Transcript

State of Emergency: Overcrowding in the ER

STATE OF EMERGENCY OVERCROWDING IN THE ER The number of U.S. emergency rooms has dropped by more than percent in the past two decades, but patient visits have continued to rise. Most experts agree that the resulting ER overcrowding has reached crisis proportions. An emergency department is considered crowded when inadequate resources lead to a reduction in the quality of care. HISTORY OF EMERGENCY MEDICINE Emergency medicine as a specialty is only 50 years old. The Federal Highway Safety Act defines standards for ambulances The American Medical Association (AMA) recognizes emergency medicine as a specialty. American Academy of Emergency Medicine (AAEM) and ambulance driver training. established. 1966 1972 1993 1961 1968 1982 Responding to a growing demand for emergency The American College of Emergency Physicians (ACEP) established. Accreditation Council for Graduate Medical Education services, physicians in Virginia and Michigan are among the first to advocate for emergency medicine specialization. (ACGME) approves special requirements for emergency medicine residency training programs. EMERGENCY CARE IN 2010 20% 16% 130 million Total ER visits Percent of adults visiting ER patients arriving by ambulance ER one or more times ER WAIT TIMES (NATIONAL AVERAGES) These times represent the wait time to be seen by a physician. The national average for total time spent in the ER ranges from 3 hours to more than 4.5 hours. Some states see average total wait times of more than 7.5 hours. 46.5 minutes Average ER wait time in 2003 58.1 minutes Average ER wait time in 2009 (25% increase) 40 minutes Average wait time in non-urban areas (2009) 62.4 minutes Average wait time in urban areas (2009) 44.1 minutes Average wait time in ERs with no boarding (2009) 61.3 minutes Average wait time in ERS with boarding (2009) The Emergency Medical Treatment & Labor Act (EMTALA) of 1986 ensures public access to emergency services regardless of ability to pay. WHY ERS HAVE TO TREAT EVERYONE ER OVERCROVWDING 50% 90% of ERs operate at or above capacity. of ERs report patient boarding while waiting for inpatient beds. 500,000 ambulances are diverted each year away from the closest hospital due to ER overcrowding. A patient remains in the ER after the decision to admit or transfer the patient has been made. Although the average waiting time for an inpatient acute or critical care bed is over 3 hours, patients in hospitals with overcrowded ERs must wait nearly twice as long on average. BOARDING AMBULANCE DIVERSION An ambulance is diverted when hospitals request that ambulances bypass their ER and transport patients to other medical facilities. TRIAGE CATEGORIZATION OF INCOMING ADULTS (2010) 80% 12% 8% Level 3 (Resuscitation/Emergent) (Urgent/Less Urgent) (Non-urgent) "Non-urgent" does not mean "unnecessary." Only 6.3% of ER patients are discharged with a “primary care treatable" diagnosis. NOTE PROBLEMS WITH ER OVERCROWDING Compromises quality of care and patient satisfaction Threatens community trust Drives up health care costs and wait times TOP CAUSES OF ER OVERCROWDING Lack of Inpatient Hospital Beds Frequently results in ER boarding for patients who must be admitted. Lack of Access to Primary Care Physicians By 2020, the U.S. faces a shortage of more than 45,000 primary care physicians. Demand Increasing Demand, Decreasing Supply According to the CDC, annual ER visits in the U.S. grew by 34% from 1995 to 2010, while the number of hospitals with ERS declined by 11% during the same period. 34% -11% Supply PATIENTS WITH MENTAL HEALTH SYMPTOMS (2010) 6.4 million 350,000 Number of ER visits involving patients with mental health or substance abuse issues, representing about 5% of all visits. Decrease in number of beds in psychiatric hospitals between 1970 and 2006 (from 400,000 to 50,000) due to national movement away from institutionalizing mental health patients and budget cuts. VS According to a 2004 survey of ER physicians, psychiatric patients are boarded more than twice as long as medical patients. ER VISITS UNDER MEDICAID EXPANSION 40% Percent ER visits increased under Medicaid expansion, according to a 2008 study conducted in Oregon. PATIENT RISKS Depending on the seriousness of a patient's condition, being admitted to the hospital when the ER is overcrowded can mean a 5% increase in the risk of dying before being discharged. Boarding critically ill patients in the ER can cause treatment delays leading to poor outcomes. ER overcrowding threatens the ability of communities to treat mass casualty victims in a disaster scenario. COST OF OVERCROWDING $38 billion $1,086 $9,693-$13,298 Annual wasteful spending due to ER overuse, according to the New England Healthcare Institute (NEHI) Additional daily revenue lost from each hour of ER boarding in a study of one inner city hospital reported in the Annals of Emergency Medicine Revenue lost from each hour of ambulance diversion UNCOMPENSATED EMERGENCY CARE Cost is one of the main reasons a hospital closes its ER. 48 billion 55% 14% 12% Amount per year spent on emergency services of emergency care goes uncompensated Uninsured only account for 14% of ER visits, and 12% of total ER expenditures. SOLUTIONS Reduce ER boarding. Increase primary care access. Reduce processing time for non-critical patients. Improve communication between ER and inpatient units. Use online wait clocks and hotlines, so patients can check ER wait times or get health questions answered before visiting. Move patients from the ER to an observation unit for additional testing and monitoring before being admitted or released. This is a cost-saving measure for ERs, buti always for patients. On average, patients are discharged 38 hours sooner than those admitted. http://www.wjem.org/upload/admin/201203/96ac491c02b55bef396335e9d126b0c5.pdf 2 http://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/index.html?redirect=/emtala/ 3 http://www.nc bi.nlm.nih.gov/pmc/articles/PMC17261 73/pdf/v020 p00402. pdf 4 http://www.cdc.gov/nchs/data/databriefs/db38.htm http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf 6 http://www.cdc.gov/nchs/data/hus/hus12.pdf 7 http://www.ahrq.gov/research/findings/final-reports/ptflow/executive-summary.html 8 http://www.ahrq.gov/professionals/systems/hospitalVesi/esihandbk.pdf 9 http://www.ahrq.gov/research/findings/final-reports/ptflow/section1.html 10 http://news.nurse.com/apps/pbcs.dl/article?AID=200770907067#.UzzTeThOWM8 11 http://www.npr.org/blogs/health/2014/01/02/2591 28081/medicaid-expansion-boosted-emergency-room-visits-in-oregon 12 http://www.washingtonpost.com/national/health-science/observation-units-may-ease-burdens-of-er-care -but-benefits-to-ptients-come-at-a-price/2013/02/08/84ddf37e-706d-11e2-a050-b83a7b35c4b5_story.html 13 http://smhs.gwu.edu/sites/default/files/acem12219.pdf 14 http://www.nehi.net/writable/publication_files/file/nehi_ed_overuse_issue_brief_032610finaledits.pdf 15 https://projects.propublica.org/emergency/ http://newsroom.acep.org/download/ACEP+Psychiatric+and+Substance+Abuse+Survey+-+April+2008.pdf 17 http://content.healthaffairs.org/content/29/9/1637.full.pdf+html 18 http://www.nehi.net/writable/publication_files/file/nehi_ed_overuse_issue_brief_032610finaledits.pdf 19 https://www.aamc.org/advocacy/campaigns_and_coalitions/fixdocshortage/ 20 http://www.aha.org/research/reports/tw/chartbook/ch3.shtml 21 http://kaiserfamilyfoundation.files.wordpress.com/2013/01/7696. pd Milken Institute School of Public Health THE GEORGE WASHINETON UNIVERSITY MHA@GW ex

State of Emergency: Overcrowding in the ER

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Whether you’re suffering from a bad flu or a life-threatening injury, a trip to the emergency room is always a scary prospect. But what happens when an ER must treat more patients than it can suppo...

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