Hospital-Based Emergency Care At the Breaking Point (2007) / Chapter Skim
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6 The Emergency Care Workforce
6 The Emergency Care Workforce
Pages 209-258
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From page 209... ...
But providers on the front lines of emergency care increasingly express frustration with the deteriorating state of the emergency care system and the health care safety net. They experience the imbalance between demand and capacity described in earlier chapters on a daily basis, and find themselves spending an increasing proportion of their time on such tasks as getting patients admitted to crowded inpatient units; finding specialists willing to come in during the middle of the night; and finding psychiatric centers, skilled nursing facilities, or specialists who are willing to accept referrals.
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From page 210... ...
They must be prepared for a wide variety of medical emergencies, and for this reason must be well versed in the emergency care aspects of such diverse subjects as anesthesia, cardiology, critical care, environmental illness, neurosciences, obstetrics/gynecology, ophthalmology, pediatrics, psychiatry, resuscitation, toxicology, trauma, disaster management, and wound management. In addition, because they often represent the sole source of primary care for patients whose only access to care is through EDs, they must be expert at delivering care for minor illnesses and injuries, providing care for chronic conditions, and delivering primary and preventive care.
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From page 211... ...
Many acquire a high level of competency in emergency care through a combination of postresidency education, directed skills training, and on-the-job experience. Demographics It is difficult to determine precisely how many ED physicians practice in the United States.
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From page 212... ...
; this number likely includes some physicians not board certified in emergency medicine but practicing in an ED on a full-time basis. The AMA survey also provided some basic demographic information on those physicians.
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From page 213... ...
medicine physicians is less diverse than that of the general physician population. Eighty-three percent of self-identified emergency physicians are nonHispanic white, compared with 75 percent of physicians overall.
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From page 214... ...
Since 1990, the number of self-identified emergency physicians in the United States has increased from 14,000 to more than 25,500 -- an increase of 79 percent compared with a 39 percent increase in the number of all physicians. One of the key reasons for the rapid growth in emergency medicine residency programs is that academic medical centers find these programs quite useful for staffing their own EDs.
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From page 215... ...
Nonetheless, a reimbursement rate of 50 percent suggests significant foregone income that has not been remediated through changes in the CMS practice expense RVU. It should be noted that other specialties that provide emergency care also deliver substantial amounts of uncompensated care and face similar economic problems.
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From page 216... ...
Trauma Surgeons The other specialty of particular relevance to emergency care is the surgical subspecialty of trauma/critical care surgery. Trauma is defined as any bodily injury severe enough to pose a threat to life and limb.
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From page 217... ...
Most level I and some level II trauma centers have trauma surgeons in house 24 hours a day, 7 days a week, who are responsible for all aspects of care of the trauma patient. Trauma care is also provided by emergency physicians, especially in some level II, III, and IV trauma centers.
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From page 218... ...
. The limited availability of certain specialists, however, is a welldocumented problem that is concerning for both consumers and emergency care providers.
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From page 219... ...
Surveys of hospital administrators, ED staff, and specialists indicate that there are at least five underlying factors affecting the availability of emergency and trauma care specialists: (1) the supply of specialists, (2)
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From page 220... ...
While there is limited direct evidence regarding regionalization of oncall specialty services, the approach has proven effective in other contexts and is consistent with the committee's broader vision of a regionalized emergency care system. There are few examples of regionalization with specific reference to emergency and trauma care specialty on-call services.
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From page 221... ...
Yoo and colleagues (2001) reported the results of a 2000 California Medical Association survey on reimbursement for on-call emergency services.
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From page 222... ...
It involves combining all emergency neurosurgery and trauma cases and issuing a request for proposals for exclusive rights to providing care for these patients. Substantial competition for the contract resulted in a qualified and committed group of neurosurgeons providing services for emergent and trauma care.
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From page 223... ...
As panels diminish at community hospitals, they increasingly transfer patients to the large safety net hospitals, which have no choice but to accept them; the result is even higher concentrations of uninsured, high-risk patients. Several reports have documented closings of trauma centers, at least temporarily, or downgrading of their status because of staffing shortages associated with liability concerns (Whaley, 2002)
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From page 224... ...
with experiences in four states not having such problems. The GAO found that in the crisis states, access to emergency care was reduced, particularly for trauma and obstetrical services; transfers of patients were increased; and the availability of on-call specialists to EDs was reduced, especially for critical specialties such as orthopedic and neurological surgery.
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From page 225... ...
A number of additional approaches could be used to protect emergency care specialists without compromising patient safety. One would be to provide "conditional immunity" for emergency physicians and specialists while seeing patients on call.
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From page 226... ...
Medical emergencies are unpredictable events, and the emergency care system must maintain a state of readiness to handle them as they arise. Because individuals cannot know when they will need emergency services, they will underconsume the readiness aspect of emergency care.
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From page 227... ...
Because hospitalists focus on inpatient care rather than traveling back and forth from their office, they are often more efficient than office-based practitioners. One hospital found
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From page 228... ...
. Critical Care Specialists/Intensiists Critical care specialists are an essential component of emergency and trauma care in addressing the needs of severely ill and injured patients.
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From page 229... ...
currently blocks residency-trained, board-certified emergency physicians and other acute and primary care specialists from obtaining subspecialty certification in critical care. To increase the pool of well-trained intensivists in both adult and pediatric practice, the committee recommends that the American Board of Medical Specialties and its constituent boards extend eligibility for certification in critical care medicine to all acute care and primary care physicians who complete an accredited critical care fellowship program (6.3)
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From page 230... ...
After graduation from one of these programs, nurses must take the state board examination to become an RN. Emergency Nurses The Emergency Department Nurses Association was formed in 1970.
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From page 231... ...
There is no national certification for APNs in emergency care, but NPs and other APNs may obtain training in emergency care skills through university-based programs, continuing education, and work experiences (Cole et al., 1999)
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From page 232... ...
Because of the intensity of emergency care, EDs often have more vacant nursing positions than the hospital's average. Nationwide, it is estimated that 12 percent of RN positions for which hospitals are actively recruiting are in EDs.
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From page 233... ...
They have tried several strategies to compensate for the shortage of ED nurses, including recruiting nurses from foreign countries and using "float" or borrowed nurses from other units of the hospital when the ED is particularly busy. While recruitment from other countries, particularly Canada, has helped relieve the shortages, the use of float nurses is more problematic because those individuals are not familiar with the complexity of the ED or emergency nursing practice
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From page 234... ...
PAs in EDs generally tend to be older than other PAs, in direct contrast to the patterns found among other emergency care personnel (AAPA, 2005)
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From page 235... ...
that work in EDs typically have a doctor of pharmacy degree and have completed a 1-year residency. Substantial evidence indicates that including pharmacists on the care team can improve the quality and safety of patient care in both inpatient and outpatient settings (Bates et al., 1995; Leape et al., 1999; Kaushal et al., 2001; Kaushal and Bates, 2001)
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From page 236... ...
ENHANCING THE SUPPLY OF EMERGENCY CARE PROVIDERS The ED workforce includes a broad cross section of the larger health care system -- physicians in fields ranging from family medicine to neurosurgery, residents, nurses, pharmacists, and PAs -- as well as those who specialize in emergency care, including emergency medicine physicians, emergency nurses, trauma surgeons, and certain medical and surgical specialists. There are substantial concerns about the long-term supply of emergency professionals in several of these categories.
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From page 237... ...
Enhanced rural training options combined with loan forgiveness programs is a possible approach for enhancing the rural emergency care workforce. Developing effective strategies to ensure an adequate supply of trained ED professionals in the future requires an understanding of the needs of the nation 10 and 20 years into the future.
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From page 238... ...
Emergency physicians are thereby excluded from certain federal and state programs designed to promote the training of primary care physicians, although in some rural counties, primary care is provided predominantly through the ED. The above discussion focuses only on emergency physicians, but concerns about the numbers of funded residency positions apply to virtually all specialties that provide emergency care.
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From page 239... ...
Similarly, not all hospitals require ED nurses to take the Emergency Nursing Pediatric Course and the Trauma Nursing Core Course, and not all require ED physicians to take the Advanced Trauma Life Support Course. Yet while exposure to these courses may help improve the level of competency for some providers, particularly those with little formal training in emergency care, it does not ensure competency.
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From page 240... ...
The next chapter addresses provider safety in the context of disasters, including chemical and biological exposure. Mental Stress Numerous studies both in the United States and abroad have identified stress as a major concern for emergency care providers.
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From page 241... ...
THE EMERGENCY CARE WORKFORCE to work a total number of hours similar to those of office-based practitioners are prone to burnout. Nurses working in the ED also experience significant stress.
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From page 242... ...
Over a 17-year period, the adoption of recommended universal precautions and the Occupational Safety and Health Administration's (OSHA) Bloodborne Pathogens Standard helped decrease the number of hepatitis B viral infections among health care workers from nearly 11,000 in 1983 to fewer than 400 in 1999 (CDC National Center for Infectious Disease, 2002)
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From page 243... ...
INCREASING INTERPROFESSIONAL COLLABORATION The concept of interprofessional collaboration gained strength in the late 1990s as attention to medical errors grew. Health services researchers and others interested in improving patient safety were energized by successes in the aviation industry, where teamwork training for the private and government aviation workforce led to reductions in errors and improved performance (Sprague, 1999)
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From page 244... ...
A November 2004 survey of members of ECRI's (formerly the Emergency Care Research Institute) Healthcare Risk Control System indicated that one-third of respondents provided teamwork training to employees, and nearly half that did not said they planned to do so in the next year (ECRI, 2005)
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From page 245... ...
An example is the Advanced Cardiac Life Support course for third-year medical students at Brown University, which involves assigning students to multidisciplinary teams with nurses and technicians. The teams receive teamwork training while learning advanced cardiac life support using a high-fidelity simulation mannequin (Morchi, 2002)
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From page 246... ...
This collaboration goes beyond transforming the patient care work environment, but must take place in parallel with such changes. For example, the operations management solutions to crowding discussed in Chapter 4 cannot work without buy-in and collabo BOX 6-2 Example of Effective Collaboration in the ED During an extremely busy shift in an ED whose entire staff had re cently been trained in teamwork and collaboration, an emergency physi cian had just come from a resuscitation and was seeing a patient with an acute but non-life-threatening condition.
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From page 247... ...
A recent IOM study, Quality Through Collaboration: The Future of Rural Health, described the special problems of rural health care and the unique challenges of providing high-quality medical services in rural areas, particularly core health services such as emergency care. The report highlighted the urgent shortages of medical personnel in rural areas, the critical need to address these shortages, and the complex challenges associated with strengthening the rural workforce (IOM, 2004b)
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From page 248... ...
, the lack of physicians trained in emergency medicine in these settings is not surprising. One strategy for increasing the emergency care workforce in rural areas would be to increase the number of emergency medicine residency programs in these areas.
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From page 249... ...
. Rural ED providers exhibit wide variability in their skill levels and the competence with which they provide emergency care.
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From page 250... ...
Given current workforce shortages in emergency care and economic conditions in the health system, rural EDs are unlikely to have residency-trained, board-certified emergency physicians on a round-theclock basis. Approaches recommended to address this situation include increased collaboration between emergency medicine and primary care specialties (such as family practice physicians who provide emergency medical care in rural areas)
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From page 251... ...
6.5: The Department of Health and Human Services, in partner ship with professional organizations, should develop national stan dards for core competencies applicable to physicians, nurses, and other key emergency and trauma professionals, using a national, evidence-based, multidisciplinary process. 6.6: States should link rural hospitals with academic health centers to enhance opportunities for professional consultation, telemedi cine, patient referral and transport, and continuing professional education.
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From page 252... ...
2004. America's emergency care system and severe acute respiratory syndrome: Are we ready?
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From page 253... ...
2002. Advance practice nurses in emergency care settings: A demographic profile.
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From page 254... ...
Rockville, MD: Department of Health and Human Services, Agency for Healthcare Research and Quality. Hockberger RS, Binder LS, Graber MA, Hoffman GL, Perina DG, Schneider SM, Sklar DP, Strauss RW, Viravec DR, Koenig WJ, Augustine JJ, Burdick WP, Henderson WV, Law rence LL, Levy DB, McCall J, Parnell MA, Shoji KT, American College of Emergency Physicians Core Content Task Force II.
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From page 255... ...
. Rockville, MD: Agency for Healthcare Research and Quality.
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From page 256... ...
Emergency Departments. Falls Church, VA: KAR Associates.
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From page 257... ...
Pediatric Emergency Care 15(1)
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From page 258... ...
2004. Cause-and-effect analysis of risk management files to assess patient care in the emergency department.
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