Index
A
Academic health centers
ED crowding in, 40
linkage with rural EDs, 11, 250, 251
recommendations for, 11, 250, 251, 297, 315
Accidental Death and Disability:
The Neglected Disease of Modern Society, 27, 82, 92, 305, 354
Accountability
challenges in implementing, 94
current efforts to improve local emergency care systems, 104, 105, 106, 107
for patient flow management, 155–156
shortcomings of current system, 14–15, 22–23
See also Performance measurement
Accrediting organizations, 95
Admissions, hospital ED
admission/discharge unit, 151
alcohol- and drug-related, 63–64
automated triage systems, 182–184
bedside registration, 150, 175
bottlenecks, 136
full-capacity protocols, 150–151
integrated health care system, 165–167
legal and regulatory requirements, 100
Medicaid enrollees, 3
mental health problem-related, 61
patient-centered care, 25
patient characteristics, 2, 3, 39, 349
patient insurance coverage, 52
patient leaving before being seen, 41–42
patterns and trends, 1, 2, 18, 38, 39, 293, 345–350
pediatric patients, 348
Advanced life support (ALS) protocols, 90–91
Advanced practice nurses, 231
Adverse events
information technology for monitoring, 173–174
information technology to prevent, 184–186
risk in EDs, 23
teamwork training to reduce, 244–245
types of, 23
Agency for Healthcare Research and Quality, 112, 115, 264, 299
Ambulance diversion
illegal, 158
recommendations, 6, 157, 159, 160
Ambulatory care, 32.
See also Primary and nonurgent care
Ambulatory care sensitive conditions, 145–146
American Board of Medical Specialties, recommendations for, 229, 251
American College of Emergency Physicians (ACEP), 215, 218, 294
American College of Surgeons, 306, 307, 357, 358
America’s Health Care Safety Net:
Intact but Endangered, 42
A Shared Destiny:
Community Effects of Uninsurance, 28, 42
Assessment
automated triage systems, 182–184
defensive medicine, 138
diagnostic imaging technology, 176–177
ED crowding and, 137
ED triage, 150
in EDs, 47
fast track processing in ED admissions, 149–150
hospitalist role, 228
laboratory services, 193
overtriage, 346
rapid diagnostic technologies, 191–193
substance abuse issues, 64
utilization of resources in ED, 137–138
Avian influenza, 9
B
Back pain among ED workers, 243
Balance Budget Act (1997), 67
Balance Budget Refinement Act (1999), 67
Beth Israel Deaconess Medical Center, 174–175, 183
Bioterrorism Hospital Preparedness Program, 283–284
Boarding
care needs, 39
psychiatric patients, 62
recommendations, 6, 157, 159, 160
Building a Better System:
A New Engineering/Health Care Partnership, 28–29
C
Capacity
categorization of services, 14, 89–90, 92, 124
disaster preparedness, 8, 9, 22, 265–266
disincentives to improve efficiency, 157–158
frequency of problems in, 4
regionalization of specialty services, 10–11
shortcomings of current system, 19
unit assessment tools, 148
See also Crowding, ED
CareGroup HealthCare Systems, 183
Categorization of ED services, 14, 89–90, 92, 124
trauma surgery, 217
Cedar-Sinai Medical Center, 154, 199
Centers for Disease Control and Prevention (CDC), 86, 264, 280–281, 284
in regional planning and coordination, 88, 89
reimbursement strategies to improve emergency care system, 99–100
Centers for Medicare and Medicaid Services (CMS), 226–227
ED physician reimbursement, 214–215
incentives for hospitals to improve ED efficiency, 156–157
recommendations for, 6, 8, 58, 70, 148, 159, 160
Chief Executive Officers, hospital
average tenure, 153
recommendations for, 5, 6, 152, 160
training for, 6
Chronic disease management, 51–52
Clinical decision support systems (CDSSs), 166, 169, 172, 176, 185–186, 200
Clinical decision units (CDUs)
recommendations for, 5, 148, 160
staffing, 144
Closure of facilities
for legal liability concerns, 223, 224
Los Angeles experience, 19, 20–21, 57
in rural areas, 66
uncompensated care and, 22
Committee on the Future of Emergency Care, 1–2, 27–29, 30–31
Communications systems
coordination of emergency care delivery, 13, 86
current efforts to integrate local emergency care systems, 102–103
digital voice communications, 175
for disaster response, 178, 270
goals for integrated system, 86–87
prehospital communications, 178
radiography and picture transmissions, 176–177
recommendations for, 7, 193, 202
See also Information technology
Community Councils on Emergency Medical Services, 82
Community health centers, 43, 44
Computed tomography angiography, 191
Computerized physician order entry, 166, 169, 184–185, 200–201
current implementations, 168
Confidentiality
human subjects research, 313, 314–315
information technology and, 181–182, 200
Contract management groups, 210–211, 215–216
Coordination of care
automated discharge systems, 180
automated referral systems, 180–181
communication system for, 86–87
current efforts to improve, 102–103, 104–107
fragmentation of current care system, 13, 16, 22, 81, 83–84, 111
goals for emergency care system, 13, 81, 82–83
information technology for, 168, 170, 178–182
interprofessional collaborations, 243–247
linkages among health care providers, 85
rationale, 13
recommendations for national agency for, 16, 119–124
strategies for improving, 85–86
trauma care systems, 358
vignette of emergency response, 165–167
See also Regionalization
Costs
care for undocumented immigrants, 55
closure of EDs, 38
disaster drills, 273
disaster preparedness funding, 9
of health care system failures, 130
traumatic injury treatment, 18
See also Economics;
Uncompensated care
Critical Access Hospital, 67–68
Critical care specialists, 228–229, 251
Crossing the Quality Chasm:
A New Health System for the 21st Century, 23, 28, 130
Crowding, ED
causes, 3, 19–20, 39, 131, 132
coordination within health care system to avoid, 13
delays in diagnostic services, 137
discharge processing and, 148–149
elective surgery schedule and, 141
incentives for hospitals to reduce, 5–6, 156–157
patient-centered care and, 25
patient departure before assessment, 42
reimbursement policies contributing to, 137
risk of adverse events, 24
See also Ambulance diversion;
Boarding;
Patient flow
Current Procedural Terminology, 54, 214–215
D
Delayed treatment
coordination within health care system to avoid, 13
related mortality, 6
Demand for ED and trauma care
patterns and trends, 3, 19, 46
population life-span effects, 52
primary and nonurgent care-seeking, 45–46
scheduled vs. nonscheduled care, 49–52
See also Crowding, ED
Demonstration projects
administration, 110
recommendations, 15–16, 108, 124–125
structure and operations, 108–110
Department of Health and Human Services (DHHS), 229
disaster preparedness policies and practices, 264, 270, 271, 282, 283, 285
emergency care bureaucracy, 111–112
funding trends, 115
recommendations for, 12, 14, 15, 16, 90, 96, 102, 119, 120, 124, 125, 237, 239, 251, 271, 285, 311, 315
Department of Homeland Security (DHS)
disaster response, 112, 268, 271, 285
National Planning Scenarios, 262, 264
recommendations for, 237, 251, 271, 285
Department of Transportation (DOT), recommendations for, 237, 251, 271, 285
Depression, ED assessment, 61
Diagnosis-related groups, 54, 100, 156–157
Diagnostic errors, 23
Diagnostic technologies, 191–193
Disaster preparedness
communications technology, 178, 270
coordination among health care entities, 268–269
cost of disaster drill, 273
current inadequacies, 8–9, 22, 259, 265, 270, 274, 282
example (Rhode Island nightclub fire), 265, 267–268
federal funding, 282, 283–284, 285
medical specialist capacity, 266
personal protective equipment, 276–279
protection of medical personnel, 9
recommendations for improving, 9, 284
recommendations for national agency for care delivery, 16
recommendations for training in, 274
recommendations for Veterans Health Administration, 271
role of hospital EDs, 1, 19, 259, 265
surge capacity, 8, 22, 265–266
surveillance role of EDs, 279–281
terrorist events, 261
threat identification, 261–262
training for, 8, 9, 271–274, 285
Veterans Health Administration role, 271, 285
Discharge processing
admission/discharge unit, 151
automated systems, 180
discharge coordinator, 149
Dispatchers, 13
Disproportionate Share Hospital (DSH) payments, 7, 42, 52–53, 54
E
Economics
barriers to primary care, 45–46
cost of ED services for Medicaid patients, 54
cost of ED services for Medicare patients, 54
cost of physician liability insurance, 224
demonstration project grants, 15–16, 108–110, 124–125
disincentives to patient flow improvement, 99–100, 130, 157–158
funding for disaster preparedness, 282, 283–284, 285
funding for new national emergency care agency, 123
government support for safety net care, 44
health care sector share of GDP, 5
implementing a national health information system, 170
incentives to reduce ED crowding, 5–6, 156–157
information technology investments, 169, 194–196
research funding, 12, 294–295, 298–300, 308–309
rural health care facilities, 66
state funding mechanisms for emergency care, 59
See also Costs;
Uncompensated care
Effectiveness of ED care, 24–25
Efficiency
barriers to improvement, 26, 152
benefits of regionalization, 88
current inadequacies, 130
disincentives to improving, 99–100, 130, 157–158
hospital leadership for improvement in, 6, 152–153
incentives to improve, 5–6, 156–157
See also Patient flow
Elderly patients
mental health problems, 61
traumatic injury mortality, 293
Elective surgery schedule, 141, 157, 158
Electronic health records (EHRs), 151–152, 168, 177
Emergency care system
current fragmentation, 16, 22, 81, 111
current reform efforts, 102–107
definition, 31
within health care system, 129–131
historical and conceptual development, 353–356
implementation of reform, 110–111
performance measurement, 94–96
public perception of performance, 94
recommendations for new national agency, 16, 119–124
Emergency Medical Services Agenda for the Future, 29, 82–83, 112, 117
Emergency medical services (EMS). See Prehospital emergency medical services
Emergency Medical Services for Children, 27, 92
Emergency Medical Services Systems Act (1973), 83, 355
Emergency Medical Treatment and Active Labor Act (EMTALA) (1996), 3, 10, 26–27, 100–101, 157, 218–219, 346
effects on physician supply, 226–227
hospital staffing and, 226
recommendations for changes in, 102, 124
violations of, 158
Emergency Medicine Foundation, 296
Emergency Severity Index, 182–184
EMS Performance Measures Project, 95
Ethical practice in human subjects research, 313–314
eTRIAGE, 184
F
Failure modes and effects analysis, 132
Federal Emergency Management Agency (FEMA), 112
Federal government
disaster preparedness policies and practices, 261–262, 264–265, 270, 283–284, 285
emergency care bureaucracy, 111–115
establishment of new agency for emergency care system integration, 16, 117–124
Federal Interagency Committee on EMS (FICEMS), 113, 115–117
recommendations for, 7–8, 9, 11, 12, 15, 16, 58, 70, 108, 119, 124–125, 284, 285, 315
reimbursement to hospitals for uncompensated care, 7–8, 58
research role, 12
support for information technology system, 170
See also specific governmental entity
Federal Interagency Committee on EMS, 113, 115–117, 122
Follow-up care
automated discharge systems, 180
barriers to, 45
Foreign-language patients, 180
Fostering Rapid Advances in Health Care:
Learning from System Demonstrations, 108, 110
Fragmentation of emergency care delivery system, 16, 22, 81, 111
information technology and, 169
strategies for integration, 115
See also Coordination of care
Full-capacity protocols, 150–151
G
General Clinical Research Centers, 12, 312–313, 315
Grady Health Systems, 144–145, 149–150
H
Health Alert Network, 178
Health Insurance Portability and Accountability Act (HIPAA), 313
recommendations for changes in, 102, 124
Health Literacy: A Prescription to End Confusion, 180
Health Plan Employer Data and Information Set (HEDIS), 98
Health Resources and Services Administration, 8, 88, 264–265, 299
recommendations for, 15–16, 108, 110, 124–125
Healthcare Resources and Services Administration, 357
Highway Safety Act (1966), 354
Home Health Compare, 98
Hospital beds
causes of ED crowding, 39
coordinated management, 141–142
Hospital Emergency Incident Command System, 269
Hours per patient visit, 232, 233
Human factors engineering, 132, 138–139
I
IHI IMPACT Network, 139
Imaging technology, 176–177, 190–191
Immigrant population, 55
Infectious disease transmission in ED, 242–243, 276
Information technology
automated discharge systems, 180
automated dispensing, 185
automated referral systems, 180–181
bedside registration, 150
clinical decision support systems, 166, 172, 182–186, 185–186
for clinical documentation, 186–187
computerized physician order entry, 184–185
confidentiality concerns, 181–182, 200
coordination of emergency care system, 86, 101–102
costs and benefits, 194–196, 200–201
electronic dashboards, 166, 173–174
electronic prescribing, 181
evolution in health care, 167–168
implementation strategies, 200–201, 202
military medicine, 360
mobile and handheld devices, 175–176
national infrastructure, 170
new clinical technologies, 190–194
obstacles to adoption and diffusion, 168, 194–200
patient clinical data collection, 96
for patient flow improvement, 154–155, 172–177
patient medical information, 86, 151, 177, 360–361
for performance assessment, 173–174
picture archiving and transmission, 176–177
population health surveillance, 172, 188–189, 280
prehospital intervention, 178
radio frequency identification tracking, 174–175
recommendations for, 7, 193, 202
registration process, 150, 175 role of, 6–7
shortcomings of current system, 7, 130
system interconnectedness, 168, 171, 178–182
technologies for emergency care, 7, 171–172, 201–202
training applications, 172, 187, 188
trends in health care, 168–169
vignette of integrated health care system, 165–167
See also Communications systems
Informed consent, 313–314, 315
Injuries, unintentional
health care system failures, 130
hospital ED admissions, 1, 18, 345
research areas, 292–293, 304–305, 307–308, 310–311
research infrastructure and funding, 308–309
Injury in America:
A Continuing Public Health Program, 27, 305, 309, 355
Insight information system, 86, 281
Insurance. See Medicaid;
Medicare;
Privately insured patients;
Uninsured patients
Interagency Committee on EMSC Research (ICER), 113
J
Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 235
disaster preparedness requirements, 265, 272
patient flow standards, 6, 139, 157, 160
recommendations for, 6, 153, 157, 160
L
Laboratory services, 193
Leadership for system integration
current federal bureaucracy, 111–115
establishment of new agency for, 16, 117–124
Federal Interagency Committee on EMS role, 113, 115–117
funding, 123
implementation, 121–122, 123–124
information technology, 170
objectives, 120
research activities and, 121
strategies, 115
Leapfrog Group, 228
Legal liability
concerns of ED physicians, 10, 11, 223–224
defensive medicine in ED and, 138
emergency medicine training and, 238–239
malpractice award limits and, 224–225
on-call immunity, 225
recommendations for research, 11, 226, 251
supply of ED providers and, 11, 22, 251
teamwork training and, 244
Legal and regulatory environment
recommendations for changes in, 102
regionalization of emergency care systems and, 100–102
Length of stay, hospitalist intervention and, 228
M
Magnetic resonance imaging (MRI), 176, 190–191
Malpractice lawsuits. See Legal liability
Medicaid
clinical decision unit reimbursement, 147–148
Disproportionate Share Hospital payments, 7, 42, 54
enrollment in rural areas, 67
managed care, 42
prehospital care reimbursement, 99
reimbursement levels, 45
See also Centers for Medicare and Medicaid Services
Medicare
Balance Budget Act and, 67
clinical decision unit reimbursement, 147–148
coverage in rural areas, 67
Disproportionate Share Hospital payments, 7
prehospital care reimbursement, 99
reimbursement system, 54
See also Centers for Medicare and Medicaid Services
Medicare Modernization Act, 55
Medication errors, 23
Mental health
ED utilization related to disorders of, 61
among elderly, 61
provider training for, 62
stresses in ED related to admissions for disorders of, 59, 62–63
Metropolitan Medical Response System (MMRS), 112, 282, 283
Military medicine, 353, 356–357, 360–362
Mortality
critical care specialist effects, 228
health care system failures, 130
life-span trends, 52
regionalization rationale, 87
treatment delay-related, 6
from unintentional injury, 1, 18, 293
Multicenter Airway Research Collaboration, 304
N
National Center for Injury Prevention and Control, 299, 309
National Committee for Quality Assurance, recommendations for, 6, 153, 160
National Electronic Injury Surveillance System, 279
National Emergency X-Radiography Utilization Study, 304
National Highway Traffic Safety Administration, 111, 299–300, 354, 355
recommendations for, 14, 90, 124
National Incident Management System (NIMS), 268
National Institute of General Medical Sciences, 304
National Institutes of Health (NIH), 12, 121, 294, 295, 298–299, 308–309
National Quality Forum, 96
Negative pressure rooms, 9, 276
Neurosurgical specialists, 10, 219, 222, 223–224
Nursing Home Compare, 98
Nursing staff
advanced practice nurses, 231
certified emergency nurses, 230
coordinated bed management, 141–143
core competencies, 239
current ED staffing, 229
demographic characteristics, 230, 231
disaster response training, 8, 274
ED functions, 229
ED staffing standards, 138, 233
information technology utilization, 198–199
overtime work, 234
psychiatric training, 62
violent assault risk, 241
zone nursing, 150
See also Workforce, medical
O
Observation units. See Clinical decision units
Occupational Safety and Health Administration (OSHA), 9, 278–279
Omnibus Reconciliation Act (OBRA) (1981), 355
On-call specialists
categorization of ED capabilities, 90
critical care specialists, 228–229
defensive medicine practices, 138
Emergency Medicine Treatment and Active Labor Act and, 226–227
obstacles to availability, 10, 22, 219
quality-of-life concerns of, 222–223
recommendations regarding, 251
regionalization, 10–11, 105–106, 220, 251
in rural areas, 11, 68, 248, 250
supply problems, 10, 22, 27, 152, 218–220, 359
surgical subspecialty, 220–221
Operations management tools, 130–131
recommendations for, 5, 6, 152, 153, 160
training for hospital leaders, 6, 153, 160
Orthopedic specialists, 10, 223
Outcome measures
ambulance diversion outcomes, 41
performance measurement, 97
regionalization rationale, 87
system performance indicators, 15, 96
P
Patient advocates, 236
Patient-centered care, 25
Patient flow
accountability for management performance, 155–156
admissions bottlenecks, 136
bottleneck management, 140–149
care delivery strategies to improve, 149–152
coordination within health care system, 13
definition, 133
disincentives to improving, 99–100, 130, 157–158
elective surgery schedule, 141
goals, 140
hospital leadership for improving, 152–153
importance of, 133
incentives to improve, 5–6, 156–157
information technology for, 171, 172–177
input/output/throughput model, 133–135, 154
management tools, 4–5, 22, 132
performance indicators, 154–155
protocols for prehospital care, 14
regional, 136
staff leadership for improving, 154
strategies for improving, 139
systemic approach to management, 132, 155–156
training for hospital administrators, 6
unit assessment tools, 148
use of clinical decision units to manage, 143–148
See also Crowding, ED
Patient Flow Benchmarking Project, 139
PatientSite Project, 183
PECARN, 304
Pediatric emergency care, 355–356
alcohol- and drug-related, 63
mental health problem related, 61–62
regional coordination of care, 86
utilization patterns, 348
Performance measurement
challenges in emergency care system evaluation, 94
data collection, 15
documentation of care, 186–187
emergency care research programs, 299–300
goals, 97
information technology for, 173–174
patient clinical data for, 96
public reporting, 15, 97–99, 159
recommendations for system performance indicators, 15, 96
shortcomings of current system, 22–23
Pharmacy
physician prescribing practices, 181, 184–185
Physician assistants, 234
Physicians
average workweek in ED, 240
demographics of ED physicians, 212–214
disaster response training, 273–274
Emergency Medical Treatment and Active Labor Act requirements, 226–227
emergency medicine training, 211–212, 214
employment patterns in EDs, 210–211, 215–216
historical development of hospital-based emergency care, 353–356
information technology utilization, 168–169, 198–199
knowledge and skills for ED work, 210
legal liability concerns, 10, 11, 223–226
moonlighting, 216
on-call coverage, 10–11, 152, 218–219
psychiatric training, 62
quality-of-life concerns of, 222–223
referral to ED from, 46–47, 137–138
regionalization of specialty services, 10–11
reimbursement patterns, 214–215
role of, in EDs, 210
trauma and emergency surgeons, 216–218, 220–221
See also Specialized medical services
Picture archiving and communications systems, 176–177
Population patterns and trends
chronic disease prevalence, 346–347
health care utilization and, 2, 38
life spans, 52
Prehospital emergency medical services
categorization of services, 90
communications technology, 178
coordination of emergency care delivery system, 13, 16, 22
definition, 31
disaster response, 266
evolution of bureaucratic structure, 111–113
historical development, 355
information technology, 178
protocols for transport, 14, 90–92
recommendations for protocol development, 14, 91–92, 124
recommendations for system integration, 16, 119
in rural areas, 69
transport decisions, 93
Prescribing practices, 181, 184–185
Preventive interventions
in emergency care settings, 84–85
injury control research, 307, 355
Primary and nonurgent care
costs, 3
ED utilization for, 43
government support, 44
patient understanding of, 48–49
physician training in emergency care, 237–238
quality of care in EDs, 25
reasons for ED utilization, 45–47, 85
scheduled vs. nonscheduled care, 49–52
Privately insured patients
denial of coverage for emergency care, 55
ED utilization, 54
Psychiatric emergency care, 25
Psychologists, 236
Public health agencies
in coordination of emergency care delivery, 13, 84–85
leadership of national emergency care system, 120–121
in regionalization of emergency care delivery, 251
Public health and public safety
emergency communications technology, 178
role of hospital EDs, 1, 18–19, 29–30
surveillance role of EDs, 279–281
syndromic surveillance, 189, 280–281
Public perception and understanding
emergency care system performance, 27, 94
health care system performance, 130
in improvement of health care system, 159
self-triage decisions, 93
urgency of medical needs, 48–49
Public reporting of performance data
goals, 97
implementation, 99
Q
Quality functional deployment, 132
Quality of care in hospital EDs
ambulance diversion outcomes, 41
causes of adverse events, 23–24
indicators, 23
for patients with mental health problems, 61–62
primary and nonurgent care, 47–48
psychiatric care, 25
recommendations for improving, 4–12, 15–16
in rural areas, 25, 68–69, 70, 249–250
Quality Through Collaboration:
The Future of Rural Health, 65, 179, 247
R
Radio frequency identification (RFID) tracking, 166, 174–175, 201
Reducing the Burden of Injury, 27
Regional Health Information Organization, 170, 179
Regionalization
benefits, 88
categorization of ED services, 14, 89–90, 92
current efforts to integrate local emergency care systems, 103, 105, 106, 107
disaster preparedness, 269–270
implications of existing statutory regime, 100–102
information technology, 171, 179
model, 89
on-call specialty services, 10–11
patient flow, 136
pediatric care, 86
scope, 89
specialty hospitals and, 88–89
trauma care, 358
See also Coordination of care
Reimbursement
clinical decision units, 147–148
Current Procedural Terminology, 214–215
disincentives to patient flow improvement, 99–100, 130, 157–158
Disproportionate Share Hospital payments, 7, 42, 52–53
ED crowding related to, 137
incentives to improve emergency care system, 5–6, 156–157
obstacles to emergency care system improvement, 99, 130
on-call emergency specialists, 221–222
relative value units, 215
in rural areas, 248
scheduled vs. nonscheduled procedures, 157, 158
substance abuse screening, 65
trends, 56
See also Uncompensated care
Relative value units, 215
Research
barriers to, 311
basic science, 301
Federalwide Assurance Program, 314–315, 316
future directions, 300–303, 310–311
General Clinical Research Centers, 12, 312–313
infrastructure and funding, 294–300, 308–309, 311–313
multicenter collaborations, 304
needs. See Research needs
recommendations, 297, 311–312, 315–316
rights of human subjects in, 313–315
Research needs
categorization of emergency services, 14
clinical decision support systems, 185–186
conventional weapons terrorism, 9
current federal efforts, 112
impact of malpractice liability on provider supply, 11, 225–226
leadership of national emergency care system and, 121
scope of emergency care, 291–293
shortcomings of current system, 23
Resource-based relative value scale, 214, 215
Resuscitation Outcomes Consortium, 304
Rhode Island nightclub fire, 265, 267–268
Robert Wood Johnson Foundation, 300
Role of Emergency Medicine in the Future of American Medical Care, 28
Role of hospital EDs
historical development, 1, 18–19, 37
perceptions of, 37
primary and nonurgent care delivery, 1, 3
scheduled vs. nonscheduled care, 49–52
See also Primary and nonurgent care
Roles and Responsibilities of Federal Agencies in Support of Comprehensive Medical Services, 83
Root-cause analysis
Rural areas
challenges for EDs in, 65
Critical Access Hospital program, 67–68
disaster preparedness, 281–282
ED workforce characteristics, 249
hospital characteristics, 66
impediments to practice in, 248
prehospital care, 69
quality of care, 25, 68–69, 70, 249–250
recommendations for hospitals in, 11, 250, 251
regionalization effects, 88
strategies to improve emergency care, 250
telemedicine applications, 179
workforce supply, 11, 68–69, 237, 247–250
S
Safety
adverse event risk, 23
ED security measures, 242
infectious disease transmission in ED, 242–243
physician liability concerns and, 225
protection of medical staff in disaster
response, 9
of workforce in disaster response, 275–279
Safety net providers
financial issues, 7, 44, 52–53, 54, 55, 56–58, 100
input/throughput/output model, 135
liability issues, 11
regional coordination, 179
role of hospital EDs, 1, 18, 29–30, 42–43, 85
urban vs. rural, 51
St. John’s Regional Health Center, 146–147
San Francisco Community Clinic Consortium, 86
SARS. See Severe acute respiratory syndrome
Scheduled vs. nonscheduled care, 49–52, 100, 157, 158
Scope of emergency care, 29, 31
Secure/Multipurpose Internet Mail Extensions, 181
Severe acute respiratory syndrome, 9, 242–243, 276, 277, 279
Simulation training, 245
Social workers, 236
Society for Academic Emergency Medicine (SAEM), 147, 296, 300
Specialists
categorization of ED services, 14
core competencies for emergency medicine, 239
critical care specialists/intensivists, 228–229, 251
disaster response, 266
emergency medicine, 211, 354–355
implications for regionalization, 88–89
legal liability concerns, 223–225
on-call, availability of, 218–219
recommendations for critical care medicine certification, 229, 251
regionalization of ED services, 10–11, 14, 103, 220
supply problems, 10, 19, 22, 25, 219–220, 221–225
See also On-call specialists
Standards of care
boarding and ambulance diversion, 6, 159, 160
core competencies for emergency professionals, 239–240, 251
patient flow, 6, 139, 157, 160
prehospital care, 14, 90–92, 124
system performance indicators, 15, 96
State Children’s Health Insurance Program, 52
State government
current efforts to integrate emergency care system, 102–107
demonstration project grants, 15–16, 108–110
disaster response, 268
emergency care funding mechanisms, 59
patient clinical data collection, 96
Statistical process control, 133
Stony Brook Hospital, State University of New York, 151
Substance abuse
assessment challenges, 64
ED admissions related to, 63–64
population patterns, 63
presentations, 64
quality of care in EDs, 59
reimbursement issues, 65
stresses for EDs related to, 59, 65
Suicidal patients, quality of ED care for, 61–62
Supply-chain management, 133
Surgical specialists, 216–218, 220–221
military medicine, 361
trauma care, 359
Surveillance, public health
coordination of communications, 86
in emergency care settings, 85
information technology for, 172, 188–189, 280
role of hospital EDs, 1, 18–19, 30, 279–281
Syndromic surveillance, 189, 280–281
Systems analysis, 131, 155–156
T
Telemedicine, 11, 179, 250, 251
Terrorist attacks, 8, 9, 261, 276, 278, 279, 281, 283–284
Tertiary hospital quality of care, 24–25
To Err Is Human:
Building a Safer Health System, 28, 130, 244
Training for health care professionals
benefits of regionalization, 88
choice of practice location related to location of, 248
core curriculum, 238
for disaster preparedness, 8, 9, 271–274, 285
emergency medicine specialty, 211–212, 214, 237–238, 238, 294–295
to enhance rural EDs, 11
graduate medical education, 237
in information technologies, 198–199
information technology for, 172, 187, 188
in mental health issues, 62
military medicine, 362
in operations management, 6, 153, 160
for providers in rural areas, 69–70, 249
recommendations, 6, 9, 11, 153, 160, 274, 285
simulation training, 245
trauma surgeons, 217
Trauma care
categorization of hospitals, 357–358
historical development, 356–357
medical specialties, 359
regional coordination, 358
research areas, 291–292, 304–307, 310–311
research infrastructure and funding, 308–309
Trauma Care Systems Planning and Development Act, 357
Trauma center(s), 31, 356, 360
Trauma system
definition, 31
as model for emergency care system coordination, 83, 89
U
Ultrasonography, 191
Uncompensated care
burden on hospitals, 21–22, 56–58
costs to physicians, 215
Medicare/Medicaid reimbursement, 7, 52–53
recommendations for federal reimbursement, 7–8, 58, 70
supply of on-call specialists and, 10
Uninsured patients
barriers to primary care, 45–46
disincentives to improving ED efficiency, 158
economic burden, 7
role of hospital EDs, 1, 42–43
undocumented immigrants, 55
See also Uncompensated care
Unit assessment tools, 148
University HealthSystem Consortium, 139
U.S. Fire Administration, 112
V
Veterans Health Administration, 198, 271, 285
Videoconferencing, 179
W
Wait times
assessment in waiting room, 25
nonemergency patients, 3
patient departure before assessment, 25–26, 42
Washington Hospital Center, 86, 281
Workforce, medical
back pain risk, 243
challenges of ED work, 10, 240
clinical decision units, 144
core competencies, 238–240, 251
disaster preparedness training, 271–274
ED staffing standards, 138
Emergency Medical Treatment and Active Labor Act requirements, 226–227
infectious disease risk, 242–243
interprofessional collaboration, 243–247
leadership for efficiency improvement, 154
malpractice liability concerns, 11, 251
moonlighting, 216
physician assistants, 234
