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EMERGENCY!!! in the Emergency Department. Ashley Killinder, PA-S University of Kentucky, 2008. Objectives…. History of Emergency Department (ED) Reasons for Overcrowding in the ED Solutions to the Problem Questions and Answers. History….

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Emergency in the emergency department l.jpg

EMERGENCY!!!in the Emergency Department

Ashley Killinder, PA-S

University of Kentucky, 2008


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Objectives…

  • History of Emergency Department (ED)

  • Reasons for Overcrowding in the ED

  • Solutions to the Problem

  • Questions and Answers


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History…

  • The first American hospital was established in 1752.

    • Patient Care = Free!

  • For-profit hospitals in 1900’s

    • Patient Care = Expensive!


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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


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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%.


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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.


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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.


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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


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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.


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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


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Increased Numbers

  • Which population contributes the most to the overcrowding problem in the ED?

    • Uninsured patients ?

    • Medicaid patients ?

    • BOTH ?!


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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.


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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.


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Who is at Fault?

  • Are Medicaid patients the “Bad Guy”?

  • Look out for large cuts in Medicaid/ SCHIP funding


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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!!!


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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


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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!


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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.


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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.



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