Posted by CEP America on Wed, Feb 17, 2010 @ 11:43 AM
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.
Posted by Guest Blogger on Thu, Dec 03, 2009 @ 04:55 PM
By Ellis Weeker MD.
As an Emergency Physician, I'm always looking for interesting articles about my profession. Recently, I came upon a study published by the California Healthcare Foundation. It raises the question about California's hospital-based ED system - and whether it's keeping up with the increased pressures placed upon it. For those of us in emergency medicine, I think its great food for thought.
For the complete study, click on the link:
Is California's Hospital-Based ED System Eroding?
The study states that worsening severity of illness may be a greater factor in ED overcrowding than the growing volume of patients. My thoughts regarding their assertions include:
The supply of California ED beds grew by 17% between 2001 and 2007, while population rose 6% and ED visits increased 2%.
The supply of beds in CA EDs has risen to accommodate the increased need of an aging population as well as the increased and unmet needs for urgent and primary care. Seniors require more procedures and our system currently rewards utilization, in particular procedures. So this is not a surprise. For many hospitals, increased ED beds mean more revenue for inpatients as well as outpatients. An increase of 17% in the supply of CA ED beds can be easily explained.
A higher proportion of ED patients are more severely ill, and a greater share of visits results in hospital admission.
The higher number of critically ill and older patients greatly impacts the efficiency of an ED. More testing and therapy are required. Even after a diagnosis is made, it takes longer to admit these patients. The average percent of patients admitted to hospitals from their EDs is now 51%. So that's another reason for more ED beds.
The numbers of ED visits considered non-emergency have increased.
Lack of urgent and primary care availability to underinsured patients remains a stressor for all EDs. While non-emergency visits have increased, many insured patients have also begun to use EDs as urgent care centers.
The study reports a large variance in the percentages of increased ED visits, hospital closings and construction throughout the state. This is because our system has little or no central planning and largely responds to the local circumstances of an area, i.e. the affluence of the patients. Hospitals and their EDs close where there's poor reimbursement for patients. New hospitals and EDs are built where there's money to support them.
As always, I welcome your comments.
Posted by Guest Blogger on Thu, Dec 03, 2009 @ 11:26 AM
By David Englander, M.D.
I wanted to add my two cents to Dr. Borger's blog in the ER Forum on Tuesday re: potential funding losses to emergency health care by the Feds.
In California alone, more than 70 hospitals have closed in the past ten years due to financial pressures, even though demand for emergency care has dramatically increased.
Our state actually had the lowest national ranking (51st) in access to Emergency Care and received very low grades in other categories of the ACEP National Report Card on the State Of Emergency Medicine.
In 2003, both Democrats and Republicans came together and passed the Medicare Modernization Act (Section 1011), which included federal funding for mandated emergency care - $250 million per year to help hospitals and providers recoup a portion of the costs they incur for providing emergency medical care to patients who cannot pay their bills. This federal reimbursement has been particularly helpful to participating hospitals and providers in border states like California that are disproportionately burdened with providing care to undocumented immigrants. Unfortunately, this funding was temporary and recently expired.
Hospitals and emergency care providers should not be responsible for absorbing the costs of health care for undocumented immigrants. The federal government should bear this responsibility, as it is responsible for securing our borders.
As noted, last year the campaign to extend Section 1011 had bi-partisan support, evidenced in a May 2008 letter to legislative leaders endorsing a two-year extension of the provision under 15 signatures, including those of Barack Obama and John McCain. But that support has been supplanted by other issues.
Extending Section 1011 funding is an important issue that needs to be addressed before it "falls through the cracks". With increased overcrowding, state budget cuts (especially in California) and likely facility closures, it's impossible to believe that quality care will be there if another source of funding for hospitals and providers is withdrawn. Our legislators need to know that this is an important issue involving a wide range of people.
To read the complete article on the topic, visit http://tinyurl.com/moos4n. For insights into ways to reach your representatives, please read a very helpful blog re: Advocacy by Carlos Medina MD. Simply click on this link: http://www.cepamericablog.com/2009/08/be-an-advocate-get-to-know-your-legislators/
I look forward to your support and to seeing any comments you may have.
Posted by Guest Blogger on Wed, Dec 02, 2009 @ 06:27 PM
By Mark Spiro, M.D.
As an emergency physician who lives and works in California, I've been watching the never-ending budget stalemate with trepidation. Now that the plan is complete and the dust is starting to settle, it's clear that health care services will be taking a hit.
The New York Times reports that Democrats largely rejected the governor's initial plans to eliminate social safety net programs such as Healthy Families and the Children's Health Insurance Program. However, yesterday's budget plan still includes substantial funding cuts for health services. Under the agreement, the state would cut funding for Healthy Families by $144 million, which would place many eligible children on a waiting list. Capitol Weekly reports that total funding for the program would drop by $226 million.
According to Capital Notes, legislators also agreed to cut $1.3 billion in spending from Medi-Cal, California's Medicaid program. In addition, the state's In-Home Supportive Services program stands to lose millions in state funding under the budget plan. Under the budget plan, HIV/AIDS programs also would lose a significant portion of their funding, says the San Francisco Chronicle.
It's still unclear what these cuts will mean to hospitals and health care providers on a day to day basis, but I think it's obvious that we're going to be in for an uncertain - and sometimes - wild ride.