EMERGENCY!!! in the Emergency Department

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

18. References • 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):1-4. • 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):324-36. • Dorsey JL. The health maintenance organization act of 1973 and prepaid group practice plans. Med Care. 1975 Jan;13(1):1-9.

19. References • 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, McKenzie 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.

20. Questions?…