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Suggested Citation:"Index." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
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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

Suggested Citation:"Index." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
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Ambulance diversion

causes, 4, 2021, 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, 145146

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, 182184

defensive medicine, 138

diagnostic imaging technology, 176177

ED crowding and, 137

ED triage, 150

in EDs, 47

fast track processing in ED admissions, 149150

hospitalist role, 228

laboratory services, 193

mental health, 61, 62

overtriage, 346

rapid diagnostic technologies, 191193

substance abuse issues, 64

utilization of resources in ED, 137138

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, 174175, 183

Bioterrorism Hospital Preparedness Program, 283284

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, 2829

C

California, 106107

Capacity

categorization of services, 14, 8990, 92, 124

current problems in, 3839

disaster preparedness, 8, 9, 22, 265266

disincentives to improve efficiency, 157158

frequency of problems in, 4

recent trends, 23

regionalization of specialty services, 1011

shortcomings of current system, 19

unit assessment tools, 148

See also Crowding, ED

Cardiac arrest data, 97, 98

CareGroup HealthCare Systems, 183

Case management, 145146

Categorization of ED services, 14, 8990, 92, 124

trauma hospitals, 357358

trauma surgery, 217

Cedar-Sinai Medical Center, 154, 199

Centers for Disease Control and Prevention (CDC), 86, 264, 280281, 284

in regional planning and coordination, 88, 89

reimbursement strategies to improve emergency care system, 99100

research program, 299, 309

Centers for Medicare and Medicaid Services (CMS), 226227

ED physician reimbursement, 214215

incentives for hospitals to improve ED efficiency, 156157

recommendations for, 6, 8, 58, 70, 148, 159, 160

Chief Executive Officers, hospital

average tenure, 153

leadership to improve hospital efficiency, 152153

Suggested Citation:"Index." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
×

recommendations for, 5, 6, 152, 160

training for, 6

Chronic disease management, 5152

Clinical decision support systems (CDSSs), 166, 169, 172, 176, 185186, 200

automated triage, 182184

Clinical decision units (CDUs)

benefits, 144145

case management and, 145146

purpose, 5, 143144

recommendations for, 5, 148, 160

reimbursement, 147148

staffing, 144

Closure of facilities

for legal liability concerns, 223, 224

Los Angeles experience, 19, 2021, 57

recent history, 23, 19, 38

in rural areas, 66

uncompensated care and, 22

Committee on the Future of Emergency Care, 12, 2729, 3031

Communications systems

coordination of emergency care delivery, 13, 86

current efforts to integrate local emergency care systems, 102103

digital voice communications, 175

for disaster response, 178, 270

goals for integrated system, 8687

prehospital communications, 178

radiography and picture transmissions, 176177

recommendations for, 7, 193, 202

secure systems, 181182

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, 184185, 200201

current implementations, 168

Confidentiality

human subjects research, 313, 314315

information technology and, 181182, 200

Connecticut, 269270

Contract management groups, 210211, 215216

Coordination of care

automated discharge systems, 180

automated referral systems, 180181

communication system for, 8687

current efforts to improve, 102103, 104107

disaster response, 268269

fragmentation of current care system, 13, 16, 22, 81, 8384, 111

goals for emergency care system, 13, 81, 8283

information technology for, 168, 170, 178182

interprofessional collaborations, 243247

linkages among health care providers, 85

obstacles to, 83, 84, 99102

rationale, 13

recommendations for national agency for, 16, 119124

strategies for improving, 8586

trauma care systems, 358

vignette of emergency response, 165167

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, 6768

Critical care specialists, 228229, 251

Crossing the Quality Chasm:

A New Health System for the 21st Century, 23, 28, 130

Crowding, ED

causes, 3, 1920, 39, 131, 132

consequences, 4, 1718, 20

coordination within health care system to avoid, 13

delays in diagnostic services, 137

discharge processing and, 148149

elective surgery schedule and, 141

frequency, 4, 19, 3940

full-capacity protocols, 150151

Suggested Citation:"Index." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
×

incentives for hospitals to reduce, 56, 156157

management strategies, 45

measures of, 154155

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, 214215

D

Delayed treatment

coordination within health care system to avoid, 13

related mortality, 6

Demand for ED and trauma care

ED capacity and, 3839

patterns and trends, 3, 19, 46

population life-span effects, 52

primary and nonurgent care-seeking, 4546

scheduled vs. nonscheduled care, 4952

See also Crowding, ED

Demonstration projects

administration, 110

rationale, 107108

recommendations, 1516, 108, 124125

structure and operations, 108110

Department of Health and Human Services (DHHS), 229

disaster preparedness policies and practices, 264, 270, 271, 282, 283, 285

emergency care bureaucracy, 111112

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, 156157

Diagnostic errors, 23

Diagnostic technologies, 191193

Disaster preparedness

communications technology, 178, 270

coordination among health care entities, 268269

cost of disaster drill, 273

current inadequacies, 89, 22, 259, 265, 270, 274, 282

disaster events, 260261

example (Rhode Island nightclub fire), 265, 267268

federal funding, 282, 283284, 285

hospital responses, 263265

medical specialist capacity, 266

personal protective equipment, 276279

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, 269270

role of hospital EDs, 1, 19, 259, 265

in rural areas, 281282

scope of, 259260

surge capacity, 8, 22, 265266

surveillance role of EDs, 279281

terrorist events, 261

threat identification, 261262

training for, 8, 9, 271274, 285

Veterans Health Administration role, 271, 285

Discharge processing

admission/discharge unit, 151

automated systems, 180

discharge coordinator, 149

ED crowding and, 148149

Dispatchers, 13

Disproportionate Share Hospital (DSH) payments, 7, 42, 5253, 54

Documentation of care, 186187

Suggested Citation:"Index." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
×

E

Economics

barriers to primary care, 4546

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, 1516, 108110, 124125

disincentives to patient flow improvement, 99100, 130, 157158

funding for disaster preparedness, 282, 283284, 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, 56, 156157

information technology investments, 169, 194196

reimbursement trends, 5658

research funding, 12, 294295, 298300, 308309

rural health care facilities, 66

state funding mechanisms for emergency care, 59

See also Costs;

Uncompensated care

Effectiveness of ED care, 2425

Efficiency

barriers to improvement, 26, 152

benefits of regionalization, 88

current inadequacies, 130

disincentives to improving, 99100, 130, 157158

hospital leadership for improvement in, 6, 152153

incentives to improve, 56, 156157

See also Patient flow

Elderly patients

ED visits, 347348

mental health problems, 61

traumatic injury mortality, 293

Elective surgery schedule, 141, 157, 158

Electronic health records (EHRs), 151152, 168, 177

Emergency care system

current fragmentation, 16, 22, 81, 111

current reform efforts, 102107

definition, 31

goals, 8182

within health care system, 129131

historical and conceptual development, 353356

implementation of reform, 110111

performance measurement, 9496

public perception of performance, 94

recommendations for new national agency, 16, 119124

scope, 31, 81

EMERGency ID NET, 280, 304

Emergency Medical Services Agenda for the Future, 29, 8283, 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, 2627, 100101, 157, 218219, 346

effects on physician supply, 226227

hospital staffing and, 226

recommendations for changes in, 102, 124

violations of, 158

Emergency Medicine Foundation, 296

Emergency Severity Index, 182184

EMS Performance Measures Project, 95

Ethical practice in human subjects research, 313314

eTRIAGE, 184

F

Failure modes and effects analysis, 132

Fast tracks, 149150

Federal Emergency Management Agency (FEMA), 112

Federal government

disaster preparedness policies and practices, 261262, 264265, 270, 283284, 285

Suggested Citation:"Index." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
×

emergency care bureaucracy, 111115

establishment of new agency for emergency care system integration, 16, 117124

Federal Interagency Committee on EMS (FICEMS), 113, 115117

recommendations for, 78, 9, 11, 12, 15, 16, 58, 70, 108, 119, 124125, 284, 285, 315

reimbursement to hospitals for uncompensated care, 78, 58

research role, 12

support for information technology system, 170

See also specific governmental entity

Federal Interagency Committee on EMS, 113, 115117, 122

Florida, 105106

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, 150151

G

General Clinical Research Centers, 12, 312313, 315

Grady Health Systems, 144145, 149150

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, 264265, 299

recommendations for, 1516, 108, 110, 124125

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, 141142

recent losses, 23, 38

surge capacity, 265266

Hospital Emergency Incident Command System, 269

Hospitalists, 227228

Hours per patient visit, 232, 233

Human factors engineering, 132, 138139

I

IHI IMPACT Network, 139

Imaging technology, 176177, 190191

Immigrant population, 55

Infectious disease transmission in ED, 242243, 276

Information technology

automated discharge systems, 180

automated dispensing, 185

automated referral systems, 180181

bedside registration, 150

clinical decision support systems, 166, 172, 182186, 185186

for clinical documentation, 186187

clinical resources, 187188

computerized physician order entry, 184185

confidentiality concerns, 181182, 200

coordination of emergency care system, 86, 101102

costs and benefits, 194196, 200201

current state, 167, 168, 171

electronic dashboards, 166, 173174

electronic prescribing, 181

evolution in health care, 167168

human factors issues, 197199

implementation strategies, 200201, 202

interoperability standards, 196197

to manage patient flow, 151152

Suggested Citation:"Index." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
×

military medicine, 360

mobile and handheld devices, 175176

national infrastructure, 170

new clinical technologies, 190194

obstacles to adoption and diffusion, 168, 194200

patient clinical data collection, 96

for patient flow improvement, 154155, 172177

patient medical information, 86, 151, 177, 360361

for performance assessment, 173174

picture archiving and transmission, 176177

population health surveillance, 172, 188189, 280

prehospital intervention, 178

radio frequency identification tracking, 174175

recommendations for, 7, 193, 202

registration process, 150, 175 role of, 67

shortcomings of current system, 7, 130

system interconnectedness, 168, 171, 178182

technologies for emergency care, 7, 171172, 201202

training applications, 172, 187, 188

trends in health care, 168169

vignette of integrated health care system, 165167

See also Communications systems

Informed consent, 313314, 315

Injuries, unintentional

health care system failures, 130

hospital ED admissions, 1, 18, 345

mortality, 1, 18

prevention, 307, 355

research areas, 292293, 304305, 307308, 310311

research infrastructure and funding, 308309

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, 228229

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, 111115

establishment of new agency for, 16, 117124

Federal Interagency Committee on EMS role, 113, 115117

funding, 123

implementation, 121122, 123124

information technology, 170

location, 120121

objectives, 120

rationale, 110111, 118

recommendations, 16, 119, 125

research activities and, 121

strategies, 115

Leapfrog Group, 228

Legal liability

concerns of ED physicians, 10, 11, 223224

defensive medicine in ED and, 138

emergency medicine training and, 238239

malpractice award limits and, 224225

on-call immunity, 225

recommendations for research, 11, 226, 251

reform strategies, 224225

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, 100102

Length of stay, hospitalist intervention and, 228

Suggested Citation:"Index." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
×

M

Magnetic resonance imaging (MRI), 176, 190191

Malpractice lawsuits. See Legal liability

Maryland, 86, 102104

Medicaid

clinical decision unit reimbursement, 147148

Disproportionate Share Hospital payments, 7, 42, 54

ED reimbursement, 3, 5354

ED utilization, 3, 46, 52

enrollment in rural areas, 67

managed care, 42

payment methods, 5354

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, 147148

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, 240241

among elderly, 61

pediatric disorders, 6162

provider training for, 62

quality of care, 59, 6162

stresses in ED related to admissions for disorders of, 59, 6263

Metropolitan Medical Response System (MMRS), 112, 282, 283

Military medicine, 353, 356357, 360362

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, 299300, 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, 298299, 308309

National Quality Forum, 96

Negative pressure rooms, 9, 276

Neurosurgical specialists, 10, 219, 222, 223224

Nursing Home Compare, 98

Nursing staff

advanced practice nurses, 231

certified emergency nurses, 230

coordinated bed management, 141143

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, 198199

overtime work, 234

psychiatric training, 62

stresses of ED work, 241, 243

supply issues, 231234

training, 229230

violent assault risk, 241

zone nursing, 150

See also Workforce, medical

Suggested Citation:"Index." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
×

O

Observation units. See Clinical decision units

Occupational Safety and Health Administration (OSHA), 9, 278279

Omnibus Reconciliation Act (OBRA) (1981), 355

On-call specialists

categorization of ED capabilities, 90

critical care specialists, 228229

defensive medicine practices, 138

in ED collaboration, 246247

Emergency Medicine Treatment and Active Labor Act and, 226227

hospitalists, 227228

liability concerns, 223226

obstacles to availability, 10, 22, 219

quality-of-life concerns of, 222223

recommendations regarding, 251

regionalization, 1011, 105106, 220, 251

reimbursement issues, 221222

in rural areas, 11, 68, 248, 250

supply problems, 10, 22, 27, 152, 218220, 359

surgical subspecialty, 220221

Operations management tools, 130131

implementation, 246247

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, 155156

admissions bottlenecks, 136

bottleneck management, 140149

care delivery strategies to improve, 149152

coordination within health care system, 13

data collection, 153154

definition, 133

discharge processing, 148149

disincentives to improving, 99100, 130, 157158

elective surgery schedule, 141

goals, 140

hospital leadership for improving, 152153

impediments to, 135139

importance of, 133

incentives to improve, 56, 156157

information technology for, 171, 172177

input/output/throughput model, 133135, 154

management tools, 45, 22, 132

performance indicators, 154155

protocols for prehospital care, 14

regional, 136

staff leadership for improving, 154

strategies for improving, 139

systemic approach to management, 132, 155156

training for hospital administrators, 6

unit assessment tools, 148

use of clinical decision units to manage, 143148

See also Crowding, ED

Patient Flow Benchmarking Project, 139

PatientSite Project, 183

PECARN, 304

Pediatric emergency care, 355356

alcohol- and drug-related, 63

current state, 348349

mental health problem related, 6162

regional coordination of care, 86

utilization patterns, 348

Performance measurement

central authority for, 9596

challenges in emergency care system evaluation, 94

current ED measures, 9495

data collection, 15

documentation of care, 186187

emergency care research programs, 299300

goals, 97

implementation, 96, 97, 159

information technology for, 173174

patient clinical data for, 96

patient flow management, 154155

Suggested Citation:"Index." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
×

public reporting, 15, 9799, 159

recommendations for system performance indicators, 15, 96

shortcomings of current system, 2223

Pharmacy

ED staff, 234235

physician prescribing practices, 181, 184185

Physician assistants, 234

Physicians

average workweek in ED, 240

demographics of ED physicians, 212214

disaster response training, 273274

Emergency Medical Treatment and Active Labor Act requirements, 226227

emergency medicine training, 211212, 214

employment patterns in EDs, 210211, 215216

historical development of hospital-based emergency care, 353356

information technology utilization, 168169, 198199

knowledge and skills for ED work, 210

legal liability concerns, 10, 11, 223226

moonlighting, 216

on-call coverage, 1011, 152, 218219

psychiatric training, 62

quality-of-life concerns of, 222223

referral to ED from, 4647, 137138

regionalization of specialty services, 1011

reimbursement patterns, 214215

role of, in EDs, 210

in rural areas, 6869

stresses of ED work, 240241

trauma and emergency surgeons, 216218, 220221

See also Specialized medical services

Picture archiving and communications systems, 176177

Population patterns and trends

chronic disease prevalence, 346347

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, 235236

evolution of bureaucratic structure, 111113

historical development, 355

information technology, 178

protocols for transport, 14, 9092

recommendations for protocol development, 14, 9192, 124

recommendations for system integration, 16, 119

in rural areas, 69

transport decisions, 93

Prescribing practices, 181, 184185

Preventive interventions

ED utilization and, 5152

in emergency care settings, 8485

injury control research, 307, 355

Primary and nonurgent care

barriers to, 4546

costs, 3

definition and scope, 3132

ED utilization for, 43

government support, 44

patient understanding of, 4849

physician training in emergency care, 237238

problems for EDs, 3, 4748

quality of care in EDs, 25

reasons for ED utilization, 4547, 85

role of hospital EDs, 1, 3

scheduled vs. nonscheduled care, 4952

Privately insured patients

denial of coverage for emergency care, 55

ED utilization, 54

reimbursement patterns, 5455

Psychiatric emergency care, 25

Psychologists, 236

Public health agencies

in coordination of emergency care delivery, 13, 8485

leadership of national emergency care system, 120121

in regionalization of emergency care delivery, 251

Public health and public safety

emergency communications technology, 178

information technologies for, 172, 188189

Suggested Citation:"Index." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
×

role of hospital EDs, 1, 1819, 2930

surveillance role of EDs, 279281

syndromic surveillance, 189, 280281

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, 4849

Public reporting of performance data

current state, 9799

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, 2324

current system, 1, 23, 81

effectiveness, 2425

indicators, 23

obstacles to improving, 1213

overcrowding effects, 4, 40

for patients with mental health problems, 6162

pediatric care, 348349

primary and nonurgent care, 4748

psychiatric care, 25

recommendations for improving, 412, 1516

in rural areas, 25, 6869, 70, 249250

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, 174175, 201

Reducing the Burden of Injury, 27

Regional Health Information Organization, 170, 179

Regionalization

benefits, 88

categorization of ED services, 14, 8990, 92

concerns, 8889

current efforts to integrate local emergency care systems, 103, 105, 106, 107

disaster preparedness, 269270

implications of existing statutory regime, 100102

information technology, 171, 179

model, 89

obstacles to, 99102

on-call specialty services, 1011

patient flow, 136

pediatric care, 86

rationale, 14, 87

recommendations, 14, 251

scope, 89

specialty hospitals and, 8889

system characteristics, 8788

trauma care, 358

See also Coordination of care

Reimbursement

clinical decision units, 147148

current inadequacies, 5658

Current Procedural Terminology, 214215

disincentives to patient flow improvement, 99100, 130, 157158

Disproportionate Share Hospital payments, 7, 42, 5253

ED crowding related to, 137

ED physicians, 214215

incentives to improve emergency care system, 56, 156157

Medicaid, 3, 45, 5657

Medicare, 5657

obstacles to emergency care system improvement, 99, 130

on-call emergency specialists, 221222

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

Suggested Citation:"Index." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
×

Research

barriers to, 311

basic science, 301

clinical, 301302

emergency medicine, 291, 293

Federalwide Assurance Program, 314315, 316

future directions, 300303, 310311

General Clinical Research Centers, 12, 312313

health services, 302303

infrastructure and funding, 294300, 308309, 311313

multicenter collaborations, 304

needs. See Research needs

recommendations, 297, 311312, 315316

researcher training, 295297

rights of human subjects in, 313315

trauma and injury, 304311

Research needs

categorization of emergency services, 14

clinical decision support systems, 185186

conventional weapons terrorism, 9

current federal efforts, 112

impact of malpractice liability on provider supply, 11, 225226

leadership of national emergency care system and, 121

recommendations, 1112, 251

scope of emergency care, 291293

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, 267268

Robert Wood Johnson Foundation, 300

Role of Emergency Medicine in the Future of American Medical Care, 28

Role of hospital EDs

current challenges, 3738

historical development, 1, 1819, 37

perceptions of, 37

primary and nonurgent care delivery, 1, 3

as safety net, 4243

scheduled vs. nonscheduled care, 4952

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, 6768

disaster preparedness, 281282

ED workforce characteristics, 249

hospital characteristics, 66

impediments to practice in, 248

payer mix, 6668

prehospital care, 69

provider training, 6970, 249

quality of care, 25, 6869, 70, 249250

recommendations for hospitals in, 11, 250, 251

regionalization effects, 88

strategies to improve emergency care, 250

telemedicine applications, 179

workforce supply, 11, 6869, 237, 247250

S

Safety

adverse event risk, 23

ED risks, 2324, 240243

ED security measures, 242

infectious disease transmission in ED, 242243

physician liability concerns and, 225

protection of medical staff in disaster

response, 9

of workforce in disaster response, 275279

Safety net providers

current challenges, 7, 10, 43

financial issues, 7, 44, 5253, 54, 55, 5658, 100

input/throughput/output model, 135

liability issues, 11

regional coordination, 179

role of hospital EDs, 1, 18, 2930, 4243, 85

transfers to, 7, 56, 100, 223

trauma centers, 217218

urban vs. rural, 51

St. John’s Regional Health Center, 146147

San Francisco Community Clinic Consortium, 86

SARS. See Severe acute respiratory syndrome

Suggested Citation:"Index." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
×

Scheduled vs. nonscheduled care, 4952, 100, 157, 158

Scope of emergency care, 29, 31

Secure/Multipurpose Internet Mail Extensions, 181

Severe acute respiratory syndrome, 9, 242243, 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, 221222

core competencies for emergency medicine, 239

critical care specialists/intensivists, 228229, 251

disaster response, 266

emergency medicine, 211, 354355

hospitalists, 227228

implications for regionalization, 8889

legal liability concerns, 223225

nursing, 230, 231

on-call, availability of, 218219

recommendations for critical care medicine certification, 229, 251

regionalization of ED services, 1011, 14, 103, 220

in rural areas, 68, 250

specialty hospitals, 8889

supply problems, 10, 19, 22, 25, 219220, 221225

See also On-call specialists

Standards of care

boarding and ambulance diversion, 6, 159, 160

core competencies for emergency professionals, 239240, 251

patient flow, 6, 139, 157, 160

prehospital care, 14, 9092, 124

system performance indicators, 15, 96

State Children’s Health Insurance Program, 52

State government

current efforts to integrate emergency care system, 102107

demonstration project grants, 1516, 108110

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, 6364

population patterns, 63

presentations, 64

quality of care in EDs, 59

reimbursement issues, 65

screening, 6465

stresses for EDs related to, 59, 65

Suicidal patients, quality of ED care for, 6162

Supply-chain management, 133

Surgical specialists, 216218, 220221

military medicine, 361

trauma care, 359

Surveillance, public health

coordination of communications, 86

in emergency care settings, 85

information technology for, 172, 188189, 280

role of hospital EDs, 1, 1819, 30, 279281

syndromic, 189, 280281

Syndromic surveillance, 189, 280281

Systems analysis, 131, 155156

T

Telemedicine, 11, 179, 250, 251

Terrorist attacks, 8, 9, 261, 276, 278, 279, 281, 283284

Tertiary hospital quality of care, 2425

Texas, 104105

Timeliness of care, 2526

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, 271274, 285

emergency medicine specialty, 211212, 214, 237238, 238, 294295

to enhance rural EDs, 11

graduate medical education, 237

improved outcomes related to, 238239

Suggested Citation:"Index." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
×

in information technologies, 198199

information technology for, 172, 187, 188

in mental health issues, 62

military medicine, 362

nursing staff, 229230, 239

in operations management, 6, 153, 160

for providers in rural areas, 6970, 249

recommendations, 6, 9, 11, 153, 160, 274, 285

researcher training, 295297

simulation training, 245

teamwork training, 244245

trauma surgeons, 217

Trauma care

categorization of hospitals, 357358

definition, 31, 356

ED visits for, 345346

historical development, 356357

medical specialties, 359

regional coordination, 358

research areas, 291292, 304307, 310311

research infrastructure and funding, 308309

surgical specialty, 216218

Trauma Care Systems Planning and Development Act, 357

Trauma center(s), 31, 356, 360

Trauma system

characteristics, 8788

definition, 31

as model for emergency care system coordination, 83, 89

U

Ultrasonography, 191

Uncompensated care

burden on hospitals, 2122, 5658

costs to physicians, 215

Medicare/Medicaid reimbursement, 7, 5253

recommendations for federal reimbursement, 78, 58, 70

supply of on-call specialists and, 10

Uninsured patients

barriers to primary care, 4546

disincentives to improving ED efficiency, 158

economic burden, 7

ED utilization, 46, 53

number of, 3, 42

role of hospital EDs, 1, 4243

rural populations, 6667

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, 241242

W

Wait times

assessment in waiting room, 25

for mental health bed, 6263

nonemergency patients, 3

patient departure before assessment, 2526, 42

Washington Hospital Center, 86, 281

Workforce, medical

back pain risk, 243

challenges of ED work, 10, 240

clinical decision units, 144

core competencies, 238240, 251

disaster preparedness training, 271274

ED pharmacists, 234235

ED staffing standards, 138

Emergency Medical Treatment and Active Labor Act requirements, 226227

EMS professionals, 235236

exposure to violence, 241242

infectious disease risk, 242243

interprofessional collaboration, 243247

leadership for efficiency improvement, 154

malpractice liability concerns, 11, 251

moonlighting, 216

physician assistants, 234

protection of, during disaster response, 9, 22, 275279

Suggested Citation:"Index." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
×

recommendations for research, 237, 251

in rural areas, 11, 6869, 237, 247250

social and psychological care, 236

stresses of ED environment, 209, 240241, 243

supply challenges, 236237

See also Nursing staff;

On-call specialists;

Physicians;

Specialized

medical services

Z

Zone nursing, 150

Suggested Citation:"Index." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
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Hospital-Based Emergency Care: At the Breaking Point Get This Book
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Today our emergency care system faces an epidemic of crowded emergency departments, patients boarding in hallways waiting to be admitted, and daily ambulance diversions. Hospital-Based Emergency Care addresses the difficulty of balancing the roles of hospital-based emergency and trauma care, not simply urgent and lifesaving care, but also safety net care for uninsured patients, public health surveillance, disaster preparation, and adjunct care in the face of increasing patient volume and limited resources. This new book considers the multiple aspects to the emergency care system in the United States by exploring its strengths, limitations, and future challenges. The wide range of issues covered includes:

• The role and impact of the emergency department within the larger hospital and health care system.

• Patient flow and information technology.

• Workforce issues across multiple disciplines.

• Patient safety and the quality and efficiency of emergency care services.

• Basic, clinical, and health services research relevant to emergency care.

• Special challenges of emergency care in rural settings.

Hospital-Based Emergency Care is one of three books in the Future of Emergency Care series. This book will be of particular interest to emergency care providers, professional organizations, and policy makers looking to address the deficiencies in emergency care systems.

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