Hospital-Based Emergency Care At the Breaking Point (2007) / Chapter Skim
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From page 383... ...
Index A elderly patients, 347–348 fast tracks, 149–150 Academic health centers frequent users, 349–350 ED crowding in, 40 full-capacity protocols, 150–151 linkage with rural EDs, 11, 250, 251 integrated health care system, 165–167 recommendations for, 11, 250, 251, legal and regulatory requirements, 100 297, 315 Medicaid enrollees, 3 research support, 297, 315 mental health problem-related, 61 Accidental Death and Disability: The patient-centered care, 25 Neglected Disease of Modern patient characteristics, 2, 3, 39, 349 Society, 27, 82, 92, 305, 354 patient insurance coverage, 52 Accountability patient leaving before being seen, 41–42 challenges in implementing, 94 patterns and trends, 1, 2, 18, 38, 39, current efforts to improve local 293, 345–350 emergency care systems, 104, 105, pediatric patients, 348 106, 107 Advanced life support (ALS) protocols, importance of, 14, 94 90–91 for patient flow management, 155–156 Advanced practice nurses, 231 shortcomings of current system, 14–15, Adverse events 22–23 causes, 23–24 See also Performance measurement information technology for monitoring, Accrediting organizations, 95 173–174 Admissions, hospital ED information technology to prevent, admission/discharge unit, 151 184–186 alcohol- and drug-related, 63–64 risk in EDs, 23 automated triage systems, 182–184 teamwork training to reduce, 244–245 bedside registration, 150, 175 types of, 23 bottlenecks, 136 Agency for Healthcare Research and causes, 1, 18 Quality, 112, 115, 264, 299
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From page 384... ...
, 215, 218, 294 92, 124 American College of Surgeons, 306, 307, current problems in, 38–39 357, 358 disaster preparedness, 8, 9, 22, 265–266 America's Health Care Safety Net: Intact disincentives to improve efficiency, but Endangered, 42 157–158 A Shared Destiny: Community Effects of frequency of problems in, 4 Uninsurance, 28, 42 recent trends, 2–3 Assessment regionalization of specialty services, automated triage systems, 182–184 10–11 defensive medicine, 138 shortcomings of current system, 19 diagnostic imaging technology, 176–177 unit assessment tools, 148 ED crowding and, 137 See also Crowding, ED ED triage, 150 Cardiac arrest data, 97, 98 in EDs, 47 CareGroup HealthCare Systems, 183 fast track processing in ED admissions, Case management, 145–146 149–150 Categorization of ED services, 14, 89–90, hospitalist role, 228 92, 124 laboratory services, 193 trauma hospitals, 357–358 mental health, 61, 62 trauma surgery, 217 overtriage, 346 Cedar-Sinai Medical Center, 154, 199 rapid diagnostic technologies, 191–193 Centers for Disease Control and Prevention substance abuse issues, 64 (CDC) , 86, 264, 280–281, 284 utilization of resources in ED, 137–138 in regional planning and coordination, Avian influenza, 9 88, 89 reimbursement strategies to improve emergency care system, 99–100 B research program, 299, 309 Back pain among ED workers, 243 Centers for Medicare and Medicaid Balance Budget Act (1997)
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From page 385... ...
disaster response, 268–269 benefits, 144–145 fragmentation of current care system, case management and, 145–146 13, 16, 22, 81, 83–84, 111 purpose, 5, 143–144 goals for emergency care system, 13, 81, recommendations for, 5, 148, 160 82–83 reimbursement, 147–148 information technology for, 168, 170, staffing, 144 178–182 Closure of facilities interprofessional collaborations, for legal liability concerns, 223, 224 243–247 Los Angeles experience, 19, 20–21, 57 linkages among health care providers, recent history, 2–3, 19, 38 85 in rural areas, 66 obstacles to, 83, 84, 99–102 uncompensated care and, 22 rationale, 13 Committee on the Future of Emergency recommendations for national agency Care, 1–2, 27–29, 30–31 for, 16, 119–124 Communications systems strategies for improving, 85–86 coordination of emergency care delivery, trauma care systems, 358 13, 86 vignette of emergency response, current efforts to integrate local 165–167 emergency care systems, 102–103 See also Regionalization digital voice communications, 175 Costs for disaster response, 178, 270 care for undocumented immigrants, 55 goals for integrated system, 86–87 closure of EDs, 38 prehospital communications, 178 disaster drills, 273 radiography and picture transmissions, disaster preparedness funding, 9 176–177 of health care system failures, 130 recommendations for, 7, 193, 202 nonemergency care, 3, 48 secure systems, 181–182 traumatic injury treatment, 18 See also Information technology trends, 5, 56 Community Councils on Emergency See also Economics; Uncompensated Medical Services, 82 care Community health centers, 43, 44 Critical Access Hospital, 67–68 Computed tomography, 176, 190 Critical care specialists, 228–229, 251 Computed tomography angiography, 191 Crossing the Quality Chasm: A New Computerized physician order entry, 166, Health System for the st Century, 169, 184–185, 200–201 23, 28, 130 current implementations, 168 Crowding, ED Confidentiality causes, 3, 19–20, 39, 131, 132 human subjects research, 313, 314–315 consequences, 4, 17–18, 20 information technology and, 181–182, coordination within health care system 200 to avoid, 13 Connecticut, 269–270 delays in diagnostic services, 137 Contract management groups, 210–211, discharge processing and, 148–149 215–216 elective surgery schedule and, 141 frequency, 4, 19, 39–40 full-capacity protocols, 150–151
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From page 386... ...
, 265, 267–268 Delayed treatment federal funding, 282, 283–284, 285 coordination within health care system hospital responses, 263–265 to avoid, 13 medical specialist capacity, 266 related mortality, 6 personal protective equipment, 276–279 Demand for ED and trauma care protection of medical personnel, 9 ED capacity and, 38–39 recommendations for improving, 9, 284 patterns and trends, 3, 19, 46 recommendations for national agency population life-span effects, 52 for care delivery, 16 primary and nonurgent care-seeking, recommendations for training in, 274 45–46 recommendations for Veterans Health scheduled s. nonscheduled care, 49–52 Administration, 271 See also Crowding, ED regionalization, 269–270 Demonstration projects role of hospital EDs, 1, 19, 259, 265 administration, 110 in rural areas, 281–282 rationale, 107–108 scope of, 259–260 recommendations, 15–16, 108, surge capacity, 8, 22, 265–266 124–125 surveillance role of EDs, 279–281 structure and operations, 108–110 terrorist events, 261 Department of Health and Human Services threat identification, 261–262 (DHHS)
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From page 387... ...
, 112 mental health problems, 61 Federal government traumatic injury mortality, 293 disaster preparedness policies and Elective surgery schedule, 141, 157, 158 practices, 261–262, 264–265, 270, 283–284, 285
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From page 388... ...
HOSPITAL-BASED EMERGENCY CARE emergency care bureaucracy, 111–115 Health Resources and Services establishment of new agency for Administration, 8, 88, 264–265, 299 emergency care system integration, recommendations for, 15–16, 108, 110, 16, 117–124 124–125 Federal Interagency Committee on EMS Healthcare Resources and Services (FICEMS) , 113, 115–117 Administration, 357 recommendations for, 7–8, 9, 11, 12, Highway Safety Act (1966)
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From page 389... ...
INDEX J military medicine, 360 mobile and handheld devices, 175–176 Joint Commission on Accreditation of national infrastructure, 170 Healthcare Organizations (JCAHO) , new clinical technologies, 190–194 235 obstacles to adoption and diffusion, disaster preparedness requirements, 168, 194–200 265, 272 patient clinical data collection, 96 patient flow standards, 6, 139, 157, 160 for patient flow improvement, 154–155, recommendations for, 6, 153, 157, 160 172–177 patient medical information, 86, 151, 177, 360–361 L for performance assessment, 173–174 picture archiving and transmission, Laboratory services, 193 176–177 Leadership for system integration population health surveillance, 172, current federal bureaucracy, 111–115 188–189, 280 establishment of new agency for, 16, prehospital intervention, 178 117–124 radio frequency identification tracking, Federal Interagency Committee on EMS 174–175 role, 113, 115–117 recommendations for, 7, 193, 202 funding, 123 registration process, 150, 175 implementation, 121–122, 123–124 role of, 6–7 information technology, 170 shortcomings of current system, 7, 130 location, 120–121 system interconnectedness, 168, 171, objectives, 120 178–182 rationale, 110–111, 118 technologies for emergency care, 7, recommendations, 16, 119, 125 171–172, 201–202 research activities and, 121 training applications, 172, 187, 188 strategies, 115 trends in health care, 168–169 Leapfrog Group, 228 vignette of integrated health care Legal liability system, 165–167 concerns of ED physicians, 10, 11, See also Communications systems 223–224 Informed consent, 313–314, 315 defensive medicine in ED and, 138 Injuries, unintentional emergency medicine training and, health care system failures, 130 238–239 hospital ED admissions, 1, 18, 345 malpractice award limits and, 224–225 mortality, 1, 18 on-call immunity, 225 prevention, 307, 355 recommendations for research, 11, 226, research areas, 292–293, 304–305, 251 307–308, 310–311 reform strategies, 224–225 research infrastructure and funding, supply of ED providers and, 11, 22, 308–309 251 Injury in America: A Continuing Public teamwork training and, 244 Health Program, 27, 305, 309, 355 Legal and regulatory environment Insight information system, 86, 281 recommendations for changes in, 102 Insurance.
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From page 390... ...
, 12, Disproportionate Share Hospital 121, 294, 295, 298–299, 308–309 payments, 7 National Quality Forum, 96 ED utilization, 52, 54 Negative pressure rooms, 9, 276 prehospital care reimbursement, 99 Neurosurgical specialists, 10, 219, 222, reimbursement system, 54 223–224 See also Centers for Medicare and Nursing Home Compare, 98 Medicaid Services Nursing staff Medicare Modernization Act, 55 advanced practice nurses, 231 Medication errors, 23 certified emergency nurses, 230 Mental health coordinated bed management, 141–143 assessment, 61, 62 core competencies, 239 ED utilization related to disorders of, current ED staffing, 229 61 demographic characteristics, 230, 231 of ED workforce, 240–241 disaster response training, 8, 274 among elderly, 61 ED functions, 229 pediatric disorders, 61–62 ED staffing standards, 138, 233 provider training for, 62 information technology utilization, quality of care, 59, 61–62 198–199 stresses in ED related to admissions for overtime work, 234 disorders of, 59, 62–63 psychiatric training, 62 Metropolitan Medical Response System stresses of ED work, 241, 243 (MMRS) , 112, 282, 283 supply issues, 231–234 Military medicine, 353, 356–357, 360–362 training, 229–230 Mortality violent assault risk, 241 critical care specialist effects, 228 zone nursing, 150 health care system failures, 130 See also Workforce, medical life-span trends, 52
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From page 391... ...
, 355 hospital leadership for improving, On-call specialists 152–153 categorization of ED capabilities, 90 impediments to, 135–139 critical care specialists, 228–229 importance of, 133 defensive medicine practices, 138 incentives to improve, 5–6, 156–157 in ED collaboration, 246–247 information technology for, 171, Emergency Medicine Treatment and 172–177 Active Labor Act and, 226–227 input/output/throughput model, hospitalists, 227–228 133–135, 154 liability concerns, 223–226 management tools, 4–5, 22, 132 obstacles to availability, 10, 22, 219 performance indicators, 154–155 quality-of-life concerns of, 222–223 protocols for prehospital care, 14 recommendations regarding, 251 regional, 136 regionalization, 10–11, 105–106, 220, staff leadership for improving, 154 251 strategies for improving, 139 reimbursement issues, 221–222 systemic approach to management, 132, in rural areas, 11, 68, 248, 250 155–156 supply problems, 10, 22, 27, 152, training for hospital administrators, 6 218–220, 359 unit assessment tools, 148 surgical subspecialty, 220–221 use of clinical decision units to manage, Operations management tools, 130–131 143–148 implementation, 246–247 See also Crowding, ED recommendations for, 5, 6, 152, 153, 160 Patient Flow Benchmarking Project, 139 training for hospital leaders, 6, 153, 160 PatientSite Project, 183 Orthopedic specialists, 10, 223 PECARN, 304 Outcome measures Pediatric emergency care, 355–356 ambulance diversion outcomes, 41 alcohol- and drug-related, 63 performance measurement, 97 current state, 348–349 regionalization rationale, 87 mental health problem related, 61–62 system performance indicators, 15, 96 regional coordination of care, 86 utilization patterns, 348 Performance measurement P central authority for, 95–96 challenges in emergency care system Patient advocates, 236 evaluation, 94 Patient-centered care, 25 current ED measures, 94–95 Patient flow data collection, 15 accountability for management documentation of care, 186–187 performance, 155–156 emergency care research programs, admissions bottlenecks, 136 299–300 bottleneck management, 140–149 goals, 97 care delivery strategies to improve, implementation, 96, 97, 159 149–152 information technology for, 173–174 coordination within health care system, patient clinical data for, 96 13 patient flow management, 154–155
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From page 392... ...
HOSPITAL-BASED EMERGENCY CARE public reporting, 15, 97–99, 159 definition, 31 recommendations for system disaster response, 266 performance indicators, 15, 96 ED staffing, 235–236 shortcomings of current system, 22–23 evolution of bureaucratic structure, Pharmacy 111–113 ED staff, 234–235 historical development, 355 physician prescribing practices, 181, information technology, 178 184–185 protocols for transport, 14, 90–92 Physician assistants, 234 recommendations for protocol Physicians development, 14, 91–92, 124 average workweek in ED, 240 recommendations for system demographics of ED physicians, integration, 16, 119 212–214 in rural areas, 69 disaster response training, 273–274 transport decisions, 93 Emergency Medical Treatment and Prescribing practices, 181, 184–185 Active Labor Act requirements, Preventive interventions 226–227 ED utilization and, 51–52 emergency medicine training, 211–212, in emergency care settings, 84–85 214 injury control research, 307, 355 employment patterns in EDs, 210–211, Primary and nonurgent care 215–216 barriers to, 45–46 historical development of hospital-based costs, 3 emergency care, 353–356 definition and scope, 31–32 information technology utilization, ED utilization for, 43 168–169, 198–199 government support, 44 knowledge and skills for ED work, 210 patient understanding of, 48–49 legal liability concerns, 10, 11, 223–226 physician training in emergency care, moonlighting, 216 237–238 on-call coverage, 10–11, 152, 218–219 problems for EDs, 3, 47–48 psychiatric training, 62 quality of care in EDs, 25 quality-of-life concerns of, 222–223 reasons for ED utilization, 45–47, 85 referral to ED from, 46–47, 137–138 role of hospital EDs, 1, 3 regionalization of specialty services, scheduled s. nonscheduled care, 49–52 10–11 Privately insured patients reimbursement patterns, 214–215 denial of coverage for emergency care, role of, in EDs, 210 55 in rural areas, 68–69 ED utilization, 54 stresses of ED work, 240–241 reimbursement patterns, 54–55 trauma and emergency surgeons, Psychiatric emergency care, 25 216–218, 220–221 Psychologists, 236 See also Specialized medical services Public health agencies Picture archiving and communications in coordination of emergency care systems, 176–177 delivery, 13, 84–85 Population patterns and trends leadership of national emergency care chronic disease prevalence, 346–347 system, 120–121 health care utilization and, 2, 38 in regionalization of emergency care life spans, 52 delivery, 251 Prehospital emergency medical services Public health and public safety categorization of services, 90 emergency communications technology, communications technology, 178 178 coordination of emergency care delivery information technologies for, 172, system, 13, 16, 22 188–189
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From page 393... ...
INDEX role of hospital EDs, 1, 18–19, 29–30 Regionalization surveillance role of EDs, 279–281 benefits, 88 syndromic surveillance, 189, 280–281 categorization of ED services, 14, Public perception and understanding 89–90, 92 emergency care system performance, 27, concerns, 88–89 94 current efforts to integrate local health care system performance, 130 emergency care systems, 103, 105, in improvement of health care system, 106, 107 159 disaster preparedness, 269–270 self-triage decisions, 93 implications of existing statutory urgency of medical needs, 48–49 regime, 100–102 Public reporting of performance data information technology, 171, 179 current state, 97–99 model, 89 forms, 15, 97 obstacles to, 99–102 goals, 97 on-call specialty services, 10–11 implementation, 99 patient flow, 136 rationale, 15, 97, 159 pediatric care, 86 rationale, 14, 87 recommendations, 14, 251 Q scope, 89 specialty hospitals and, 88–89 Quality functional deployment, 132 system characteristics, 87–88 Quality of care in hospital EDs trauma care, 358 ambulance diversion outcomes, 41 See also Coordination of care causes of adverse events, 23–24 Reimbursement current system, 1, 23, 81 clinical decision units, 147–148 effectiveness, 24–25 current inadequacies, 56–58 indicators, 23 Current Procedural Terminology, obstacles to improving, 12–13 214–215 overcrowding effects, 4, 40 disincentives to patient flow for patients with mental health improvement, 99–100, 130, problems, 61–62 157–158 pediatric care, 348–349 Disproportionate Share Hospital primary and nonurgent care, 47–48 payments, 7, 42, 52–53 psychiatric care, 25 ED crowding related to, 137 recommendations for improving, 4–12, ED physicians, 214–215 15–16 incentives to improve emergency care in rural areas, 25, 68–69, 70, 249–250 system, 5–6, 156–157 systemic context, 12, 13 Medicaid, 3, 45, 56–57 Quality Through Collaboration: The Future Medicare, 56–57 of Rural Health, 65, 179, 247 obstacles to emergency care system Queuing theory, 5, 133, 140 improvement, 99, 130 on-call emergency specialists, 221–222 relative value units, 215 R in rural areas, 248 scheduled s. nonscheduled procedures, Race/ethnicity, 26, 349 157, 158 Radio frequency identification (RFID)
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From page 394... ...
HOSPITAL-BASED EMERGENCY CARE Research Root-cause analysis barriers to, 311 Rural areas basic science, 301 challenges for EDs in, 65 clinical, 301–302 Critical Access Hospital program, emergency medicine, 291, 293 67–68 Federalwide Assurance Program, disaster preparedness, 281–282 314–315, 316 ED workforce characteristics, 249 future directions, 300–303, 310–311 hospital characteristics, 66 General Clinical Research Centers, 12, impediments to practice in, 248 312–313 payer mix, 66–68 health services, 302–303 prehospital care, 69 infrastructure and funding, 294–300, provider training, 69–70, 249 308–309, 311–313 quality of care, 25, 68–69, 70, 249–250 multicenter collaborations, 304 recommendations for hospitals in, 11, needs. See Research needs 250, 251 recommendations, 297, 311–312, regionalization effects, 88 315–316 strategies to improve emergency care, researcher training, 295–297 250 rights of human subjects in, 313–315 telemedicine applications, 179 trauma and injury, 304–311 workforce supply, 11, 68–69, 237, Research needs 247–250 categorization of emergency services, 14 clinical decision support systems, S 185–186 conventional weapons terrorism, 9 Safety current federal efforts, 112 adverse event risk, 23 impact of malpractice liability on ED risks, 23–24, 240–243 provider supply, 11, 225–226 ED security measures, 242 leadership of national emergency care infectious disease transmission in ED, system and, 121 242–243 recommendations, 11–12, 251 physician liability concerns and, 225 scope of emergency care, 291–293 protection of medical staff in disaster shortcomings of current system, 23 response, 9 workforce supply, 237, 251 of workforce in disaster response, Resource-based relative value scale, 214, 275–279 215 Safety net providers Resuscitation Outcomes Consortium, 304 current challenges, 7, 10, 43 Rhode Island nightclub fire, 265, 267–268 financial issues, 7, 44, 52–53, 54, 55, Robert Wood Johnson Foundation, 300 56–58, 100 Role of Emergency Medicine in the Future input/throughput/output model, 135 of American Medical Care, 28 liability issues, 11 Role of hospital EDs regional coordination, 179 current challenges, 37–38 role of hospital EDs, 1, 18, 29–30, historical development, 1, 18–19, 37 42–43, 85 perceptions of, 37 transfers to, 7, 56, 100, 223 primary and nonurgent care delivery, 1, 3 trauma centers, 217–218 as safety net, 42–43 urban s.
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From page 395... ...
, 147, 296, 300 screening, 64–65 Specialists stresses for EDs related to, 59, 65 categorization of ED services, 14 Suicidal patients, quality of ED care for, compensation, 221–222 61–62 core competencies for emergency Supply-chain management, 133 medicine, 239 Surgical specialists, 216–218, 220–221 critical care specialists/intensivists, military medicine, 361 228–229, 251 trauma care, 359 disaster response, 266 Surveillance, public health emergency medicine, 211, 354–355 coordination of communications, 86 hospitalists, 227–228 in emergency care settings, 85 implications for regionalization, 88–89 information technology for, 172, legal liability concerns, 223–225 188–189, 280 nursing, 230, 231 role of hospital EDs, 1, 18–19, 30, on-call, availability of, 218–219 279–281 recommendations for critical care syndromic, 189, 280–281 medicine certification, 229, 251 Syndromic surveillance, 189, 280–281 regionalization of ED services, 10–11, Systems analysis, 131, 155–156 14, 103, 220 in rural areas, 68, 250 T specialty hospitals, 88–89 supply problems, 10, 19, 22, 25, Telemedicine, 11, 179, 250, 251 219–220, 221–225 Terrorist attacks, 8, 9, 261, 276, 278, 279, See also On-call specialists 281, 283–284 Standards of care Tertiary hospital quality of care, 24–25 boarding and ambulance diversion, 6, Texas, 104–105 159, 160 Timeliness of care, 25–26 core competencies for emergency To Err Is Human: Building a Safer Health professionals, 239–240, 251 System, 28, 130, 244 patient flow, 6, 139, 157, 160 Training for health care professionals prehospital care, 14, 90–92, 124 benefits of regionalization, 88 system performance indicators, 15, 96 choice of practice location related to State Children's Health Insurance Program, location of, 248 52 core curriculum, 238 State government for disaster preparedness, 8, 9, 271– current efforts to integrate emergency 274, 285 care system, 102–107 emergency medicine specialty, 211–212, demonstration project grants, 15–16, 214, 237–238, 238, 294–295 108–110 to enhance rural EDs, 11 disaster response, 268 graduate medical education, 237 emergency care funding mechanisms, 59 improved outcomes related to, 238–239 patient clinical data collection, 96
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From page 396... ...
HOSPITAL-BASED EMERGENCY CARE in information technologies, 198–199 ED utilization, 46, 53 information technology for, 172, 187, number of, 3, 42 188 role of hospital EDs, 1, 42–43 in mental health issues, 62 rural populations, 66–67 military medicine, 362 undocumented immigrants, 55 nursing staff, 229–230, 239 See also Uncompensated care in operations management, 6, 153, 160 Unit assessment tools, 148 for providers in rural areas, 69–70, 249 University HealthSystem Consortium, 139 recommendations, 6, 9, 11, 153, 160, Urgent Matters, 139, 154, 300 274, 285 U.S. Fire Administration, 112 researcher training, 295–297 simulation training, 245 V teamwork training, 244–245 trauma surgeons, 217 Veterans Health Administration, 198, 271, Trauma care 285 categorization of hospitals, 357–358 Videoconferencing, 179 definition, 31, 356 Violence risk in ED, 241–242 ED visits for, 345–346 historical development, 356–357 medical specialties, 359 W regional coordination, 358 research areas, 291–292, 304–307, Wait times 310–311 assessment in waiting room, 25 research infrastructure and funding, for mental health bed, 62–63 308–309 nonemergency patients, 3 surgical specialty, 216–218 patient departure before assessment, Trauma Care Systems Planning and 25–26, 42 Development Act, 357 Washington Hospital Center, 86, 281 Trauma center(s)
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From page 397... ...
INDEX recommendations for research, 237, See also Nursing staff; On-call 251 specialists; Physicians; Specialized in rural areas, 11, 68–69, 237, 247–250 medical services social and psychological care, 236 stresses of ED environment, 209, Z 240–241, 243 supply challenges, 236–237 Zone nursing, 150
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