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
SPEECH BY ENG. M.S.M KAMAU, CBS, CABINET SECRETARY,MINISTRY OF TRANSPORT AND INFRASTRUCTURE, DURING THELAUNCH OF THE ENGINEERS BOARD OF KENYA (EBK)STRATEGIC PLAN AND LOGO ON 24 th MARCH 2015 AT THE KICC,NAIROBI