EMERGENCY in the Emergency Department Ashley Killinder PAS

EMERGENCY!!! in the Emergency Department Ashley Killinder, PA-S University of Kentucky, 2008

Objectives… l History of Emergency Department (ED) l Reasons for Overcrowding in the ED l Solutions to the Problem l Questions and Answers

History… l The first American hospital was established in 1752. l Patient Care = Free! l For-profit l hospitals in 1900’s Patient Care = Expensive!

History… l The introductions of Medicare, Medicaid, HMOs, and DRGs in 1970 s-80 s. l Patient Care = Free for some, expensive for others. l National Hospitals 2007 Administration Corruption l Abuse of the System l Collapse of Infrastructure l

Shocking Statistics… l 90% of Nation’s large hospitals operate Above Capacity l In the past 10 years, the number of patients seen in the ED has risen 26%, while population has grown only 11%. l In the past 5 years, the number of Medicaid patients seen in ED risen 23%.

How is the ED compensating? l They are not! l In the past decade, 500 EDs have been closed, 1/3 of those in rural populations. l There is currently a 114, 000 bed shortage in hospitals nationwide. l The US is currently in a state of Nursing Shortage as large numbers are leaving the medical field.

Why should we care? l The Emergency Department is the sole Safety Net healthcare provider in the US. l Since 1986, Federal Law requires the ED to treat all patients, regardless of the ability to pay. l Collapse in the ED Collapse of US healthcare system l Saturation of patient care outside the hospital.

The Bottom Line l The Emergency Department is in a state of Emergency!!! l Caused by: Decreased Bed Availability l Increased Numbers on Medicaid l Outflux of Hospital Staff l

Methods l The information presented today is based on data collected via Pub. Med. l The data is construed from 17 core articles, the majority of which were conducted research studies within the past five years.

Define Overcrowding… l How crowded is too crowded? National ED Overcrowding Study (NEDOCS) l Trzeciak and Rivers l l Quantitative l rather than Subjective Putting patient numbers makes more of a statement than personal judgment of overcrowding in the ED

Increased Numbers l Which population contributes the most to the overcrowding problem in the ED? l Uninsured patients ? l Medicaid patients ? l BOTH ? !

Increased Numbers: Ethnic, low-income, uninsured populations l Communities with higher levels of… Low-income l Racial/ethnic minorities l Immigrant residents l Uninsured population l l …were NOT the communities with the highest numbers of ED visits.

Increased Numbers: Influx of Medicaid/SCHIP l Populations with highest numbers of ED visits = highest number of Medicaid enrollees. l The average Medicaid patient has 16 more ED visits than the average uninsured patient.

Who is at Fault? l Are Medicaid patients the “Bad Guy”? l Look out for large cuts in Medicaid/ SCHIP funding

Outflux of Staff l Increased patient numbers = increased responsibility l 2004 NEDOCS questionnaire: 1. Qualify the degree of overcrowding l 2. If the staff felt rushed l 3. Quantify the degree of overcrowding l l Patient l : Staff ratio Overcrowding = Unsafe!!!

Solutions l Donated Care Program Local physicians provide pro bono work l Hospitals contribute $20, 000/year toward free community healthcare. l l Employeeing Mid-Level Providers Physicians Assistants are cost effective, skilled, and on the rise in the ED. l 47% of EDs use PAs in the ED l

Conclusion The ED is in trouble, reflecting a problem on the entire healthcare system. l Solutions to the problem must be initiated at every level of care. l Local communities provide hope for restoration. l Utilization of PAs eases burdens in ED. l Action must start NOW! l

References l l l l Barlett DL, Steel JB. Critical condition: how healthcare in America became big business and bad medicine. New York (NY): Doubleday; 2004. Brewer C, Kovner CT. Is there another nursing shortage? What the date tells us. Nursing Outlook. 2001 Jan; 49(1): 20 -26. Brewster LR, Felland LE. Emergency department diversions: hospital and community strategies alleviate the crisis. Issue Brief Cent Stud Health Syst Change. 2004 Mar; (78): 14. Congress of the United States. Diagnosis related groups (DRGs) and the medicare program: implications for medical technology – a technical memorandum. Office of Technological Assessment. 1983 Jul: 23 -25. Cowan RM, Trzeciak S. Clinical review: emergency department overcrowding and the potential impact on the critically ill. Crit Care. 2005 Jun; 9(3): 291 -5. Cunningham PJ. Medicaid/SCHIP cuts and hospital emergency department use. Health Aff (Millwood). 2006 Jan-Feb; 25(1): 237 -47. Cunningham PJ. What accounts for differences in the use of hospital emergency departments across U. S. communities? Health Aff (Millwood). 2006 Sep-Oct; 25(5): 32436. Dorsey JL. The health maintenance organization act of 1973 and prepaid group practice plans. Med Care. 1975 Jan; 13(1): 1 -9.

References l l l l Eastaugh SR. Overcrowding and fiscal pressures in emergency medicine. Hosp Top. 2002 Winter; 80(1): 7 -11. Ganapathy S, Zwemer F. Coping with a crowded ED: An expanded unique role for midlevel providers. Am J Emerg Med. 2003 Mar; 21(2): 125 -128. O’Malley AS, Gerland AM, Pham HH, Berenson RA. Rising pressure: hospital emergency departments as barometers of the health care system. Issue Brief Cent Stud Health Syst Change. 2005 Nov; (101): 1 -4. Oswanski MF, Sharma OP, Raj SS. Comparative review of use of physician assistant in a level I trauma center. Am Surg. 2004 Mar; 70(3): 272 -9. Taylor EF, Cunningham P, Mc. Kenzie K. Community approaches to providing care for the uninsured. Health Aff (Millwood). 2006 May-Jun; 25(3): 173 -82. Trzeciak S, Rivers EP. Emergency department overcrowding in the United States: an emerging threat to patient safety and public health. Emerg Med J. 2003 Sep; 20(5): 402 -5. U. S. Department of Health and Human Services. EMTALA: emergency medical treatment and labor act. Center for Medicare and Medicaid Services. 2006 Oct, Available on: http: //www. cms. hhs. gov/FACA/07_emtalatag. asp. Weiss SJ, Derlet R, Arndahl J, Ernst AA, et al. Estimating the degree of emergency department overcrowding in academic medical centers: results of the National ED Overcrowding Study (NEDOCS). Acad Emerg Med. 2004 Jan; 11(1): 38 -50.

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