FHA Task Force on Challenges in the Emergency Department

1. FHA Task Force on Challenges in the Emergency Department

2. Challenges facing Florida’s Emergency Departments • Increased patient volume • Sicker patients • Increased number of uninsured patients • ED staffing – On call coverage • Nursing shortage • Insufficient ED space • Bed shortage • Lack of critical care beds • Delays • Transferring ED patients to an inpatient bed • Radiology reads • Pathology results • Consultations • Documentation requirements • Medical liability • Lack of or inadequate primary care network resulting in physicians referring patients to ED for non-emergent care • Psych patients – decreased outpatient capacity

3. Use of Emergency Services continues to grow nationally Emergency Department VisitsUnited States1993 - 2003 • ER visits nationally reached 113.9 million in 2003, up 26% since 1993. During this same time, the number of EDs had shrunk to 3,910 (I am looking for 1993 # of EDs) • ED visits are growing by 2 million per year. • ED use rate grew from 35.5 visits per 100 in 1993 to 39.9 visits in 2003. • 14.2% of the patients arrived by ambulance. • Most patients arrived between 8 a.m. and 10 p.m. • 60% of patients saw a physician within 1 hour; duration of the visit averaged 3.2 hours • AHA and ACEP study found that more than 90% of large hospitals reported their EDs were at or over capacity in 2002. Source: National Ambulatory Medical Care Survey, 2003 Emergency Department Summary, Centers for Disease Control and Prevention, May 26, 2005

4. Demand for ED services in Florida growing at an accelerated pace ED Visits to Florida Hospitals 1993-2003 • ED visits to Florida hospitals reached 7 million in 2003, up 46% from 1993. • This reflects an annual increase of 220,000 ED visits per year. • 59% of patients (1.3 million) admitted to Florida hospitals were first seen in the ED. • ED visits per 100 grew from 35.6 per 100 in 1993 to 40.8 per 100 in 2003.

5. Demand for ED services is up, supply is down Florida’s Population and Number of Hospital Emergency Departments • Since 1993, 3.6 million more people live in Florida • During this same period, the number of hospitals with emergency departments fell from 226 to 214, a loss of 12 EDs. • According to AHCA Plans and Construction records, since 1994, approximately 31 hospitals expanded/added to their emergency department. • Unfortunately, there are no data on how many additional treatment rooms or additional patients can be cared for due to those expansion activities.

6. Number of visits per day growing Average Number of Emergency Department Visits per Day to Florida’s Hospitals • Over 19,000 people are treated in Florida's EDs on a daily basis, an increase of 5,800 additional patients per day since 1993. • While the number of hospitals with EDs shrunk during this time, it is uncertain how much additional capacity was created through hospital ED expansion projects.

7. Hospital inpatient resources have not expanded Total Beds and ICU Beds in Florida’s Hospitals • Florida has seen a drop in the number of available hospital beds since 1993, when there were 56,160 acute care beds. By 2003, there were 2,400 fewer, bringing the number of beds to 53,770. • The beds per 1000 population fell to 3.1 beds in 2003, compared to 4.1 beds in 1993. • Over the 10 year period, hospitals added 311 ICU beds, but the ICU beds per 1000 population fell to .27 from .32 in 1993.

8. Key Issues facing the Task Force • On-call specialty coverage • ED access to care • Jan 2004 survey: • Lack of on-call specialty coverage is primary reason for ambulance diversions • 76% diverted because of specialty care shortages

9. Then: Requirement of medical staff participation Created a base of potential patients for new physicians Specialists couldn’t practice without hospital privileges Now: Exempt because of medical staff tenure Life style issues Adverse impact on medical practice Increased liability exposure Specialties no longer need hospital to practice Specialist shortages Issues of On-Call Coverage

10. AHA Survey, Emergency Department Overload: A Growing Crisis, 2002 • Surveyed hospitals across the country to gather data on perceptions of volume vs. capacity, diversion rates, reasons for diversion, impact on service levels, volume trends and uninsured. • Findings: • Majority of hospital EDs perceive they are “at” or “over” capacity • 1/3 of all hospitals experienced ED diversions • Lack of available staffed critical care beds was the # 1 reason for ED diversion • Hospitals reporting time on diversion at 20% or more had an average RN vacancy rate of 16% • Average waiting time for transfer from ED to an acute or critical care bed ranged from 1.2 hours to 5.8 hours • Neurosurgery, neurology and cardio/thoracic surgery were the hardest physician coverage slots to fill • On call coverage issue stems from: • Uncompensated care • Medical liability fears • Changes in the lifestyle expectations of physicians • Physician limited-service hospitals • EMTALA does not create a mandate for physicians to serve on-call • Conducted follow up case studies in four communities in April 2004

11. California Experience California • 2003 Report “Growing Gaps in California’s Emergency Room Backup System” • CHA study found 46% of hospitals considered the lack of on-call physician backup as a “serious problem” and 78% thought it would become “very serious” within 2 years. • On-call coverage responsibility of hospitals, medical staffs, health plans, medical groups, local EMS agencies and public payers • Burden for on-call should be broadly shared among physicians • Increased funding necessary to cover uncompensated care related to provision of on-call services • Contracts with health plans should ensure payment sufficient to ensure availability of on-call physicians. • Remove legal and regulatory barriers to sharing on-call resources among hospitals • Explore additional liability protections for on-call services • Monitor gaps in availability of specialists • State should closely monitor problems with accessibility of on-call services • 2005 Issue Brief: “On-Call Physicians at California Emergency Departments” • Identified various legislative funding recommendations to pay for on-call coverage and care of uninsured patients; use by hospitals of “mandatory” call and payment of stipends for ED coverage; use of productivity-based guarantees; using hospitalists and intensivists to care for unassigned patients.

12. Arizona Experience • ACEP- The Emergency Services Crisis of 2000 • ED volume up; revenue down • Large number of uninsured (#1 in US); large undocumented population • On-call specialty physician shortage • Bed shortages • Ambulance diversions • Collapse of primary care network resulted in ED only alternative for insured and uninsured patients • Ambulances waiting 2 hours to offload patients at ED • Ambulance diversion and hospital crowding resulted of unfunding. • Followup summit in June 2005

13. FHA Survey on ED Call Coverage Policies • FHA surveyed hospitals in 2003 to gather information on hospital on-call coverage policies. • Majority of hospitals required physician to take ED call as a condition of medical staff participation. • 87% reported some type of exemption for ED call coverage • Active years of services most common exemption (15+) • Age of physician(55+ yrs) • Combined active years/age • Nine hospitals reported having combined ED call coverage with another hospital • 25% of hospitals revisiting ED coverage policies.

14. Palm Beach County • ED specialty coverage issue highly publicized in 2001 • Palm Beach County Medical Services commissioned a study in 2004 to develop recommendations for specialty on-call coverage in Palm Beach County Emergency Departments. Survey of providers found • 84% would stop taking ED call once they meet the number of years on the medical staff that would exempt them from ED call • 40% indicated they would give up clinical privileges to avoid ED call • Recommendations • Create an Emergency Department Management Group • Investigate the clinical repercussions of shortages of on-call specialty care • Provide stop-gap funding to ensure adequate supplies of on-call coverage. • Build a countywide electronic ED call schedule and regionalize on-call coverage for some specialties. • Fundamentally alter malpractice risk management. • Invest in county wide quality assurance programs • Take multiple measures to resolve the shortage of physicians taking ED call. • Increase the staffing of ED physicians during peak periods. Source: “Specialist On-Call Coverage of Palm Beach County Emergency Departments,” MD Content Study commissioned by the Palm Beach Count Medical Society Services, December 13, 2004

15. Other Areas of the State Facing Challenges • Florida Keys • 2005 highly publicized hospital physician discussions over on-call coverage policies • Orlando • 2001: orthopedic surgeon on-call refuses to treat child with broken arm • Manatee county • 2001: 30 physicians pulled out of hospital on-call coverage program • Lakeland • Major increase in ED volume resulted in going on diversion for first time since 2003; instituted a “code purple”

16. Statutory Requirements for ED Coverage Florida Access to Emergency Services (Ch. 395.1041(3)(d) F.S) • Requires any service perform in a hospital on an elective basis to also be available in the emergency room. The only exceptions are if another physician in advance agrees to accept the emergency or the state gives an exemption. Therefore, if specialists do not provide emergency on call services, they may not provide elective services. Penalties for failure or refusal to respond within a reasonable time after notification when on call include civil liability, misdemeanor charges and violation of licensure requirement. EMTALA • Places additional requirements and penalties for on call physicians who fail to respond. 42 USC section 1395 requires hospitals to maintain on call physicians to assist in further screening, examination or transfers of patients. Hospitals are required to report any physician failing to respond for on call services. Penalties include $50,000 fines and loss of Medicare certification. Board of Medicine • Failure or refusal of an on call physician to come in is considered a violation of the physician’s license and would be considered practicing below the standard of care under section 548.331(1)(t) F.S. • Two or more physicians are prohibited from engaging in a concerted effort to refuse or get physicians to refuse to render services to patients in a hospital emergency room by failing to report to duty, absenting themselves from their positions, submitting their resignations, or abstaining from the full and faithful performance of their medical duties. Penalties include $5,000 fines, liability for damages, and disciplinary action pursuant to Section 458.3295 F.S.

17. EMTALA and the “On-Call” requirements – recent changes • On-call requirements • Hospitals must maintain a list of physicians who agree to take call • Physicians on list must show up when called • This is a requirement for participation in Medicare • Not required: • Physicians not required to take call nor are physicians required to be on call at all times • No “Rule of 3” • Permitted • Simultaneous call • Performing surgery while on call if suitable back-up plan • Changes from proposed rule • “Best meets the need of the patient” standard modified to include language recognizing that resource limitations of the hospital. • “Best meets the needs of the patients who are receiving services required under EMTALA in accordance with the resources available to the hospital, including the availability of on-call physicians.” • EMTALA Technical Advisory Group created to discuss concerns with recent revisions including the withdrawal of specialists from call panels

18. Potential Solutions to On-Call Specialist Crisis • Contract with outside multi-specialty medical groups to take call. • Pay stipends to specialists. • Linking state licensure to ED call. • Linking CMS participation to ED call • Malpractice premium discounts for physicians taking ED call. • State granting sovereign immunity to services provided in the ED. • Require managed care plans and other insurers to contribute to a state fund to be used to provide safety net compensation proportionate to the payers percentage of insured patients. Such contributions could be used to provide stipends to doctors. • Suggest citizens to pay for emergency care as line items on their property tax bills as they do for fire and police protection. • Lobby lawmakers to raise local sales taxes to pay for emergency care. • Mandate managed care contracts with physicians include call services as part of the contractual arrangement. • Regionalization – multiple hospitals that have transfer agreements with different hospitals take responsibility for covering certain specific emergency services during any given day or week. Some communities are doing this but it may not be EMTALA-compliant. • Use hospitalists to do non-surgical ER admissions. • Urge medical staff leaders to come up with reasonable call policies that are EMTALA compliant. • Keep internal data on how much call is taken by each physician to demonstrate that the burden on any one doctor is not excessive. • Educate all players about EMTALA regulations- physicians and hospital management – so everyone knows rules and potential penalties. • Educate nearby hospital leaders about their own EMTALA liability for dumping of patients. Source: “Specialists Shortage Shakes Emergency Rooms; More Hospitals Forced to Pay for Specialists Care,” The Physician Executive, May-June 2005.

19. Advisory Board’s Call Coverage Strategies • Mandatory on-call system • ED response time tracking • Tier-based stipends • Productivity-based payment guarantees • Hybrid compensation model • Physician assistants as first responder • ED dedicated hospitalists • Hospital-sponsored malpractice insurance Source: Health Care Advisory Board, May 2005

20. ED Crowding/Diversions • GAO 2003 Report, “Hospital Emergency Departments: Crowded Conditions Vary among Hospitals and Communities” • Three indicators of ED Crowding • Number of hours a hospital is on diversion status • Proportion of patients and length of time patients “board” or remain in the ED • Proportion of patients who leave ED before medical evaluation • Findings: • Two of every three EDs reporting going on diversion some time in 2001 • 10% of the hospitals were on diversion more than 20% of the time • Key factor contributing to crowding was inability to move patients out of emergency departments into inpatient beds when patients need to be admitted. If bed isn’t available, patients are “boarded” in the ED. Need for critical care or telemetry beds were cited as major hold up for patient transfer. • Lack of available beds most common factor • Inability to transfer to telemetry beds • Inability to transfer to critical care beds • Inability to transfer to other inpatient beds • ED capacity • Actions taken to address crowding issue • Increasing capacity • Increasing efficiency • Developing standard definitions and policies for when hospitals can go on diversion • Improving communications among hospitals • Reasons for not having inpatient capacity • Financial incentives to control costs and maximize review by staffing beds to fullest extent • Competition between ED admissions and scheduled admissions for available beds • Efficiency Issues • Patients are older and more complex • New technology allows patients to be monitored before admitted • Delays in receiving lab and radiology results • Delays in discharging patients due to later physician rounds

21. Urgent Matters Project: ED Overcrowding and the Health Care Safety Net • Initiative of Robert Wood Johnson Foundation to help hospitals eliminate ED crowing and help communities understand the challenges facing the health care safety net. • The program has three specific goals: • Improve the ability of the safety net providers to respond to increasing ED volumes; • To assess and highlight the state of local safety nets in select communities; and • To publicize the program’s findings to local and national audiences.

22. JCAHO Emergency Department Overcrowding Standards • Proposed Leadership Standard lD3.4: • Leadership engages in planning that assess the scope and impact of ED overcrowding and seeks to resolve identified issues • Planning encompasses the delivery of care to patients who must be placed in temporary bed locations. These temporary locations must be outside of the ED and in appropriate patient care areas. • Planning includes coordination with community resources for the purpose of expediting discharges from the ED. • Specific performance indicators are measured that monitor the capacity of support services and patient care and treatment areas that receive ED patients. • The organization’s handling of ED overcrowding is integrated into the organization-wide Performance Improvement activities. • The organization develops performance measures that monitor the effectiveness of the plan’s implementation. • Planning includes methods to minimize diversion through coordination with community resources such as EMS, air ambulance or fire departments. NOTE: This was incorporated into another standard where it address other areas of the hospital too, not just the ED.

23. ED Diversion Program Legislation • HB1629 (Passed in 2004 Legislative Session) focused on the development of community emergency room diversion programs by requiring • FQHCs to provide extended hours of operation to treat urgent care patients and include case management for emergency room follow-up care. • Hospitals to develop ER diversion programs including an “emergency hotline” to help patients determine if emergency care is appropriate, “fast track” programs allowing nonemergency patients to be treated at an alternative site (FQHC, CHDs or other nonhospital provider). Programs must include provisions for follow up care and case management • Health Plan to provide on their Internet website information regarding the appropriate utilization of emergency care services, including a list of alternative urgent care contracted providers, types of services offered by these providers and what to do in the event of a true emergency. HMOs required to develop community emergency department diversion programs which include enlisting providers to be on call to subscribers after hours, coordinating care through local community resources and providing incentives to providers for case management. Also allows higher copays for urgent or primary care provided in the ED.

24. Florida Emergency Services Task Force, 2000 • Bureau of EMS has received complaints about ambulances being diverted from original destination to other hospitals for the past 25 years. • Unlike past, ambulance diversions occur year round. More people are using hospital emergency departments as their primary care providers, which results in crowded emergency rooms, disruption of patient flow and impacts access for true emergencies. • Hospital staffing shortages make it difficult to handle increased volume. • Increased number of uninsured patients seeking care in the ED has resulted in negative financial impacts on hospitals and physicians. • Problem is no longer limited to the safety net but impacting all providers in the state.

25. Detached ED Legislation • Since 1996, AHCA has licensed two detached EDs, which are emergency departments that are located off the premises of the main hospital. • Were required to meet the same regulatory standards that apply to EDs that are part of a hospital • 2004 Legislature required AHCA to study these types of facilities and submit a report recommending appropriate regulatory standards. Legislature also imposed a moratorium on any additional detached EDs until July 1, 2005. • AHCA report recommended the addition of CON regulation for these entities. • 2005 Legislature extended the moratorium until July 1, 2006.

26. Florida Examples • Ocala • AHCA granted Marion county hospitals (Munroe Regional Medical Center, Ocala Regional Medical Center, TimberRidge ED and West Marion Community Hospital) permission to implement a program to reduce the use of EDs for non-emergencies. • Hospitals still would have to do the medical screening, patient notified no emergency medical condition exists, then counseling would be provided regarding treatment options. Patients under the age of 4 and over the age of 65 are exempt from the referral process. • Shands Healthcare: • “Bed Crunch” workgroup to identify delays in the admission process; decreased turnaround time for urgent care patients; encourage physicians to make rounds earlier to facilitate patient discharges; opened a chest pain unit

27. Definitions • Emergency Department Crowding: A situation in which the identified need for emergency services outstrips available resources in the ED. This situation occurs in hospital EDS when there are more patients than staffed ED treatment beds and/or wait times exceed a reasonable period. Crowding typically involves patients being monitored in non-treatment areas awaiting ED treatment beds or inpatient beds. Crowding may also involve an inability to appropriately triage patients and/or a large number of patients in the ED waiting area of any triage assessment category. • Emergency Dept Saturation: A situation when patient need, defined as timely evaluation and treatment based on triage assessment category, cannot be met for existing and/or additional patients due to fully committed ED resources. Source: Arizona College of Emergency Physicians, May 15, 2002