America’s Emergency Departments in Crisis --- Expanding Holes in Our Safety Net.

Andrew P. Garlisi MD FACEP

 

 

     This chapter will define and examine the role of the emergency department (ED) as our nation’s public health care safety net.  We will examine the evolution of the modern-day ED, identify some key structural and functional features, and explore the formidable challenges and issues threatening our emergency departments and the overall health and safety of the American public.  We will end by reviewing current ED trends and future innovative responses to these challenges.

 

     The emergency department stands alone as the only health care agency in this country, which is federally mandated to provide access to medical care 24/7 for all patients, regardless of ability to pay.  “There is a long-standing notion in the United States, dating back to the nineteenth century, that we should maintain a health care safety net for persons who are uninsured, difficult to serve, discriminated against, or who cannot get care elsewhere” (Fields 1).  Hospitals and emergency physicians risk serious financial and civil penalties for discriminating against indigent patients.  Because there are more than 42 million people in our nation without health care insurance, the emergency department often is the only health care alternative available to the poor, or uninsured.  As such, the emergency department among its other obligations and responsibilities, can be considered as a health care “safety net” – in essence rescuing and providing medical care to those that “fall through the cracks” of our nations’ health care system.

     Emergency medicine provides a unique role in public health.  The ED provides primary care and emergency specialty care 24/7 and offers the following public health interventions:

·        Health Screening- Blood pressure screening is done for every adult patient who is treated in the emergency department.  Patients who are identified with high blood pressure are referred to primary care providers for follow-up and treatment.  Emergency patients who have lab tests can be screened for diabetes and referred for appropriate management.  Emergency physicians commonly perform fecal occult blood tests, a screening test for colon cancer.  Emergency physicians and nurses screen for tobacco and alcohol abuse and counsel patients against these activities. 

·        Immunizations- The emergency physician often provides tetanus and rabies immunizations for at risk populations.  Childhood immunization programs have had a major impact on the health of the US population by preventing and eliminating certain infectious diseases (Auer 12).  All emergency pediatric patients are screened for immunization history.   Emergency staff can take the opportunity to advise parents about the need for maintaining current pediatric immunizations and refer them to primary care providers or local health departments

·        Domestic violence- “As a subset of all violent injuries, domestic violence is recognized as a significant public health problem affecting primarily women” (13).  The Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) have declared violence prevention a public health priority (13).  Victims of domestic violence frequently present to the emergency departments and emergency nurses and physicians have a unique opportunity to identify, evaluate, treat, counsel and refer domestic violence victims (13).   Thus, emergency personnel have the opportunity to decrease public morbidity and mortality associated with domestic violence.

·        Child Abuse / Elder Abuse—Emergency staff are trained to screen susceptible patient populations (the very young and the elderly) for symptoms and signs of abuse.  Within the past 10 years, elder abuse has been recognized as a major public health problem, with serious increases in reported cases.  Appropriate agencies are notified and can intervene in these abuse cases.

·        Sexually Transmitted Disease- Treatment for sexually transmitted disease is a common reason for presentation to many emergency departments.  Patients can be examined and screened / tested for chlamydia, gonorrhea, syphilis, herpes and HIV infections.  Treatment can be immediately provided in some diseases, or arranged for on an outpatient basis for others.  The emergency staff has an opportunity to advise patients about preventive measures (condom use, safe sex practices) and refer them to appropriate clinics or primary care providers.

·        Role in Mass Casualties and Terror Attacks – The emergency department plays a critical role in identifying outbreaks of diseases.  “Surveillance, a fundamental public health methodology, provides the conceptual framework for systematically collecting population-based information on the occurrence, outcome, and costs of illnesses and injuries of ED patients” (Kirsch 14).  EDs are well positioned to provide data on emerging infections, injuries, patterns of drug abuse, and immunization rates for vaccine-preventable diseases (14).  Such a data surveillance system requires the collaboration of public health officials, clinicians, government and private sector organizations (14).  Emergency physicians are trained to recognize signs/ symptoms and treatments of smallpox, anthrax and nerve agents – used in terrorist warfare.  The ED plays a vital role in disaster management and mass decontamination of public exposed to toxins.

 

 

History and Evolution of Emergency Medicine as a Medical Specialty in the U.S.

     The emergency departments of today are vastly different than those that existed prior to 1970.  Interns and residents, with little or no attending physician supervision, staffed the early academic “emergency rooms”.  In the 1960’s and 70’s, in some smaller community hospitals, nurses would manage the emergency rooms and call in physicians if and when needed.  In the busier emergency rooms, the “ER doc” could be a retired pathologist, a moonlighting intern, or family physician with little or no emergency medicine experience.  There were no formal emergency medicine training programs.  Some emergency rooms utilized an “on –call” rotational system, whereby every hospital staff physician took their turn working shifts in the emergency rooms.  Needless to day, the skills and experiences of these early day emergency physicians were extremely variable, as was the quality of emergency care delivery.  Inexperienced physicians or physicians untrained in invasive procedures (chest tubes, intubations, central line placements, lumbar puncture) could not appropriately manage the critically ill or traumatized patient.   As public demand for 24/7 emergency services increased, so did the recognition for the need for consistent, predictably reliable, high-quality emergency care.  According to Hamilton in Emergency Medicine, in 1968, the American College of Emergency Physicians (ACEP) was established, and with it the birth of emergency medicine as a formal medical specialty.  ACEP was founded to support quality emergency medical care, and to promote the interests of emergency physicians.  In 1970, the University of Cincinnati established the first emergency medicine residency program (3).  In 1973, the Emergency Medical Services Act authorized the establishment and expansion of emergency medical services system and research (3).  Also in 1973, the Office of Telecommunications Policy issued a national policy statement recognizing the benefits of 9-1-1 as a national emergency number and encouraged nationwide adoption of that number (3).  The American Medical Association approved a permanent section on Emergency Medicine and accepted standards for emergency medicine in 1975 (3).  The American Board of Medical Specialties recognized emergency medicine as an official medical specialty in 1979, and certification examinations were offered in 1980.  In 1989, the American Board of Medical Specialties granted emergency medicine primary board status (3).

     In addition to providing care to the acutely ill or injured patient, the specialty has evolved to accept new responsibilities.  According to Hamilton, these include:

1)      Administration – management of medical and administrative aspects of EMS, and 911 systems

2)      Disaster planning on a wide scale

3)      Toxicology and development of regional and national poison control centers

4)      Health care services research – many societal problems are first noted in the ED

(homeless health care, illicit drug problems, teen pregnancies, domestic violence, alcohol related motor vehicle accidents)

5)      Education

6)      Preventive medicine – job safety, enforcement of seat belt laws, gun control, motorcycle helmet use, and laws related to driving while intoxicated (5).

 

 In 1975, the American Medical Association defined the emergency physician as a physician trained to engage in:

1)      The immediate initial recognition, evaluation, care and disposition of patients with acute illness and injury.

2)      The administration, research and teaching of all aspects of emergency medical care

3)      The direction of the patient to sources of follow-up care, in or out of the hospital

4)      The management of the emergency medical system for the provision of pre-hospital emergency care (4).

     In 1981, the American College of Emergency Physicians summarized the practice of the specialty:

      “Emergency medicine encompasses the immediate decision-making and action necessary to prevent death or any further disability for patients in health crises.  Emergency medicine is practiced as a patient-demanded and continuously accessible care.  It is the time-dependent process of initial recognition, stabilization, evaluation, treatment, and disposition.  The patient population is unrestricted and presents with a full spectrum of episodic, undifferentiated physical and behavioral conditions.  Emergency medicine is primarily hospital-based but with extensive prehospital responsibilities” (ACEP.org).

 

Residency Training /Board Certification in Emergency Medicine

     “Physicians who choose to specialize and become board-certified in emergency medicine must complete three to four years of residency training beyond medical school.   These residency programs provide formal training and direct hands-on experience in a wide range of adult and pediatric emergencies, including medical, surgical, trauma, cardiac, orthopedic and obstetric.  Residents also learn recognition and intervention skills for dealing with a wide range of social emergencies, including substance abuse, and family violence” (ACEP Frontline 6). 

     According to ACEP, as of March 2004, there were 132 U.S. emergency residency training programs approved by the Accreditation Council for Graduate Medical Education   As of 1999 there were also 25 osteopathic emergency medicine residency programs (6).  (Although in the past there had been philosophical and practical differences in training methods between doctors of osteopathy and doctors of medicine, more recently the training and practice patterns are essentially identical).  Combined, these programs graduate more than 1050 each year (6).  After completing an accredited training program, emergency physicians must pass a series of rigorous examinations to achieve board certification in their specialty.   Most emergency departments now require either board certification or residency training in emergency medicine as a necessary prerequisite for emergency department employment.  Emergency physicians are required to complete yearly emergency medicine continuing education training and must pass recertification examinations every 10 years to maintain board certification.  According to ACEP, as of August 2003, there were 31,797 emergency physicians in clinical practice (down from 32,020 in June 1997) (ACEP.org 1).  Approximately 67% of emergency physicians were board certified as of December 2002; data on percent of board-eligible physicians were not available.  In August 2002 there were 89,300 emergency nurses (1).  As of March 2004, there were 815,000 emergency medical service prehospital providers (paramedics, EMTs, first responders) (2).

 

 

Anatomy of Emergency Departments

     To many patients, the emergency department (ED) can appear to be chaotic, disorganized and frightening.  This perception can be misleading, as most EDs are complex mircrosystems generating and coordinating a variety of diverse activities in relatively short time frames. Most of the activities involved in patient care are invisible to the patient.  Physicians take a patient history, perform a physical examination, perform interventions and complicated medical procedures, order lab tests and radiology studies, document the medical record, review/interpret/document the lab and radiology data, consult with primary care or specialty physicians, discuss results with patient and family members, all while managing multiple patients simultaneously several of whom may be critically ill or injured.  The ED is a highly stressful environment, not only to the patient, but also to the emergency providers.  Emergency physicians must make thousands of decisions in the course of a shift.  Despite the hectic appearance, most EDs are actually very well organized and highly functional.

     There were 4,037 emergency departments in 2002; reduced from 4,270 EDs in 1997.  From 1988-1998, 1,128 emergency departments closed.   Despite closure of many hospitals and EDs, the numbers of emergency department patient visits have increased from 97,427,807 in 1997 to 114,207,460 in 2002 (1).  Increased visits and higher public expectations in the face of reduced capacity have placed a strain on the safety net.

   There are several different categories of emergency departments.  Most EDs are physically attached to hospitals; and most hospitals are community hospitals located in suburbs or small to medium-sized towns or cities.  Some EDs are located in more remote rural settings.  A few emergency departments are freestanding, not physically attached to a hospital.  Urban EDs are placed in the central areas of large cities like New York, Los Angeles and Chicago.  Some emergency departments qualify as “level-one trauma centers”.  A level one-trauma center must pass strict tests in order to receive this designation (must have 24-hour on site anesthesiology and surgery personnel for example).  These trauma centers serve large geographical regions and care for the most critically injured patients.  Metro Hospital in Cleveland, Ohio is an example of this type of trauma center.  Patients can be transferred by ground or helicopter to the Metro emergency/ trauma center either from a community hospital emergency department, or directly from the scene of the accident.  The helicopter flight crew can include a nurse, paramedic and physician trained in the management of critically ill or injured patients.   Metro trauma center serves populations of several counties adjacent to the Cleveland area.   Emergency departments vary in design, size, staffing and functional capacity.   Some emergency departments are relatively antiquated and outmoded; others have been remodeled and some newly constructed.   Rural facilities tend to be smaller in size and have lower census (5 to 10,000 emergency patients visits annually).   Larger community hospital emergency departments may have a yearly volume of 10 to 50,000 patients.  Urban facilities and busy trauma centers may treat over 100,000 patients annually.  In 1996, the average annual ED census was 19,600, increase from 15,600 in 1988 (ACEP Safety Net 2).  Patient volume and acuity generally dictate the staffing models for the various EDs.   At least one emergency physician and nurse staff the department.  As the volume increases, more nurses per shift are required.  At approximately 15,000 patients annually, depending on the acuity, often there is need for a second physician or mid level provider (nurse practitioner or physician assistant) during the busier portions of the day.  At higher volumes, two or more physicians will be scheduled for most of the day and evening shifts.  Some emergency departments have created “fast track” or “urgent care” areas physically separated from the main department.  These special areas are designed and staffed for lower acuity patients (sore throats, ankle sprains, minor injuries).  Ideally these patients require lower intensity evaluation and treatment, and can be “in and out” of the department within a much shorter time frame—one hour.  The emergency staff in the main department will treat the more complex, sicker, higher-acuity patients—who consume more staff time and resources. 

     Physicians and nurses treat the patients who are admitted to the hospital, discharged or transferred to another health care facility.  The capabilities and services offered by the hospital and the patients’ specific medical needs determine whether the patient will be admitted to the hospital, or transferred to another facility.  Some hospitals do not offer cardiac surgery, neurosurgery, critical pediatric or neonatal care, trauma care, burn care, or inpatient psychiatric treatment.  Patients who require such services will be medically stabilized in the hospital emergency department and transferred to the nearest facility offering the needed specialty care.  Stringent federal laws (EMTALA) have been enacted to prevent inappropriate transfers or “dumping” of indigent patients to other facilities strictly for financial reasons.

 

Ancillary Services

     Patients seeking emergency care often require ancillary testing from other hospital departments such as respiratory, EKG, laboratory and radiology.  The emergency department relies heavily on these other microsystems to ensure timely, safe, and efficient evaluation of the emergency patients.  It is critical for these ancillary departments to prioritize emergency patients in obtaining results of these studies.  Unfortunately all too often the laboratory and radiology departments are overwhelmed by responsibilities to all other hospital patients who also may demand immediate services (ICU patients, patients in the operating room) and interfere with the timely care of the patient in the ED.

 

Consultants/Admissions to the Hospital

     At times, the emergency physician, while caring for a patient, will deem it necessary to obtain consultation from a primary care provider or specialist.  In a teaching facility with active residency training programs, this consultant may be a resident-in-training, who would be notified to examine the patient for a second opinion regarding care.  The resident would examine the patient and contact his or her supervising attending physician who may or may not also come to the ED to see the patient.  In a non-teaching facility (most community hospital EDs) the emergency physician would contact the patient’s own physician or specialist.  If the patient does not have a primary care physician or specialist, the emergency physician can refer to an “on call” list of hospital physicians.  This on call list provides the names of hospital staff physicians who agree to be available to admit patients who do not have a doctor.  Most hospital by-laws require that physicians who have active staff privileges be required to “take their turn” with the on call roster on a daily or weekly rotational basis (depending on the number of physicians on staff).   If a patient presents to the emergency department, has no established physician, and requires admission to the hospital, the emergency physician contacts the appropriate specialty on call physician, who ideally will accept the patient for admission—regardless of the patient’s financial status.  In theory, this system seems equitable and reasonable.  In practice, the on call physician may be reluctant to accept a barrage of uninsured indigent patients on a given night.  Due to staff shortages in some specialty areas (obstetrics & neurosurgery) some physicians are on call frequently and are expected to care for large numbers of patients without compensation.   Some physicians have threatened to withdraw their staff privileges from a particular hospital rather than be on call for indigent patients.  A growing number of hospitals have responded by providing on call physicians a financial subsidy for being on call for uninsured patients. 

      If a patient requires hospital admission and the hospital provides the required medical services, the emergency physician will notify the patient’s primary care physician specialist, or on call physician to admit the patient into the hospital.   A patient may be admitted to a general medial/surgical ward, a psychiatry unit, the intensive care unit, a telemetry unit (patients can be monitored, but are less acutely ill) or go directly to surgery.  The admitting physician within a reasonable time frame, should present to the hospital and physically examine all patients who are admitted to their care.

 

Discharge process

     If a patient is discharged from the emergency department, it is the responsibility of the emergency physician to provide clear, concise, detailed and legible discharge instructions to the patient.  These instructions should include information for self-care for the specific medical condition, information on prescription medications provided, and detailed instructions concerning when and with whom outpatient follow-up should be sought.  A complete set of discharge instructions would include specific guidelines for when the patient should immediately return to the emergency department (i.e., if symptoms progress or unexpectedly change for the worse).  More than 50% of lawsuits originate from the discharge process.  These malpractice suits are filed because the discharge instructions are vague, inadequate, inaccurate or illegible.  Many emergency departments have converted to an electronic discharge instruction process, thereby ensuring consistency, completeness and legibility.  Recently there has been a major national thrust for improving the discharge process.  Emergency physicians are encouraged to provide the discharge instructions personally, instead of relying on the nurse.  The patient will generally be referred back to the established primary care provider (PCP) or specialist (i.e. Cardiologist).  If the patient has no established physician, the emergency physician can provide to the patient the name of the on call physician for medical follow-up.  Many on call physicians will agree to admit patients to the hospital but refuse to treat indigent patients referred to their private offices.  These physicians claim the hospital has no authority or right to enforce policies in their private offices.  On the other hand, the hospital has an obligation to ensure follow-up care for patients with unresolved medical problems discharged from their emergency departments.  The debate continues with no immediate solution in sight.

 

PROBLEMS and CHALLENGES THREATENING THE SAFETY NET

 

EMTALA/ Indigent Care and the Problem of Overcrowding

     In 1985 the Federal Government passed the Emergency Medical Treatment and Active Labor Act (EMTALA).  No law in the history of this country has had greater impact on the practice of emergency medicine.   This law had several intentions, which included: 

·        Preventing private (for profit) hospitals from transferring, or “dumping” medically unstable indigent patients to public hospitals.

·        Forcing every emergency department to evaluate (medically screen) all patients who present to them regardless of ability to pay for services

·        Preventing discrimination against patients who cannot afford services.

·        Establishing significant financial and civil penalties against hospitals/emergency departments/physicians who violate EMTALA.

 

     “As enforced by the Health Care Finance Administration (now known as the Center for Medicare and Medicaid Services, or CMS), and recently upheld by the United States Supreme Court, EMTALA is a civil right extended to all US residents.  … Hospitals with EDs, emergency physicians and the medical and surgical specialists who back them up are providers of the first health care benefit to be universally guaranteed by the US government” (Fields 1).  This benefit comes at a price.  EMTALA is an unfunded mandate that falls unevenly on hospitals and providers of emergency services, especially in rural and inner city communities where the uninsured are found in disproportionate numbers (1).  Uncompensated costs to emergency physicians for services provided under EMTALA in 1996 were estimated at $226 million (1).  Total uncompensated inpatient costs provided by physicians and hospitals for the same year exceeded $10 billion.   “The nation’s EDs are the portal of entry for three out of four uninsured patients admitted to US hospitals” (1).

     Because the emergency department is the only source of medical care for a sizable portion of the population, there is a tendency for the indigent to utilize the emergency department for non-emergent conditions.  But not all of the uninsured are indigent.  In 1997, the US census Bureau reported that 60% of the uninsured are working adults, with their dependents comprising another 20% (6).  “The typical profile of the person most likely to be without health insurance is an adult with children and a household income of $20,000 to $50,000.  75% are black, Hispanic or Asian.  44.5% have a high school education or less.  They are most likely to be found working in service industries, especially restaurants or one of the construction trades (7).  “In recent years, the popular media and health care analysts have helped to firmly identify the ED…with at risk populations.  These include mothers and infants without access to maternal or child health services, the chronically ill or disabled, person with AIDS, the mentally ill or gravely disabled, alcohol and drug abusers, the suicidal and homicidal, victims of domestic violence, the homeless and recent immigrants” (1).

     With few health care options, the working poor and indigent turn to the emergency department for emergency and non-urgent care.  Coupled with a national decline in the number of hospital EDs despite increasing patient visits to emergency departments, “it doesn’t take a rocket scientist” to understand why delays in the ED and facility saturation and overcrowding have become commonplace in recent years (9).  For 1996, the National Center for Healthcare Statistics (NCHS) reported that 16.8% of all ED patients were uninsured, and responsible for 16.4 million ED visits that year (11).  This figure is somewhat higher than might be expected on a per capita basis from Census Bureau date, which indicates that only 15.6% of the US population in 1996 was uninsured (11).  According to Fields, it is no surprise that the uninsured are more likely than the rest of the population to seek acute care services.  However, the NCHS data does not support the widely held opinion that the uninsured have a significantly higher pattern of ED utilization than the insured.  In 1996 the NCHS reported that the US population had 342 ED visits per 1,000 annually; the uninsured was slightly higher at 393 per 1,000.  In a study performed by Charlene Irvin et al reported in 2003, the investigators discovered that there were only small differences among the privately insured, uninsured and Medicaid populations in regards to low-acuity care received in the emergency department.  The statistics revealed that 30% of pediatric Blue Cross Blue Shield patients received low acuity care vs. 35.7% for Medicaid and 35.8% for the uninsured (Irvin et al).  Although there were limitations to this study, it does suggest that other factors may be responsible for ED overcrowding rather than indigent patients “clogging-up the system.”

      Other experts disagree.  In the 2001 ACEP report from the Task Force on Health Care and the Uninsured investigators report that “dramatic increases in the number of uninsured in recent years, combined with significant reductions in hospital staff and resources, patients at hospital emergency departments are experiencing longer waiting times and overcrowding or gridlock” (5).  It is not uncommon for acutely ill patients to wait for days in an emergency department due to lack of available hospital beds.  “Emergency rooms are also seeing sicker patients, as well as more patients who are uninsured,” says former ACEP president Robert Williams MD, PHD, FACEP (6). 

     It is reasonable to assume that alternate forms or healthcare delivery (community clinics, public urgent care centers) could alleviate the overcrowding problem.  However, other issues must also be addressed.  These include:

·        Hospital and ED closure

·        Nursing shortages

·        Lack of reimbursement to emergency providers for indigent care

·        Skyrocketing costs for malpractice insurance premiums

·        Increased utilization of services & technology due to fear of malpractice lawsuits

·        Increased use of emergency departments by an ever increasing geriatric population

·        Demand for emergency services by more critically ill and injured patients

  

     The nation’s aging baby boomer population will place a serious strain on emergency services as they reach their senior years and develop medical problems.  According to ACEP’s October 2003 news release, 38 out of 100 persons in the general population will visit the emergency department within one year.  For those 75 years and older, the visit rate is 60 per 100 persons (2).  Hospitals are discharging patients earlier due to financial pressure from insurance companies.  There is a trend towards outpatient management of illnesses.  Home health care is utilized with increasing frequency.  These trends contribute to patients having more serious symptoms and critical conditions by the time they seek treatment in the emergency department.

 

The Specter of Medical Malpractice

     With the possible exception of advances in pharmacology and health care technology, no single factor has impacted the US physician more than the medical malpractice insurance crisis and its ramifications.  Skyrocketing malpractice insurance premium costs over the past five years have had direct financial and non-financial consequences.  From a pure financial perspective, the increased premium costs lower the physician’s earnings.  According to the 2003 GAO report, the largest writer of medical malpractice insurance in Dade County, Florida quoted a 2002 premium for general surgeons at $174,300—an increase of 80% from 1999.  Some emergency physicians have seen their premium costs jump 500% (ACEP).  To make matters worse, many insurance carriers have “bailed out” of the malpractice market, limiting the physicians’ choices and locking in high premium costs.  Emergency medicine is considered one of the high-risk medical specialties.  Within the past year malpractice insurance carriers have denied coverage to physicians who have had prior malpractice claims.  A physician so denied has a career in jeopardy, as most hospitals and clinics will not allow a physician to practice in their facility without malpractice coverage.  One reason for increased malpractice insurance premiums is the rising number of high-award medical malpractice lawsuits.  Physicians are incensed because it is relatively easy to institute a lawsuit against a physician, and awards have become more generous.  To make matters worse, the increased cost consequences of these lawsuit awards are passed on directly to the physicians in the form of increased malpractice insurance premiums—and physicians are not able to recoup these losses by cost shifting.

 

 Malpractice Exodus

     Physicians are leaving counties and states where premiums are high and malpractice lawsuits more common.  The full impact of this exodus is not yet known, however some states report a physician shortage crisis.  Hardest hit states include Florida, West Virginia, New Jersey and Pennsylvania.  According to Helen Matheny, spokeswoman for the West Virginia Medical Association, “Medical liability truly is a crisis in West Virginia.  Unfortunately, patients are experiencing problems getting access to care.”  The hardest hit specialties are emergency medicine, orthopedics, obstetrics, and neurosurgery.  “Wheeling no longer has a neurosurgeon available,” adds Matheny (Cook 2).   It has become more difficult for emergency staffing companies to find physicians to work in emergency departments in these hard-hit areas.  Across the country, physicians are curtailing services in emergency rooms, trauma and maternity centers because of increased costs. 

     ACEP states that in 2001, 12 malpractice verdicts exceeded $20 million and the costs of America’s tort system are predicted to go from $200 billion in 2002 to $300 billion by 2005.  Fifty-seven percent of medical malpractice premiums go towards attorneys’ fees (ACEP fact sheet 2).   While hundreds of EDs close their doors, the number of ED visits climb over 20% in the past 10 years.  While more Americans are seeking emergency care, EDs continue to lose staff and resources and are at the breaking point (ACEP fact sheet 4). 

     Adding to the pain, the medical malpractice insurance crisis has even affected the construction industry.  “In an ominous sign of future setbacks in construction, Orlando-based Florida Hospital---the state’s busiest facility—has abruptly abandoned plans for a new suburban facility after spending over $750,000 obtaining a precious certificate of need (CON) from the state’s health planning department” (Romano 26).  The reason is simple; not enough doctors to staff the new facility.

Richard Morrison, regional VP of government and community relations for Florida Hospital in Orlando, states, “It’s a miserable situation; this malpractice crisis is wreaking havoc on us” (26).  Lars Houmann, Florida Hospital’s executive VP and COO, says he believes similar concerns about physician supply will have a ripple effect on hospital construction in other vulnerable states:  “I think it’s unprecedented for an institution holding a new CON not to build…because the physician supply isn’t adequate.  It’s ugly, doctors are leaving this state, they are retiring early” (26).

 

Fear/Uncertainty/Resentment/Dissatisfaction/Burnout

     The impact of rising medical malpractice costs and risk of lawsuits against physicians have cast an onerous pall over the medical profession.  Physician attitudes are being shaped by this crisis.  The general public no longer views physicians as “benign healers.”  Much publicity has been made of statistics indicating that American doctors kill over 80,000 patients a year due to medical error (Couch 30).  Many physicians view patients as adversaries, as proverbial “lawsuits waiting to happen.”  Physicians may be overly preoccupied with making a medical error, and the consequences.  “One consistent theme seems to emerge from all…studies of physicians in practice:  the fear of personal inadequacy and failure” (Benbassat 53).  This fear has been compounded by recent developments in the malpractice arena.

     “Fear of criticism and litigation has also been claimed to affect physicians’ attitudes toward their patients… the most common functional consequence of fear of litigation appears to be the tendency toward defensive practice, characterized by ordering diagnostic tests even when clinical judgment deems them unnecessary…”(53).  According to Benbassat, 60% of polled physicians claimed to have adopted risk-avoidance practices.   Defensive medicine may be a very likely response in the unique and dangerous clinical setting of the ED, where physicians do not have ongoing relationships with patients, and patients do not know the physicians delivering the emergency service. 

     The current tort system seem unfair to many emergency physicians.  Even if medical treatments and decisions were appropriate and not responsible for a patient’s adverse event, the physician can still be sued for the bad outcome.  Physicians pay exorbitant amounts of money for malpractice insurance; yet receive very little by way of protection or defense against litigation.  All too often in a lawsuit the defense attorneys and insurance companies are quick to settle the case rather than risk a lengthy and expensive court trial.  In settling cases which could be argued favorably for the defense, the physician is deprived the opportunity to defend his/her actions in court.  For the physician a settlement is a losing proposition.  The settlement is permanently recorded against the physician on the national practitioner data bank.  A physician with two or more settlements is at risk for being denied malpractice insurance coverage or if coverage is available, the cost is unaffordable.

     “Physicians quickly realize that in a malpractice allegation there is a strong correlation between severity of disability and jury outcome, but there is little correlation between negligence and outcome” (Couch 30).  Lanser states, “Today the perception is that an adverse outcome equals malpractice.”  This prompts strong reactions from physicians who perceive this as an injustice in the system.  “In only one-sixth of the claims did we find persuasive evidence of negligent injury on the record…a sizable financial and emotional burden is imposed on physicians and their insurers… due to mistakes made by patients’ lawyers” (30).  Added to this perception is the fact that the jury system is designed to exclude health care providers from the process.  “As a result, those who are best suited by training and experience to understand the complexities of medicine seldom serve as jurors”(30).  In malpractice cases the physician is not “judged by a jury of peers,” but more likely by patients who have their own biases and experiences with physician burnout.  “Burnout is a state of physical, emotional and mental exhaustion that results from intense involvement with people over long periods of time in situations that are emotionally demanding” (Sotile 314).  Increased malpractice insurance expenses, inability to increase income and the constant threat of lawsuits have greatly contributed to physicians stress and burnout.  Symptoms of burnout impair behavioral performance (316).  These symptoms increase the likelihood of physician error, which increases the risk of lawsuits—thus creating a vicious cycle. 

 

POSITIVE RESOPNSES TO THE CHALLENGES FACING AMERICA’S EDS

 

Risk Reduction/Patient Safety/the UES Experience

     The Harvard Medical Practice Study implies that there are too few lawsuits, with over 80,000 patients killed each year by America’s doctors.  Many experts believe that these adverse events are caused by substandard, antiquated systems of healthcare delivery, poor communication among healthcare team members, in attention to risk management issues and lack of a patient-centered approach.  Nationally many physician leaders have responded to the need for improvement in healthcare delivery systems.  The Institute of Healthcare Improvement (IHI) exemplifies the growing trend in this nation towards improving the quality of medical care.  The IHI focuses on creating awareness of the problems in healthcare, provides information and education on innovative methods for improvement and how to measure outcomes.  “Physicians can play a critical role in finding, developing, and implementing safety improvements” (Schoenbaum 51).  Collective physician effort was especially successful for anesthesiology.  “In the mid-1980s, high malpractice awards made anesthesiologists pay high premiums that were increasing faster than for any other specialty.  After the American Society of Anesthesiologists adopted practice guidelines to reduce patient harm, death and premiums have both decreased dramatically” (51).  Anesthesia now is the only health sector to achieve “six sigma” quality, or fewer than 4 deaths per 1 million exposures.  In contrast surgeons leave instruments or sponges in 1500 surgical patients each year---more than 15 times the six-sigma rate (52).

      Physicians must take responsibility for systems safety and improvement in clinical quality.  This requires change in culture, behavior and internal organization.  “In the long run, better quality and safety can save money.  Up front, however, time, effort and financial investment are required” (52). 

    4M Emergency Systems Inc. operates 15 emergency departments and urgent care centers in northeast Ohio and West Virginia.  Recognizing the need for quality improvement (QI) and patient safety, in 2002 this company enhanced their risk management/quality improvement division.  Thus began a formal process of investigation and research.  The QI team identified specific high-risk areas to the practice of emergency medicine.  They visited each UES emergency department/urgent care center and performed a detailed analysis of staffing, processes, protocols, systems implementation and constraints.  The QI team interviewed department physician and nursing leaders.  After analyzing the data and determining areas for quality improvement, the team created a series of initiatives and programs that were implemented in each of the emergency departments.  These included:

 

·        Standardized “difficult airway carts” for pediatric and adult patients

·        Clinical guidelines to standardize treatment of conditions such as MI and stroke

·        Converting to electronic discharge instructions

·        Mandatory customer service training for all emergency physicians

·        Formalized sign out system for physicians at change of shift

·        Institution of medical record documentation training

·        Implementation of clinical “risk reminders” to assist physicians in creating differential diagnoses

·        Distribution of palm pilots loaded with clinical and pharmacological information for quick reference

·        On line continuing medical education

·        Institution of a journal club

 

Pushing for Policy Change/Tort Reform

     According to ACEP the average jury award in medical malpractice cases has tripled since 1994.  The number of medical liability claims rose 5% nationwide between 1996 and 1999.  During the same time frame, the average jury award in medical liability cases increased by 76% (ACEP fact sheet 2).  ACEP cites an out-of-control litigation system as one reason for the current malpractice insurance crisis.  Seven of the top awards in 2001-2002 were medical liability cases totaling $3 billion.  In 2002, 52% of all awards were for $1 million or more and today the average award is  $3.5 million (2).  Possible solutions:

 

  • Legislative caps on non-economic damages (HR 5 padded by the US House of Representatives in March 2003) at $250,000.  It would not cap economic damages (lost earnings, medical care and rehabilitation costs).  Non-economic damages account for 50% of total awards.
  • Establish time limits on filing lawsuits
  • Place a monetary cap on attorney fees--California has such a system
  • Place sanctions against frivolous lawsuits—The Ohio State Medical Association in 2004 became the first medical association in the country to establish a “Frivolous Lawsuit Committee” to investigate and call for sanctions against frivolous medical malpractice lawsuits.  In the past physicians who have been named in frivolous lawsuits had no recourse.  Many practicing physicians suffered emotionally and financially while these frivolous suits dragged on, often for years.  OSMA intends to provide such physicians recourse against these lawsuits (OSMA newsletter April 04).

 

Innovations in ED Care

     Some EDs have developed innovative methods and programs to handle current public demand.  Cardiovascular disease is our nation’s number one killer.  In response to the high incidence of heart disease, St. Agnes HealthCare in Baltimore opened the first Chest Pain Emergency Department (CPED) in 1981 (Gill 4).   These units are designed to rapidly identify and treat those patients with coronary disease as the etiology of their chest pain.  “Since 1981 the spread of CPEDs has been significant, and today more than 800 hospitals have or are about to introduce such units” (4).

     Fast Track—Many EDs have implemented a “fast track” area designed to rapidly diagnose and treat patients with minor medical problems.  These areas can be physically separate from the main emergency department, reserved for the more acutely ill or injured patients.

     Observation Units—Some emergency departments have designed “observation units” within their confines and under their direction.  Patients who require prolonged medical observation for certain illnesses (asthma attack, allergic reaction, dehydration, alcohol intoxication, minor head injury etc.) yet are not ill enough to warrant lengthy hospital admission are candidates for these observation units.  “Observation units are often used as a way to lower costs and increase the quality of care in outpatient facilities” (ENA Position Statement).  As of 2002, about 33% of U.S. emergency departments had observation care beds (ENA 1).

 

Emerging Technologies

     Dramatic technological advances—especially information systems…can be expected to impact the practice of emergency medicine” (Case 25).  Computerized and integrated electronic systems for patient records have proven immensely beneficial to institutions such as the Louis Stokes Veteran’s Affairs Medical Center (VAMC) in Cleveland, Ohio.  The electronic medical record has obvious advantages.  In-hospital chart documentation, ancillary study results, past patient history, and outpatient visit records from community VA facilities can all be obtained with a few clicks and keystrokes.  Emergency departments are slowly making the transition to an electronic medical record.  The Internet may soon become the primary candidate for information infrastructure for the communication and management of health care information (25). 

     “A communication system incorporating real-time audiovisual capability and, in some cases, remote robotic devices constitutes the technological platform for telemedicine” (25).  At a minimum, it expands the potential geographic reach of a practitioner and raises the possibility of remote consultation (25).  

     Emerging technologies will no doubt have a profound impact on emergency medicine.  “Technology will help decrease the time costs of an Ed visit for patients by allowing emergency physicians to function as information integrators and to provide less expensive full-price services.  It will assist emergency physicians in providing such services by collaborating with mid-level providers at remote geographic locations”(25).  As a result of technological advances, emergency physicians will be able to expand their roles and provide improved health care to the people they serve.

 

     Despite financial, economic and political pressures, our nation’s EDs continue to stand strong.  Physician and nurse shortages, unsubsidized care of the indigent/ uninsured population, medical malpractice burdens and reduction in number of facilities despite significant increases in ED patients impose a mighty burden that stretches every fiber of the health care safety net.   Until this nation addresses the 43 million people without health care insurance, physician and health care leaders must face these challenges and issues to ensure that America’s safety net remains viable and available to everyone.