Index

A

Academic health centers

ED crowding in, 40

linkage with rural EDs, 11, 250, 251

recommendations for, 11, 250, 251, 297, 315

research support, 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

importance of, 14, 94

for patient flow management, 155156

shortcomings of current system, 1415, 2223

See also Performance measurement

Accrediting organizations, 95

Admissions, hospital ED

admission/discharge unit, 151

alcohol- and drug-related, 6364

automated triage systems, 182184

bedside registration, 150, 175

bottlenecks, 136

causes, 1, 18

elderly patients, 347348

fast tracks, 149150

frequent users, 349350

full-capacity protocols, 150151

integrated health care system, 165167

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, 4142

patterns and trends, 1, 2, 18, 38, 39, 293, 345350

pediatric patients, 348

Advanced life support (ALS) protocols, 9091

Advanced practice nurses, 231

Adverse events

causes, 2324

information technology for monitoring, 173174

information technology to prevent, 184186

risk in EDs, 23

teamwork training to reduce, 244245

types of, 23

Agency for Healthcare Research and Quality, 112, 115, 264, 299



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 383
Hospital-Based Emergency Care: At the Breaking Point Index A Academic health centers ED crowding in, 40 linkage with rural EDs, 11, 250, 251 recommendations for, 11, 250, 251, 297, 315 research support, 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 importance of, 14, 94 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 causes, 1, 18 elderly patients, 347–348 fast tracks, 149–150 frequent users, 349–350 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 causes, 23–24 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

OCR for page 383
Hospital-Based Emergency Care: At the Breaking Point Ambulance diversion causes, 4, 20–21, 136 consequences, 4, 41 frequency, 4, 19, 21, 41 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 mental health, 61, 62 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 causes, 3, 4, 39, 136 costs, 4, 20 definition, 4, 20, 39 extent, 4, 20, 40 psychiatric patients, 62 recommendations, 6, 157, 159, 160 Building a Better System: A New Engineering/Health Care Partnership, 28–29 C California, 106–107 Capacity categorization of services, 14, 89–90, 92, 124 current problems in, 38–39 disaster preparedness, 8, 9, 22, 265–266 disincentives to improve efficiency, 157–158 frequency of problems in, 4 recent trends, 2–3 regionalization of specialty services, 10–11 shortcomings of current system, 19 unit assessment tools, 148 See also Crowding, ED Cardiac arrest data, 97, 98 CareGroup HealthCare Systems, 183 Case management, 145–146 Categorization of ED services, 14, 89–90, 92, 124 trauma hospitals, 357–358 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 research program, 299, 309 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 leadership to improve hospital efficiency, 152–153

OCR for page 383
Hospital-Based Emergency Care: At the Breaking Point 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 automated triage, 182–184 Clinical decision units (CDUs) benefits, 144–145 case management and, 145–146 purpose, 5, 143–144 recommendations for, 5, 148, 160 reimbursement, 147–148 staffing, 144 Closure of facilities for legal liability concerns, 223, 224 Los Angeles experience, 19, 20–21, 57 recent history, 2–3, 19, 38 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 secure systems, 181–182 See also Information technology Community Councils on Emergency Medical Services, 82 Community health centers, 43, 44 Computed tomography, 176, 190 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 Connecticut, 269–270 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 disaster response, 268–269 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 obstacles to, 83, 84, 99–102 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 nonemergency care, 3, 48 traumatic injury treatment, 18 trends, 5, 56 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 consequences, 4, 17–18, 20 coordination within health care system to avoid, 13 delays in diagnostic services, 137 discharge processing and, 148–149 elective surgery schedule and, 141 frequency, 4, 19, 39–40 full-capacity protocols, 150–151

OCR for page 383
Hospital-Based Emergency Care: At the Breaking Point incentives for hospitals to reduce, 5–6, 156–157 management strategies, 4–5 measures of, 154–155 patient-centered care and, 25 patient departure before assessment, 42 recommendations, 6, 157 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 ED capacity and, 38–39 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 rationale, 107–108 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 disaster events, 260–261 example (Rhode Island nightclub fire), 265, 267–268 federal funding, 282, 283–284, 285 hospital responses, 263–265 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 regionalization, 269–270 role of hospital EDs, 1, 19, 259, 265 in rural areas, 281–282 scope of, 259–260 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 ED crowding and, 148–149 Dispatchers, 13 Disproportionate Share Hospital (DSH) payments, 7, 42, 52–53, 54 Documentation of care, 186–187

OCR for page 383
Hospital-Based Emergency Care: At the Breaking Point 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 reimbursement trends, 56–58 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 ED visits, 347–348 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 goals, 81–82 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 scope, 31, 81 EMERGency ID NET, 280, 304 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 Fast tracks, 149–150 Federal Emergency Management Agency (FEMA), 112 Federal government disaster preparedness policies and practices, 261–262, 264–265, 270, 283–284, 285

OCR for page 383
Hospital-Based Emergency Care: At the Breaking Point 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 Florida, 105–106 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 Hill-Burton Act, 170, 353 Home Health Compare, 98 Hospital beds causes of ED crowding, 39 coordinated management, 141–142 recent losses, 2–3, 38 surge capacity, 265–266 Hospital Emergency Incident Command System, 269 Hospitalists, 227–228 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 clinical resources, 187–188 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 current state, 167, 168, 171 electronic dashboards, 166, 173–174 electronic prescribing, 181 evolution in health care, 167–168 human factors issues, 197–199 implementation strategies, 200–201, 202 interoperability standards, 196–197 to manage patient flow, 151–152

OCR for page 383
Hospital-Based Emergency Care: At the Breaking Point 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 mortality, 1, 18 prevention, 307, 355 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 Intensivists, 228–229 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 location, 120–121 objectives, 120 rationale, 110–111, 118 recommendations, 16, 119, 125 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 reform strategies, 224–225 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

OCR for page 383
Hospital-Based Emergency Care: At the Breaking Point M Magnetic resonance imaging (MRI), 176, 190–191 Malpractice lawsuits. See Legal liability Maryland, 86, 102–104 Medicaid clinical decision unit reimbursement, 147–148 Disproportionate Share Hospital payments, 7, 42, 54 ED reimbursement, 3, 53–54 ED utilization, 3, 46, 52 enrollment in rural areas, 67 managed care, 42 payment methods, 53–54 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 ED utilization, 52, 54 prehospital care reimbursement, 99 reimbursement system, 54 See also Centers for Medicare and Medicaid Services Medicare Modernization Act, 55 Medication errors, 23 Mental health assessment, 61, 62 ED utilization related to disorders of, 61 of ED workforce, 240–241 among elderly, 61 pediatric disorders, 61–62 provider training for, 62 quality of care, 59, 61–62 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 stresses of ED work, 241, 243 supply issues, 231–234 training, 229–230 violent assault risk, 241 zone nursing, 150 See also Workforce, medical

OCR for page 383
Hospital-Based Emergency Care: At the Breaking Point 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 in ED collaboration, 246–247 Emergency Medicine Treatment and Active Labor Act and, 226–227 hospitalists, 227–228 liability concerns, 223–226 obstacles to availability, 10, 22, 219 quality-of-life concerns of, 222–223 recommendations regarding, 251 regionalization, 10–11, 105–106, 220, 251 reimbursement issues, 221–222 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 implementation, 246–247 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 data collection, 153–154 definition, 133 discharge processing, 148–149 disincentives to improving, 99–100, 130, 157–158 elective surgery schedule, 141 goals, 140 hospital leadership for improving, 152–153 impediments to, 135–139 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 current state, 348–349 mental health problem related, 61–62 regional coordination of care, 86 utilization patterns, 348 Performance measurement central authority for, 95–96 challenges in emergency care system evaluation, 94 current ED measures, 94–95 data collection, 15 documentation of care, 186–187 emergency care research programs, 299–300 goals, 97 implementation, 96, 97, 159 information technology for, 173–174 patient clinical data for, 96 patient flow management, 154–155

OCR for page 383
Hospital-Based Emergency Care: At the Breaking Point public reporting, 15, 97–99, 159 recommendations for system performance indicators, 15, 96 shortcomings of current system, 22–23 Pharmacy ED staff, 234–235 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 in rural areas, 68–69 stresses of ED work, 240–241 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 ED staffing, 235–236 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 ED utilization and, 51–52 in emergency care settings, 84–85 injury control research, 307, 355 Primary and nonurgent care barriers to, 45–46 costs, 3 definition and scope, 31–32 ED utilization for, 43 government support, 44 patient understanding of, 48–49 physician training in emergency care, 237–238 problems for EDs, 3, 47–48 quality of care in EDs, 25 reasons for ED utilization, 45–47, 85 role of hospital EDs, 1, 3 scheduled vs. nonscheduled care, 49–52 Privately insured patients denial of coverage for emergency care, 55 ED utilization, 54 reimbursement patterns, 54–55 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 information technologies for, 172, 188–189

OCR for page 383
Hospital-Based Emergency Care: At the Breaking Point 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 current state, 97–99 forms, 15, 97 goals, 97 implementation, 99 rationale, 15, 97, 159 Q Quality functional deployment, 132 Quality of care in hospital EDs ambulance diversion outcomes, 41 causes of adverse events, 23–24 current system, 1, 23, 81 effectiveness, 24–25 indicators, 23 obstacles to improving, 12–13 overcrowding effects, 4, 40 for patients with mental health problems, 61–62 pediatric care, 348–349 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 systemic context, 12, 13 Quality Through Collaboration: The Future of Rural Health, 65, 179, 247 Queuing theory, 5, 133, 140 R Race/ethnicity, 26, 349 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 concerns, 88–89 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 obstacles to, 99–102 on-call specialty services, 10–11 patient flow, 136 pediatric care, 86 rationale, 14, 87 recommendations, 14, 251 scope, 89 specialty hospitals and, 88–89 system characteristics, 87–88 trauma care, 358 See also Coordination of care Reimbursement clinical decision units, 147–148 current inadequacies, 56–58 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 ED physicians, 214–215 incentives to improve emergency care system, 5–6, 156–157 Medicaid, 3, 45, 56–57 Medicare, 56–57 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

OCR for page 383
Hospital-Based Emergency Care: At the Breaking Point Research barriers to, 311 basic science, 301 clinical, 301–302 emergency medicine, 291, 293 Federalwide Assurance Program, 314–315, 316 future directions, 300–303, 310–311 General Clinical Research Centers, 12, 312–313 health services, 302–303 infrastructure and funding, 294–300, 308–309, 311–313 multicenter collaborations, 304 needs. See Research needs recommendations, 297, 311–312, 315–316 researcher training, 295–297 rights of human subjects in, 313–315 trauma and injury, 304–311 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 recommendations, 11–12, 251 scope of emergency care, 291–293 shortcomings of current system, 23 workforce supply, 237, 251 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 current challenges, 37–38 historical development, 1, 18–19, 37 perceptions of, 37 primary and nonurgent care delivery, 1, 3 as safety net, 42–43 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 payer mix, 66–68 prehospital care, 69 provider training, 69–70, 249 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 risks, 23–24, 240–243 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 current challenges, 7, 10, 43 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 transfers to, 7, 56, 100, 223 trauma centers, 217–218 urban vs. rural, 51 St. John’s Regional Health Center, 146–147 San Francisco Community Clinic Consortium, 86 SARS. See Severe acute respiratory syndrome

OCR for page 383
Hospital-Based Emergency Care: At the Breaking Point 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 compensation, 221–222 core competencies for emergency medicine, 239 critical care specialists/intensivists, 228–229, 251 disaster response, 266 emergency medicine, 211, 354–355 hospitalists, 227–228 implications for regionalization, 88–89 legal liability concerns, 223–225 nursing, 230, 231 on-call, availability of, 218–219 recommendations for critical care medicine certification, 229, 251 regionalization of ED services, 10–11, 14, 103, 220 in rural areas, 68, 250 specialty hospitals, 88–89 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 screening, 64–65 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, 189, 280–281 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 Texas, 104–105 Timeliness of care, 25–26 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 improved outcomes related to, 238–239

OCR for page 383
Hospital-Based Emergency Care: At the Breaking Point in information technologies, 198–199 information technology for, 172, 187, 188 in mental health issues, 62 military medicine, 362 nursing staff, 229–230, 239 in operations management, 6, 153, 160 for providers in rural areas, 69–70, 249 recommendations, 6, 9, 11, 153, 160, 274, 285 researcher training, 295–297 simulation training, 245 teamwork training, 244–245 trauma surgeons, 217 Trauma care categorization of hospitals, 357–358 definition, 31, 356 ED visits for, 345–346 historical development, 356–357 medical specialties, 359 regional coordination, 358 research areas, 291–292, 304–307, 310–311 research infrastructure and funding, 308–309 surgical specialty, 216–218 Trauma Care Systems Planning and Development Act, 357 Trauma center(s), 31, 356, 360 Trauma system characteristics, 87–88 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 ED utilization, 46, 53 number of, 3, 42 role of hospital EDs, 1, 42–43 rural populations, 66–67 undocumented immigrants, 55 See also Uncompensated care Unit assessment tools, 148 University HealthSystem Consortium, 139 Urgent Matters, 139, 154, 300 U.S. Fire Administration, 112 V Veterans Health Administration, 198, 271, 285 Videoconferencing, 179 Violence risk in ED, 241–242 W Wait times assessment in waiting room, 25 for mental health bed, 62–63 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 pharmacists, 234–235 ED staffing standards, 138 Emergency Medical Treatment and Active Labor Act requirements, 226–227 EMS professionals, 235–236 exposure to violence, 241–242 infectious disease risk, 242–243 interprofessional collaboration, 243–247 leadership for efficiency improvement, 154 malpractice liability concerns, 11, 251 moonlighting, 216 physician assistants, 234 protection of, during disaster response, 9, 22, 275–279

OCR for page 383
Hospital-Based Emergency Care: At the Breaking Point recommendations for research, 237, 251 in rural areas, 11, 68–69, 237, 247–250 social and psychological care, 236 stresses of ED environment, 209, 240–241, 243 supply challenges, 236–237 See also Nursing staff; On-call specialists; Physicians; Specialized medical services Z Zone nursing, 150

OCR for page 383
Hospital-Based Emergency Care: At the Breaking Point This page intentionally left blank.