Beds vs. chairs: what's the answer in the emergency department?

By John Ruffner

As an emergency physician or nurse practitioner, have you ever noticed how difficult it is to get a patient out of a bed in the ER?

On a recent tour of a soon to be opened new emergency department, several RN’s commented that the triage rooms were not big enough to accommodate a bed. All this is reflective of the conventional wisdom and culture that exists in our emergency rooms, and as such deserves examination as a continuous improvement effort.

Those comments raise the larger question: how many patients really need a bed for their treatment in the ER? In most cases the answer is probably less than 50%. If you narrow the question to just triage or PAT patients, that number shrinks dramatically. In fact, we don’t want beds in triage as it delays initiating treatment and ultimate discharge.

So then, why do we put so many patients in ‘beds’ and what are the consequences? As to the ‘why’ part of the question, it has a lot to do with the “Department” culture as expressed in the phrase “because that’s the way we’ve always done it.” It is also true that on rare occasions we may need lot’s of beds (disaster) and part of our operating mandate is to account for such contingencies.

Long wait times, delay in treatment and slower turnover are all consequences of bedding low acuity patients. This means lower quality of care and underutilization of the capital asset (treatment space). The bed culture is supported by expectations from both providers and staff as well as patients. Patients expect to be put in a bed. What then are the alternatives?

An emerging answer is a chair designed and built especially for patients in triage / PAT actively receiving treatment. Using such a chair not only changes the ‘bed’ culture’ but if introduced to the patient properly, can drive higher levels of patient satisfaction. It will also facilitate more rapid turnover of patients unloading the waiting room, increasing productivity and quality of care.

It’s an idea whose time has likely come – and a perfect way to break out of the “the way we’ve always done it” mold.

What are your thoughts on beds vs. chairs in the ER? Is there an upside or downside from your perspective? I’d love to hear your comments.

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. 

An emergency physician’s wish for tort reform.

By Marty Ogle MD

As an emergency physician and part of a national emergency physician partnership - I keep hoping for the best in regards to tort reform. If only pigs could fly.

As you likely know, Tort reform refers to proposed changes in the system that would reduce tort litigation or damages. "Tort" is a system for compensating wrongs and harm done by one party to another's person, property or other protected interests. Sounds pretty logical, but of course, as in many things in the U.S., tort reform is a contentious political issue.

Nowhere is this more apparent than with healthcare tort reform as it relates to eliminating the "friction" in the system that wastes dollars. These wasted dollars are most often diverted to lawyers, malpractice insurance companies, etc.

Aside from billing costs - which could ultimately be reduced by requiring one standard billing form/procedure for ALL payors- medical malpractice coverage is the single largest expense in an emergency medicine practice. And yet, tort reform appears to be off the table - hmmm, I wonder if it's because most members of the U.S Congress and Senate are lawyers...nah!!!

So what to do? You can certainly let your representatives know that tort reform needs to be back on the table; that true, cost-effective healthcare reform can't happen without it. It may seem like our government isn't listening. Or they're listening to the wrong people. But if enough of us raise our voices, funny things can happen.  Like real, honest tort reform?

Here are two excellent links: 

http://www.calacep.org/advocacy/  (Advocacy Section)

http://www.acep.org/   (Advocacy Section)

I look forward to your comments.  

Here's to a positive year for emergency medicine.

This first blog of the New Year focuses on some of the interesting stories you may have missed over the past few days. In the coming weeks, we'll be touching on the relevant and timely issues that affect emergency medicine and the emergency physicians and PAs who work so diligently to make a difference. So visit often.

We begin where we left off - with Healthcare Reform. Right before Christmas the Senate approved its healthcare reform bill. And now the complicated process lies ahead to reconcile this bill with the House bill, which was approved last month. An article 10 issues that Congress will need to resolve in final reform bill, published in HealthLeaders Media, outlines the work still needed to be done.

An interesting story from the Daily Mail in Great Britain on the National Health Service's dictum of a maximum four hour wait time for patients needing emergency treatment. According to their records, a "vast majority" of patients are seen within 3 hours. However it was revealed that hospitals have been fudging the figures. Truth or politics? It's causing quite a heated debate. 

Just this past week, a list of the top ten "overblown healthcare stories" of the past decade was posted in the Healthcare Economist. Not surprisingly the H1N1 pandemic was number one. Coming in at number four is the notion that uninsured patients cause ED overcrowding. An interesting read to be sure.

This story from the Los Angeles Times highlights a unique Chicago-area doc who is both trauma surgeon and SWAT team member. If you think your day is stressful -- read this!

And finally, an article posted on the Wall Street Journal reminds us that the Congressional stimulus bill passed back in February allows for docs and hospitals that make "meaningful use" of electronic medical records to receive big bonus payments from Medicare and Medicaid. The government released details last week on how to qualify for the money. Read the facts in How to Get $20 Billion for Using Electronic Medical Records.

As always, this page welcomes your comments and observations.

 

Healthcare reform bill by Christmas?

Unlike emergency departments and many emergency physicians, this blog will be taking the next several days off, returning the week of January 4th, 2010. In the meantime, we hope you enjoy a happy and safe Holiday season.

But before we sign off, this space would be remiss to not mention today's news that the AMA has officially thrown its support for the Senate's health reform package after it won assurances from lawmakers that they would work to craft a long-term solution for Medicare payment come January 2010.

Appearing with Senate leaders, Cecil Wilson, president-elect of the American Medical Association, cited a number of health insurance and other provisions that stress wellness and prevention as some of the reasons it would back the bill. President Obama is optimistic that a bill can be passed by Christmas.

Part of the association's support is based on lawmakers shaping a long-term fix to the Medicare payment formula.

The original Senate bill included a measure that would permanently erase a 21% pay cut in 2010 with a 0.5% increase, but an amendment, filed on Saturday, squashed the provision.

Additionally, the AMA also fought against a measure that would have required physicians to pay a $200 fee each year for treating Medicare and Medicaid patients.

So who knows?  By January we may be talking about the passage of heathcare reform legislation. After all, this IS the season for dreams.

Happy Holidays!

Texas proposal could leave emergency patients on the outside looking in.

By Dan Culhane, M.D.

As published in a recently published story, Texas state health officials are discussing the merits of changing a requirement that Texas emergency rooms have a physician on-site at all times, as long as a physician can get to the hospital within 30 minutes.

According to the story, the proposed change would ease financial strain on small specialty hospitals. These facilities are required to have emergency rooms, yet they have very low emergency room traffic.

On the face of it, the proposed change makes financial sense. Why should a hospital with very few ER patients have to pay for on site ER physicians 24/7?

But opponents say the proposal would create risks for patients coming to emergency rooms with the need to see a doctor immediately. What's more, there's the fear that hospitals trying to avoid costs would eliminate on-site ER docs to avoid uninsured patients - and instead specialize in high-dollar/high-profit surgical procedures.

My view on the proposal is that the status quo requires all hospitals to provide emergency services, and thus spreads out uninsured and underinsured patients. In the absence of a system that provides health care for a higher percentage of Americans, I'm in favor of spreading the care for the uninsured around.

This issue might be less contentious if we provided adequate coverage for more of our citizens. If everyone had quality coverage that provided for emergency care I suspect this would be much less of an issue.

I look forward to your comments.

Many American surgeons are suffering from burnout. But what about emergency physicians?

By Ellis Weeker, M.D.

As an emergency physician who's no stranger to working long shifts, a recent study in the online version of the Annals of Surgery caught my eye.  In it, nearly 9% of the 8,000 members surveyed from the American College of Surgeons said they'd made a major medical error or lapse in judgment within the last three months. The reason?  The study found that 40% of the surgeons who responded said they were burned out and/or depressed.  

The authors stated that in August, the same group of researchers reported in the Annals of Surgery that burnout is common among American surgeons and is the single greatest predictor of surgeons' satisfaction with career.

So what about emergency medicine - and the physicians who diligently work long, often stressful shifts? It's true that we talk about fatigue and long working hours. But as emergency physicians, what are we doing to ensure we're not becoming burnout cases or suffering from depression as the study suggests with surgeons?

Working in an emergency department is a mixture of exhilaration and challenge, which creates both physical and mental stress. Yet we know that patients in the emergency room need their treating physicians to be attentive, alert and at the top of their game.  This means being fresh and not over-working ourselves - an ideal we don't always achieve.

Often emergency physicians try to squeeze as many shifts as possible into the beginning or end of a month to take a long stretch of time off in between. PAs and NPs also succumb to the siren sound of far away adventures, only achievable by taking long stretches of time off and then trying to cram as many shifts as possible into the remaining time frame to pay for it.

The other trap is to live beyond our means, causing us to work more shifts than we can tolerate, and reducing our effectiveness as physicians.

The antidote is to pace yourself. Remember, emergency medicine can be a long and satisfying career if you don't burn out. And you will provide better care to your patients.

Only work the number of shifts you can handle and don't try to compress them into short time frames. If you want to take a long vacation, place the extra shifts into other months of the year to compensate. And lastly, live within your means.

I look forward to your comments.

The importance of including IT in hospital disaster planning

By Nancy Burghart-Hall

As we move closer to winter, weather-related disasters can often become a concern for hospitals. With more facilities increasing their reliance on IT, systems going down as part of a disaster will have widespread negative effects on the clinical front line, the emergency room - and on how information is communicated.

A recent article published in HealthLeaders Media discusses the importance of including IT in a hospital's staged disaster drills. The reasons seem obvious, but the fact is, IT recovery is often not factored into a hospital's disaster plan.

According to the article, conducting risk assessments is a good start to uncovering IT-related and other vulnerabilities in advance of a real disaster:

Identify threats Consider the risks to your organization using the categories of natural threats (e.g., tornadoes, hurricanes, snow storms, and floods), human threats (e.g., staff shortages), and environmental threats (e.g., power failures)

Recognize vulnerabilities What if your emergency generator is in the basement and you're in a flood prone or hurricane area? The likelihood that you will lose electric power-and potentially IT systems-because of flooding is a vulnerability. What if your datacenter is in the basement - is the floor raised to protect the equipment from water? And what about the power lines - are they overhead or under the floor?

Determine the effect If a flood causes you to lose power, what other problems will it lead to? How will this affect your hospital?

Develop a list of remediation activities Figure out possible steps to offset the various threats and vulnerabilities you've identified

A logical approach to hospital disaster planning is vital.  And so is including IT in the equation. Is your hospital prepared?  How has IT been brought into the loop? I look forward to your comments.

 

Troubling study shows uninsured ER patients are twice as likely to die.

By Barbara Victor, M.D.

How are the uninsured faring under our present healthcare system? A recent study by Harvard University researchers, and published in the November issue of Archives of Surgery, paints a grim picture.

According to the study, uninsured patients suffering from traumatic injuries caused by car crashes, falls and gunshot wounds, are almost twice as likely to die in the hospital as similarly injured patients with health insurance.  This flies in the face of what many physicians and health experts had previously believed.

Though researchers couldn't pinpoint the exact reasons behind their findings, the takeaway is that the majority of uninsured patients are treated differently  than insured patients.  For example, the uninsured might experience delays being transferred from hospital to hospital - with some private hospitals more likely to transfer an uninsured patient than an insured patient. The uninsured might receive different care. Or the hospitals that treat them may have fewer resources and lower levels of staffing.

From my perspective, it's hard to believe the results. I feel like there needs to be further studies in the area of trauma care. I've worked in three large Los Angeles County Trauma Centers and observed the highest quality trauma care that the United States can provide. In my experience, the care was always given without any consideration of medical insurance coverage. The Trauma Center hospitals readily accept anyone from outside hospitals without reservation. But my experience is in California only.  If the results are true cross the country, then we as doctors and care givers are not doing our job. 

In the study, the overall death rate was 4.7%. The commercially insured patients had a death rate of 3.3%. The uninsured patients' death rate was 5.7%. Those rates were before adjustments for other risk factors and are based on data analysis from the National Trauma Data Bank, which includes more than 900 U.S. hospitals.

How is your emergency department coping with uninsured patients? And what are your thoughts on the study's findings?

Healthcare reform: can Emergency Medicine survive a fifth public option?

By Wesley A. Curry, M.D.

I'm not the first healthcare professional to point out that this country already has variants of a "public option" in health care. The Senate's latest rendition will hopefully reverse a trend and not further burden hospitals and ER physicians with more uncompensated care. But the fact is any new program will be the "fifth" public option since 1965. And each one has ultimately increased the economic challenges on the emergency care system.

The existing public option variants are Medicare and Medicaid, both established in 1965 and both obviously financed by tax payer revenue. Another is the Health Maintenance Organization Act of 1973, which gives HMOs certain economic advantages including the ability to force non participating physicians and hospitals to accept lower reimbursement for treatment of HMO patients. Lastly there's the Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986, an unfunded mandate that ensures public access to emergency services regardless of the individual's ability to pay.

Medicare and Medicaid patients are becoming less desirable to healthcare providers because of decreasing reimbursement rates (legislated decreases or because rates have failed to keep up with inflation). That means more people are coming to hospitals under the mandates of EMTALA. The problem is, it remains unfunded and is the "last resort" for people without health care. Their default option then becomes the hospital ER.

Emergency care providers and hospitals can ill afford to have another "public option" that does not adequately reimburse primary care physicians and specialists. Increasingly hospitals have had to make up the difference and provide financial support for emergency care providers and on call physicians. Some hospitals have closed and the number of emergency rooms has dropped nationwide as the average reimbursement continues to decrease for patients in emergency rooms.

A fifth public option is a good thing for the country - but only if more people get access to primary care. The covered services must be limited and tort reform needs to be included, because whatever form the public option takes, the benefits won't be equivalent to the best commercial insurance plans which are quite expensive in comparison. With more people covered by medical insurance, the rise in cost will be mitigated if the hospitals and health care providers don't have to factor in significant losses from uninsured and underinsured patients. There is no free lunch and no free health care.  I would appreciate hearing your thoughts and comments.