Posts Tagged emergency

Your Opinion is Important to Us

Sandra Schneider, MD, FACEP, ACEP Past President

I would like to personally invite you to become a member of the Emergency Medicine Practice Research Network – EM-PRN. Becoming a member is simple; just click on this link and answer a brief survey. It will take less than five minutes. We want to know if you are seeing patients with chronic pain, we want to know if you are experiencing medication shortages and how you are coping. We want to know how you practice. YOUR ANSWERS will provide ACEP with essential information for our advocacy in Washington and improving emergency care. To stay a member, all you need TO DO is to agree that you will complete 3-4 surveys, five minutes or less, each year.

Membership at this time is only open to ACEP members, residents, attendings and life members. Sorry, we cannot as yet accommodate non-members or medical students. Many other specialities have built practice research networks. Pediatrics has had one for more than a decade. They started small, like us. They have found that getting data from physicians on the front lines is often very different than getting it from inner city, teaching hospitals. Once you join EM-PRN, you will be able to do much more than just give opinions to survey questions. We want to submit ideas for research projects and survey questions that YOU would be interested in. Our group will pick the more interesting and the most popular IDEAS for the next survey. So you not only will be providing answers, you’ll be designing the questions.

Right now and for the next few years, EM-PRN will be largely surveys. Eventually, we will likely want to grow to collect some data. For example, IN THE FUTURE we might want to monitor the number of patients seen with chronic pain in emergency departments. You would simply count the actual number of patients you see during a single shift (no names, no identifiers) and submit it to ACEP.

We could then monitor this number over time to see if it is increasing, decreasing or staying the same. The members of EM-PRN will help direct what research projects we consider and will be acknowledged on any publication. Members will also receive the results of any project ahead of publication. So in the time it has taken you to read this Blog, YOU could contribute to advancing our knowledge of the real practice of emergency medicine. Join now.



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Does a Visit to the ER Represent a Failure of the Health Care System?

Does this look like the failure of a health care system?

In a widely read article in the January 2011 issue of The New Yorker by Atul Gawande that details the efforts of Dr. Jeffrey Brennerto improve care to a number of high-cost patients in Camden, NJ; Dr. Brenner was quoted as saying “Emergency-room visits and hospital admissions should be considered failures of the health-care system until proven otherwise.” This observation has often been quoted by any number of health care policy wonks, health plan advocates, and politicians in efforts to justify their particular distaste for ‘unnecessary’ ER care. Like many such generalizations, Dr. Brenner’s comments are often taken out of context or misinterpreted, and in some cases have been used to denigrate the care provided in ERs, or the patients that rely on the ER. Dr. Brenner was referring to “failures of prevention and of timely, effective care” in the rest of the health care system, and I cannot disagree with him that ERs are often called upon to address these failures. Nonetheless, my antipathy for Dr. Brenner’s observation is that it is glib, and too easy to misconstrue.

Emergency Departments provide such a broad scope of services, and play so many roles in health care, that it is rather short-sighted to view ER visits as the if they were almost inevitably the result of misuse, abuse, inattention, inappropriate delay, or a failure of prevention. If someone falls off a ladder and breaks their leg, that obviously is not a failure of the health care system, unless of course you plan to hold the health care system responsible for poor ladder design. Likewise, not all heart attacks or strokes can be prevented by good primary care, Lipitor, aspirin, and exercise; and not all pneumonias represent a failure to immunize or prescribe controller inhalers for asthma. The reasons why the number of ER visits have grown so rapidly go way beyond the fact that the health care system often fails us; or that the ER is open 24/7; or the EMTALA mandate to treat everyone regardless of insurance status or ability to pay.

ERs have become the diagnostic centers of the health care system; and many patients are sent to the ER by their doctor specifically because of the broad array of diagnostic services available, ER physician expertise as ‘diagnosticologists’, the ready availability of specialist expertise, and the efficiency of ER workups. It would not surprise me if more than a third of all cancers in the chest and abdomen are first detected in the course of an ER visit. In addition, the ER fills many roles that, if they had to be met by other health care providers and venues, would render those providers or venues overwhelmed, even more inefficient, and often just unavailable. Imagine if primary care doctors, or even urgent care centers, had to repair all lacerations, or treat all kidney stones, or manage every alcoholic who drank himself into a stupor. Think what it would cost if those offices and facilities had to stay open until 2 am to accommodate those who were not able to get their care during office hours. You don’t have to imagine closing every ER in the country to realize that ER care is not just some regrettable but necessary safety net established to manage the failures of the health care system. Just watch what happens when the last ER in a community closes: you will find that ERs represent what is often the best of what the health care system offers: timeliness, efficiency, effectiveness, scope, availability, responsiveness, surge capacity, compassion, and decisiveness; and this will be sorely missed by the residents of that community.

The tendency of many to misconstrue comments like those of Dr. Brenner is reflected in a host of similar aspersions cast on the ER.  Jane Stevens also wrote an article about Dr. Brenner, and about a similar effort to reduce costs through an ER diversion program in Bend, Oregon, designed to help patients who frequently landed on the doorstep of the ER to get access to other, more appropriate places to get the things they needed, some health care related, but often focused on social service needs. The title of this article was “Improve health, lower health care costs by reducing emergency room visits”, implying that simply by blocking the door to our ERs, we could solve what is wrong with health care.  At least, this is how many readers were likely to interpret the message. Taken to an extreme, this is the kind of message that leads policy makers and legislators to believe that if they just stopped paying for ER visits, they could keep everyone healthy AND solve their budget crises.

Dr. Brenner’s linkage of ER visits to failure has also become insinuated into even the most thoughtful discussions about health care reform. Brad Wright wrote a post in the Kevin MD blog that pointed out the mistaken belief by many that universal health insurance would lead to a reduction in ER use. He noted that “people go to the emergency room for a host of reasons that have nothing to do with their insurance status. Among these reasons are low health literacy, a health care system that is often complicated to navigate and inaccessible for people who can’t get off work during typical business hours, and a lack of continuity of care that arises for a host of reasons. Waiting to be seen in the ER is no picnic, but for many people it is a more easily understood process than trying to get a referral to a specialist from their primary care physician–assuming they even have one.” As I have noted above, this accounts for just a fraction of the reasons why patients use the ER. Mr. Wright notes that consequently, reduced ER use should NOT be considered a measure of the success of health reform.

I believe that ER use is an indicator of many things, some reflecting the failures of our health care system and our social safety net; others reflecting great advances in acute care, resuscitation, and diagnostic services; and still others reflecting our society’s need for, and desire for, efficiency, availability, and timeliness of care. You can’t hope to cover all of these attributes in a single, facile observation, no matter how well intended.

This post also appears in The Fickle Finger.

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Health Care Reform Takes Center Stage

Rep. Bart Gordon at ACEP's Leadership and Advocacy Conference

Rep. Bart Gordon at ACEP's Leadership and Advocacy Conference

Democratic leaders in the House and Senate released their long-awaited health care reform plans on June 9. The House released an outline that three major committees will work off of, while Senator Edward Kennedy (D-MA) released a full bill. Senator Max Baucus (D-MT), the other leading architect of reform legislation is expected to put out a bill before the end of June.

One of the key provisions of the Kennedy plan is a requirement that every person in America have health insurance. The legislation also creates a government run insurance program that would compete directly with private insurance companies. But as emergency physicians know, access to health insurance does not always equate to access to health care. If the primary care docs do not accept new patients with government insurance because of low reimbursement rates, they will eventually present in the emergency department.

ACEP’s Washington office– headed by Gordon Wheeler – has been working with the House and Senate committees responsible for developing health care reform legislation with the goal of assuring that emergency medicine’s issues are being addressed. In addition, ACEP recently launched a letter writing campaign urging members to contact Congress and demand that emergency patients’ needs are included in health care reform.

 ACEP is having some success in bringing emergency medicine’s issues to the attention of Congress, Mr. Wheeler said, and Senator Kennedy’s bill, “The Affordable Health Choices Act,” includes several provisions important to the specialty, including:

  • Reauthorization of the emergency medical services for children program ($25 million in 2010, to $30.3 million in 2014)
  • Design and implementation of regionalized systems for emergency care
  • Competitive grants for regionalized systems for emergency care response
  • Support for emergency medicine research
  • Mental health assessments, crisis intervention, counseling, treatment, and referral to a continuum of services, including emergency psychiatric care¸ community support programs, inpatient care, and outpatient programs.

In addition, Rep. Bart Gordon (D-TN), House sponsor of the “Access to Emergency Medical Services Act of 2009” (H.R. 1188) said recently that he would like to see language from that bill included in the House’s health care reform legislation. Rep. Gordon said that all of the bill’s provisions (listed below) should be considered:

  • The creation of a national bipartisan commission to examine factors that affect the delivery of care in emergency departments
  • The need for additional resources in support of emergency care delivery
  • The development of standards, guidelines and measures by the CMS to address boarding and ambulance diversion

Rep. Gordon is also encouraging the development of pilot programs to model effective and efficient trauma regionalization systems, especially in dealing with capacity and diversion issues. Rep. Gordon, a long time supporter of emergency medicine, is also concerned about emergency medicine workforce issues and reimbursement for emergency medical services. He recently sponsored “The Health Care Safety Net Enhancement Act of 2009” (H.R. 1998), a bill that would improve access to emergency medical services and provide liability coverage for emergency physicians when providing care to EMTALA patients.

Rep Gordon is also the sponsor of “The Medicaid Emergency Psychiatric Care Demonstration Project Act of 2009,” (H.R. 1415) legislation that would fund a demonstration project that allows Medicaid to pay for emergency psych services at non-publicly owned or operated institutions. The goal of the project is to help alleviate the psych bed shortage and move patients out of the emergency department and into treatment.

Debate on the numerous bills being discussed is expected to begin in July. At this juncture, it is unclear what the final health care reform legislation will look like, or if comprehensive health care reform will be successful this time around. ACEP will continue to lobby for emergency medicine’s interests and seek solutions to the critical problems confronting the specialty. This blog will continue to keep you informed of ACEP’s progress.

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