, our modern guru of leadership has stated; "Leaders do the right thing, and managers do things right". The best leaders in any field have a strong sense of what, when, and how to do the right thing, often with  less than perfect information and limited resources -- and under time constraints.  These attributes sound a lot like a highly proficient and compassionate emergency physician who cares for many sick or injured patients daily, while providing quality medical care.

I know firsthand what it's like to go from "pit doc" to an executive office.  I was transformed by my clinical practice, which I still maintain today. The many "lessons learned" from this experience continue to influence my leadership style. I am now the CEO of one of the largest physician partnerships in the country. As a younger physician, I never imagined I would now influence and lead a large number of healthcare providers who treat millions of patients each year in seven states.

Not every emergency physician is destined to be a leader, especially outside the emergency room. But I expect the trend of healthcare leaders and managers being recruited from the ranks of emergency physicians in practice today, will only accelerate in the future. The crucible that is the ER will continue to produce new healthcare leaders able to use their skills to inspire others to "do the right thing" for our patients as well as our healthcare providers. More emergency physicians in leadership positions outside the ER will only improve healthcare long term for everyone.  

I look forward to your comments.

Attention emergency physicians: How about 8 hour shifts?

By Imamu Tomlinson, MD, Dan Culhane, MD, John Ruffner

It's been suggested that the best emergency physician work schedule is 24 one-hour shifts per month. If pigs could fly! It seems the 12 hour shift is the most popular, but is it the best?  (It came from emergency medicine's operating needs, and had little to do with patient considerations).

More relevant discussions center around ER shift lengths of 7 to 12 hours. After numerous discussions with colleagues about shift length, we asked: "What's wrong with 8 hour shifts?" The following are the findings of some of the key components of this discussion:  

Scheduling  Shorter shifts create more flexibility in drawing up the schedule (covering open days) and allows for better matching of provider hours to patient volume throughout the day. Shorter shifts also mean a provider will work more days in a month.

Productivity  Many emergency physicians have described their experiences of substantial productivity drop-off in the last two hours of a 12-hour shift as they anticipated the arrival of the shift change. One comment seems to capture this dynamic: "With an 8-hour shift, it seems like a new provider is coming on just as productivity starts to drop." Another common response was: "It makes it easier to stay an extra hour when needed."

Clinical Decision Making Many colleagues expressed a concern about the quality of clinical decision making over 12-hour shifts. There really isn't conclusive data on this element, but there is a risk associated with the increased number of ‘hand offs' associated with more scheduled shifts. 

Quality of Life  Numerous colleagues provided their experience with shorter shifts, many of whom saw themselves as 12-hour providers - that's just who they were. 

Here are some comments of those who converted to 8 hours shifts:

"Having 8-hour shifts is like having a real life."

"I don't feel that I'm working as hard."

"I don't know of any site that has converted to shorter shifts that has gone back to 12's."

"The nursing staff and our mid levels tell us it feels like they have more help."

"Working more days but on the days I work, I can get stuff done."

"I saw 35 patients on one of our 7-hour shifts and feel productivity is enhanced."

"Shorter shifts changed my life."

"As I get older, the short shift really works for me"

"I sure haven't seen any negative impact on patient care."

We'd love to hear your thoughts on emergency physician shifts. What about 8 hours?

Patient faking seizure in the ER and how to handle.

By Joel A. Stettner, MD

If you've worked the emergency room for any length of time, you've likely heard some pretty creative stories from people trying to illegally obtain a controlled substance.

This rather humorous video of a patient faking a seizure in the emergency room is making the rounds on YouTube and has created quite a buzz on the internet. While it's meant to be funny - and certainly exaggerates - a lot of the dialog hits pretty close to home.

My community hospital has its share of folks who seem to be seeking drugs; they can be pretty creative, both in terms of how they present and how they identify themselves. After a lot of thought and discussion, we created a "Treatment Plan" approach to help deal with these individuals.

Once they have been identified, and their medical history reviewed, each is sent a registered letter clearly identifying our assessment of the problem and our plan to deal with it during future visits. Where possible, any outside PMD and/or clinic used by the patient is involved in plan development, and incorporated into the specific steps we will follow. The letters, which outline each specific plan, are maintained in a binder for easy ED MD access; we are trying to add a flag to our ADT system as well (not so easy).  There are now well over one hundred such letters.

Having the physician reference the letter and Treatment Plan during the patient's visit has been very helpful in controlling this problem. We of course do not deny an MSE, nor do we absolutely refuse narcotics, etc. in the face of obvious need. But over time, the number of inappropriate visits and demands has dropped off.

This arrangement works for us, but I would be interested to know what types of procedures you use in your emergency department to combat this problem.

Bad news for emergency medicine in New York

By Marty Ogle, MD

If there were any doubts that our healthcare system is broken, the news from New York City regarding the closure of venerable St. Vincent's hospital should make it clear.

This isn't a community clinic we're talking about. For more than 150 years, St. Vincent's has treated victims of calamities including the cholera epidemic of 1849, the sinking of the Titanic in 1912, the 9/11 attack and, just last year, the Hudson River landing of US Airways flight 1549.

As the article states, a chain of hospitals has offered to take over St Vincent's, shut down its inpatient beds and most of its emergency room services, and convert it into an outpatient center tied to hospitals uptown and on the East Side. A day after the proposal was given, members of the Sisters of Charity, the order of nuns that founded the hospital in 1849, gathered for a noon Mass at St. Vincent's chapel and declared that they would continue to serve the community, including the poor.

Yet it seems this calling is why the hospital has become obsolete. Other hospitals emphasize high-tech care and rush to invest in fancy equipment and celebrity doctors that attract patients with the means to pay. Meanwhile, St. Vincent 's simply sticks to its motto of "compassionate care."

Cash-wise, St. Vincent's has few places left to turn. With low hopes of finding more money, its emergency room is now barely open, and has told the fire department to start rerouting ambulances to other facilities.

It's astounding that a hospital that's served its community for over 150 years -- that continued until the end to provide compassionate care to the most needy -- just doesn't seem to be what the special interests have in mind. And if you're thinking that somehow healthcare reform will save the day, there's a nearby bridge I'd like to sell to you.This is another example of how our healthcare system has let the public down. Instead, the system moves away from those in need and marches lockstep with what the special interests want. As emergency physicians, we have the duty to ensure that we don't forfeit our integrity and control to those who see "healthcare" as nothing more than a revenue stream. Advocacy is the only way our voices will be heard, so don't be afraid to speak out! Before the next St. Vincent's happens.

I look forward to your comments. 

The importance of emergency medical personnel in Haiti.

Emergency physicians and nurses are typically used to being in extremely stressful situations.

But when an emergency medical team from Selma hospital in Fresno, California landed in Port-au-Prince Haiti following the catastrophic earthquake, they weren't quite ready for what they experienced.

The team, made up of three nurses, one emergency physician (the assistant Medical Director for the Selma emergency department) and a former army medic were captured on film and recently shown on local station KFSN-TV in Fresno.  

This story is an excellent illustration of the dedication to patient well being and selflessness in the face of daunting circumstances that so many in the emergency medicine - and medical field in general - exhibit daily.

Heroic stories are starting to come out of Haiti - this is one certainly worth watching.

Are you a physician, or a businessperson? You need to be both!

By Mike Harrington, CEO MedAmerica, Inc.

"If I wanted to go into business, I would've gone to business school." I've heard this uttered more than once by emergency physicians and doctors in general over the years.

Physicians enter the medical profession to practice medicine, and most are not trained, or have the inclination, to run a business. But the fact is, sooner or later doctors find themselves in a position where the pressure to achieve financial results becomes as important as how they practice medicine.  Those physician groups or physicians who don't - or won't - pay close attention to their financial bottom line do so at their own peril. If physicians don't perform their due diligence - or have someone perform it on their behalf -no one will!

With more than 30 years of experience in the medical practice support and strategic consulting business, I see the daily challenges that physician groups and physicians must overcome to be successful on the business side. Many - if not the majority - of physicians are not trained to run a business or focus on business metrics.

But the doctor who knows how to properly and accurately bill for his or her time will generate more revenue, and provide more value to the overall practice.  And if you're an emergency physician who thinks you don't need to know about business, it's just not true.

The bottom line is there's a lot that goes into running a successful physician group or practice.  Physicians need to spend quality time with their patients, instead of feeling the need to squeeze in appointments or hurry through treatments.  Having a firm grasp on the business side of the practice allows physicians to do just that.

So what's the best way to balance superb patient care with the time and skills needed to run a viable practice? Don't count on healthcare reform.  Based on the successful physician groups and practices I've seen and worked with, it's a challenge that's certainly attainable.

More to come.

 

Updates in healthcare and emergency medicine.

Welcome to the first week of February - where did January go? A lot is on the plate for emergency medicine and healthcare in general as the year progresses, and this blog will attempt to highlight some of the news that will likely affect ED physicians and NPs in the coming days and weeks.

We'll start with that old war horse, healthcare reform. As of this writing, broad healthcare reform has stalled. With one less Senate seat, Democratic leaders are still considering their options - here's where we are at the moment.  

Speaking of the government, President Obama's new budget is due out today, and there are several areas of interest re: healthcare, including a possible added $25 billion in Medicaid funding for states.  Read what's being reported about the President's budget and healthcare spending.

Medicare payments to doctors were supposed to fall by 21% at the start of this year, but Congress passed a last-minute, two-month fix to block the cuts. Now, a five-year fix could be on the way. Here's where it all stands with the clock ticking.

An article in Emergency Medical News makes the case that emergency Residents are not being trained to function properly in the real world. The 154 emergency medicine residencies in this country provide training in very large teaching hospitals with a focus on tertiary care. Residents training in large urban centers typically see more than 200 patients a day and have access to all subspecialty care. Given that only 5% of graduating emergency medicine Residents will actually practice in such situations, do training procedures need to be changed?

And finally, the Apple iPad was unveiled last week. Right behind it came an article that outlined the 10 ways the iPad can help doctors improve patient care. The current first generation Apple iPad probably won't run a robust electronic health record (EHR), but there are ways physicians and RNs could leverage the iPad right away - some of which may surprise you.

You comments are welcome.

 

  

 

No waiting! Time to optimize your emergency department’s efficiency.

By Bonnie Carl, MBA, RN

As the demand for emergency services grows, resources in emergency medicine are being stretched.  No surprise, but what's being done about longer ER wait times, overcrowding, ambulance diversion, increased patient suffering and poor morale?

One approach that I'm involved with - and is getting real results in hospitals in California, Arizona, Oregon, Washington, Texas, Georgia and Illinois - is our process known as Rapid Medical Evaluation® (RME). First implemented in 2002, RME is considered a best practice at more than 30 facilities.

RME places one or more providers - physician, nurse practitioner or physician assistant - in triage to perform initial medical screening examinations and either order additional testing or treat and release the patient without ever taking up a bed on the unit. The whole focus of RME is how quickly a provider sees a patient and begins a workup. It's also about how you use space and how patients will flow.

The idea is for patients to be seen in an area of the ED appropriate for their condition. Not every patient in the ED needs to lie down, so if they don't, they might not need a bed. With a triage nurse and a provider working together up front, there can be parallel processing. The patient can then be moved to the internal waiting area. Now the waiting time is productive - it's time spent waiting for results instead of waiting for the next thing to happen.

Having the right people up front managing the process and patients is another important part of RME. Just as some nurses are good at triage and others are not, you really need someone who is good at multitasking, anticipating the needs of the providers and keeping things flowing.

Speaking of flowing - our goal for time to provider is less than 30 minutes, turnaround time for discharge patients of no more than 2 hours, lab and imaging to be less than 30 minutes and the left-without-being-seen rate to be less than 2 percent. And you know what, we're doing it.

At Mercy Medical Center Redding (CA), for example, we saw the door to provider time decrease from more than 40 minutes to just nine minutes within the first month of implementation, and ED patients who left without being seen dropped from 3% earlier that month to .2% - a big boon to hospital revenue.

In my experience, RME works. And thanks to everyone including physicians, nurses, lab, imaging, and registration being on the same page, it will continue to work.

I look forward to your comments!