EMERGENCY MEDICINEEMERGENCY MEDICINE

LAC +USC MEDICAL CENTER

Ed Newton, M.D., Chair Emergency Medicine

LAC +USC MEDICAL CENTER

Ed Newton, M.D., Chair Emergency Medicine

A DAY IN THE LIFEA DAY IN THE LIFE

• Clinical: 400 patients/day in 6 EDs; busiest Level I Trauma Center in US

• Teaching: 54 EM residents, competitive specialty draws top residents to the MC; med student rotation

• Administration: planning, problem resolution, evaluations; recruiting/retention

• Scholarly Activity: writing and editing texts/journals; speaking at conferences

• Clinical: 400 patients/day in 6 EDs; busiest Level I Trauma Center in US

• Teaching: 54 EM residents, competitive specialty draws top residents to the MC; med student rotation

• Administration: planning, problem resolution, evaluations; recruiting/retention

• Scholarly Activity: writing and editing texts/journals; speaking at conferences

Safety Net HospitalsSafety Net Hospitals

• Urban, academic centers, Trauma Centers

• Care for a disproportionate number of uninsured, medically complex patients with additional significant social problems; specialty care

• Underfunded: Less able to implement changes in structure, equipment, personnel, information systems

• Urban, academic centers, Trauma Centers

• Care for a disproportionate number of uninsured, medically complex patients with additional significant social problems; specialty care

• Underfunded: Less able to implement changes in structure, equipment, personnel, information systems

SAFETY NETSAFETY NET

• In addition Safety Net functions to:• Train large % of health care

workers• Prepare for and provide care in

disaster situations• Perform disease surveillance, public

health functions

• In addition Safety Net functions to:• Train large % of health care

workers• Prepare for and provide care in

disaster situations• Perform disease surveillance, public

health functions

SAFETY NETSAFETY NET

• Safety net is unraveling as more hospitals close completely or close their EDs

• Virtually no “surge capacity” exists to accommodate a sudden increase in the number of patients from natural disasters; flu or other epidemics; bioterrorism

• Increased diversions and transport times• Only 4% of $3.8 billion Homeland Security

funds for emergency preparedness has gone to emergency medical services (2003)

• Safety net is unraveling as more hospitals close completely or close their EDs

• Virtually no “surge capacity” exists to accommodate a sudden increase in the number of patients from natural disasters; flu or other epidemics; bioterrorism

• Increased diversions and transport times• Only 4% of $3.8 billion Homeland Security

funds for emergency preparedness has gone to emergency medical services (2003)

EMERGENCY DEPARTMENT OVERCROWDING

EMERGENCY DEPARTMENT OVERCROWDING

ED OVERCROWDINGED OVERCROWDING

• Victims of our own success:– always open; don’t have to take time

off work to see a physician– can deal with any medical problem– get immediate access to whole

diagnostic capability of the hospital

• Most of the increase in # of visits is from insured patients

• Victims of our own success:– always open; don’t have to take time

off work to see a physician– can deal with any medical problem– get immediate access to whole

diagnostic capability of the hospital

• Most of the increase in # of visits is from insured patients

A FEW FACTS: 1993-2003A FEW FACTS: 1993-2003

• 114 million ED visits/year (26% increase)

• Net loss of 703 hospitals; 198,000 hospital beds; 425 EDs (15%)

• 60%-79% of hospitals operating over capacity

• 45 million uninsured, many more underinsured (e.g. MediCal, high deductible policies)

• 114 million ED visits/year (26% increase)

• Net loss of 703 hospitals; 198,000 hospital beds; 425 EDs (15%)

• 60%-79% of hospitals operating over capacity

• 45 million uninsured, many more underinsured (e.g. MediCal, high deductible policies)

INCREASED DEMAND FOR ED SERVICES

INCREASED DEMAND FOR ED SERVICES

• Aging population• Diabetes epidemic; CHF epidemic• Increased referrals by PMD’s to ED

especially for sicker patients• More invasive treatment options

available that can’t be provided in an office

• Aging population• Diabetes epidemic; CHF epidemic• Increased referrals by PMD’s to ED

especially for sicker patients• More invasive treatment options

available that can’t be provided in an office

IMPACT OF OVERCROWDING ON EMERGENCY MEDICINE

IMPACT OF OVERCROWDING ON EMERGENCY MEDICINE

• Changed scope of practice of EM to include more critical care, inpatient care and primary care

• Increased turnover of staff, burnout• Increased errors• Not an ideal environment for

providing inpatient care

• Changed scope of practice of EM to include more critical care, inpatient care and primary care

• Increased turnover of staff, burnout• Increased errors• Not an ideal environment for

providing inpatient care

CAUSES OF ED OVERCROWDINGCAUSES OF ED

OVERCROWDING• High levels of uninsured and

underinsured (45% in LA County) lack of access to all but ED; failure of primary care

• EMTALA Federal law (1986)• Reduced inpatient bed capacity• Hospital closures• Nursing shortage• Nursing ratios

• High levels of uninsured and underinsured (45% in LA County) lack of access to all but ED; failure of primary care

• EMTALA Federal law (1986)• Reduced inpatient bed capacity• Hospital closures• Nursing shortage• Nursing ratios

The UninsuredThe Uninsured

• Linking a national health plan to insurance companies and employment will still leave out a huge population

• The sickest patients are too sick to work

• Linking a national health plan to insurance companies and employment will still leave out a huge population

• The sickest patients are too sick to work

EMTALAEMTALA

• Annual “bad debt” per physician $12,300• Annual “bad debt” per Emergency

Physician: $138,000 (AMA)• Guarantees access for all patients but is

an unfunded mandate• Has resulted in other specialists refusing

to participate in “on call” panels and rise of specialty surgical specialty hospitals with no EDnot subject to EMTALA

• Annual “bad debt” per physician $12,300• Annual “bad debt” per Emergency

Physician: $138,000 (AMA)• Guarantees access for all patients but is

an unfunded mandate• Has resulted in other specialists refusing

to participate in “on call” panels and rise of specialty surgical specialty hospitals with no EDnot subject to EMTALA

HOSPITAL CLOSURES: California Data

HOSPITAL CLOSURES: California Data

• 79 hospital closures 1996-2006 (CHA)

• 11 recent hospital closures in LA County including MLK

• California MediCal reimbursement ranks 50th vs all states

• 79 hospital closures 1996-2006 (CHA)

• 11 recent hospital closures in LA County including MLK

• California MediCal reimbursement ranks 50th vs all states

NURSING SHORTAGENURSING SHORTAGE

• Nurse ratio are a good idea to improve quality of care but have resulted in additional closures of inpatient beds

• Implemented at the same time as serious nursing shortage

• Ratios are not enforced in the ED patients accumulate in ED as “boarding admitted patients” ED cannot accept new critical patients

• Nurse ratio are a good idea to improve quality of care but have resulted in additional closures of inpatient beds

• Implemented at the same time as serious nursing shortage

• Ratios are not enforced in the ED patients accumulate in ED as “boarding admitted patients” ED cannot accept new critical patients

Additional Health Costs in US

Additional Health Costs in US

• Highest levels of interpersonal violence of any Western society

• High levels of drug and alcohol addiction and abuse

• Ability to provide very expensive technologies

• High level of futile care at the end of life

• Lack of investment in preventive care

• Highest levels of interpersonal violence of any Western society

• High levels of drug and alcohol addiction and abuse

• Ability to provide very expensive technologies

• High level of futile care at the end of life

• Lack of investment in preventive care

SOME SOLUTIONSSOME SOLUTIONS• National health plan without links to insurance

companies and employment• Provide funding for EMTALA related care• Increase inpatient, psychiatric and convalescent

hospital bed capacity• Every hospital should have a surge capacity plan

that involves the whole institution • Build up primary care capacity• Entice more nurses into profession by increasing

wages and benefits; increase training capacity• Mandate participation in ED call panel as a

condition for medical staff privileges• Gun control, violence intervention and rehab

programs

• National health plan without links to insurance companies and employment

• Provide funding for EMTALA related care• Increase inpatient, psychiatric and convalescent

hospital bed capacity• Every hospital should have a surge capacity plan

that involves the whole institution • Build up primary care capacity• Entice more nurses into profession by increasing

wages and benefits; increase training capacity• Mandate participation in ED call panel as a

condition for medical staff privileges• Gun control, violence intervention and rehab

programs