Ed Newton, M.D., Chair Emergency Medicine A 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 Safety 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 SAFETY 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 SAFETY 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) EMERGENCY DEPARTMENT OVERCROWDING ED 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 A 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) 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 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 CAUSES 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 The 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 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 ED∴ not subject to EMTALA 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 NURSING 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 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 SOME 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