Long term prognosis for emergency care

This is a link to an article in Congressional Quarterly this week, written by Rebecca Adams. It is a fairly impartial assessment of the emergency department environments and the unanticipated consequences of health reform legislation.

http://www.cqpolitics.com/wmspage.cfm?docID=weeklyreport-000003259823

After Ike - Lessons from Rita don't work

Galveston Mayor Lyda Ann Thomas announced in a press conference yesterday that the island would implement the “Look and Leave” policy beginning at noon. Three hours later the policy was rescinded. Why? Three lanes of traffic lined up 15 miles, trying to get onto the island. The backup delayed emergency crews working to restore power to the crippled island. According to Texas’ oldest newspaper, The Galveston County Daily News, police had their hands full dealing with irate drivers trying to return to the island.

More concerning to me is the rumor that most of these people had no intention of honoring the “Look and Leave” provisions. Most intended to stay in their homes – without sanitation, water, or power. Dr. David Lakey, state health commissioner, has declared the island a health hazard, and warns of water-borne illness, food-borne illness, and the lack of health care on the island. UTMB is the state’s oldest medical school, and most residents have no concept of life on the island without nearby medical care.

Evidence of this was borne out today, when the Kroger grocery store opened. The Kroger suffered no flood damage, and only minor roof damage. They imported workers from neighboring workers, and brought in 16 dump trucks to carry out food spoilage. They were given clearance to sell packaged/dry goods and any remaining fruits and vegetables. They also opened the pharmacy, saying they would fill any existing prescriptions with a 72 hour supply. They also promised to honor new prescriptions, unless for narcotics, with a 72 hours supply. They declined to fulfill any narcotic prescriptions.

Guess what happened? Needing new or replacement prescriptions, people lined up to be seen in the emergency department. The emergency department, and indeed the entire medical facility, is closed. The DMAT teams are treating minor injuries and transferring serious injuries to mainland facilities.

My sources are in disagreement about what happened next, but the crowd eventually dispersed, upset and angry.

I am not in the middle of this maelstrom, but I ask these questions:

If the island is unlivable, why are people being allowed to live there?

If the island is a health hazard, why are people being allowed to live there?

If there is no medical care, no sanitation, no water, no electricity, and a grave health

threat to the remaining population, why are people being allowed to stay?

In a policy developed as a result of Hurricane Rita, residents were supposed to be allowed to come to the island between 6 AM and 6 PM to view their property. However, with 3500 people still living on the island 24/7, it is difficult to rationalize the 12-hour-only policy. What seemed so practical in 2005 has proven to be unworkable in 2008. Ah, well, another lesson learned. I feel certain that more are to follow.

For those of you with morbid curiosity, you may view the island by relatively recent satellite image at http://ngs.woc.noaa.gov/ike/IKE0000.HTM. The views were sufficient for me to tell that a corner of my roof collapsed, but the main structure is still standing. And, as I still maintain, it’s only stuff.

Killer Pain Killers

According to a CDC report published in June, medications were either given in the ED or prescribed at discharge at 76.7 percent of all emergency department visits. This represents about 1.8 medications given per person, per visit. The most frequently prescribed drugs at discharge are pain relievers. (In fact, the first antibiotic on the list of top twenty prescribed drugs appears at number eight on the list.) The top medications prescribed/ordered/recommended at discharge, in order of frequency, were:

1. Ibuprofen
2. Acetaminophen with hydrocodone
3. Acetaminophen alone

This makes sense, given the fact that the number one reason people give for coming to the emergency department is to obtain pain relief. Given the number of prescriptions written annually for prescription pain medications, parents and caregivers are reminded that these medications are a threat to teenagers and very small children, principally because they are so readily available at home.

The news on young people and drugs these days is mixed. A government report out this week shows a decline in all types of drug abuse by children ages 12 to 17, from 11.6 percent in 2002 to 9.5 percent in 2007. The same study shows a rise of 12 percent in illicit use of prescription pain relievers among young adults ages 18 to 25. A report out earlier this year from the Centers for Disease Control and Prevention shows that despite an overall drop in illicit drug use, deaths from drug use among people age 15 to 24 more than doubled between 1999 and 2005.

A study published this week in the Annals of Emergency Medicine reports nearly 10,000 accidental ingestions of opiates by children age six and under; study authors speculate that the actual number is likely much higher, since their study only assessed a portion of U.S. poison control centers, not all of them.

Here are some tips for restricting access to prescription medications:

· Hide all medications in a secure location, which may not be the bathroom medicine cabinet.

· Discard any prescription medications that are left over or expired.

· Alert grandparents who visit or host their grandchildren that their prescriptions should always be locked up and hidden away, including individual pills which curious toddlers may put into their mouths.

· Monitor your teenager’s internet use for shopping on pharmaceutical websites.

· Discuss with neighbors and parents of your child’s friends the importance of keeping prescription medications locked away.

McCain's Misstep

The American College of Emergency Physicians (ACEP) today lambasted McCain health policy advisor John Goodman’s assertion that anyone with access to an emergency department effectively has health insurance, and called his logic flawed and his statement irresponsible toward all patients, insured and uninsured alike.
“The Centers for Disease Control and Prevention’s latest report showed visits to emergency departments climbed 32 percent over a ten-year period, and there is no sign that this trend is slowing,” said Dr. Linda Lawrence, president of ACEP. “Emergency departments are the nation’s health care safety net, but that net is breaking under the load, in part because so much of the care goes uncompensated. To suggest that there are no uninsured patients is to cast a blind eye toward the needs of all emergency patients, insured or not, who are waiting longer and longer for care, sometimes with deadly consequences.”
“We urge the McCain campaign to rethink the reckless suggestion by Mr. Goodman that the tragedy of uninsured patients can be erased by the magic of emergency departments,” said Dr. Lawrence. “Emergency physicians can and do perform miracles every day, but taking on the full-time, medical care for 46 million uninsured Americans is one miracle even we cannot perform. Access to care in the emergency department is no substitute for the comprehensive health care reform policy that should be at the heart of the platform of any presidential campaign.”
ACEP is a national medical specialty society representing emergency medicine with more than 26,000 members. ACEP is committed to advancing emergency care through continuing education, research and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies.

Too Many Patients !?!

Visits to American emergency departments have reached a record high of 199.2 million in 2006, according to the “National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary”, published by the CDC (Centers for Disease Control and Prevention) this week. This is an increase of 4 million people coming to emergency departments for care since the previous report from 2005. That’s as if the entire city of Los Angeles went to the emergency department on top of the patients that were already being seen.

Over the past decade, the number of patients coming to the emergency department has increased 32%, from 90.3 million to 119.2 million. Emergency departments are now averaging 227 visits per minute. At the same time, the number of hospital emergency departments has dropped, from 4109 to 3833.

Here are some of the COMMON MYTHS:

It’s because of people being treated for “minor” complaints.

Actually, only 12.1% of the visits were characterized as patients who could wait 2 to 24 hours to be seen. (Nonurgent)

It’s because people without insurance are crowding the emergency department.

Actually, patients WITH private insurance represent the largest category of patients, 39%. Uninsured patients represented 17.4% of the patient pool.

It’s just because the population has grown.

Actually, the population-based ED utilization rate increased by 18%, from 34.2 visits per 100 persons in 2005 to 40.5 visits per 100 persons in 2006.

Here are some HARD TRUTHS:

There aren’t enough beds in the hospitals.

People wait hours and days in the ED after they have been admitted because there is no hospital room available for them. This is called boarding.

There aren’t enough nurses to take care of patients.

According to a report released by the American Hospital Association in July 2007, U.S. hospitals need approximately 116,000 RNs to fill vacant positions nationwide. This translates into a national RN vacancy rate of 8.1%.

There aren’t enough doctors.

Eleven (11) percent of all ambulatory medical care visits in the U.S. occur in the emergency department, and yet emergency physicians represent only 3.3% of active physicians.

As the population ages and as the economic situation worsens, these problems are unlikely to be corrected without purposeful, thoughtful change in the healthcare system.

Top Ten Reasons to Come To the Emergency Department

QAccording to data in Emergency Department Visits for Adults in Community Hospitals from Selected State, 2005, released by the Agency for Healthcare Research and Quality (AHRQ) yesterday, these are the top reasons for emergency department visits:

1.) Sprains and strains (2.4 million visits)
2.) Bruises and other superficial injuries (2.0 million visits)
3.) Abdominal pain (1.7 million visits)
4.) Non-cardiac (not heart related) chest pain (1.6 million visits)
5.) Back problems (1.4 million visits)
6.) Leg and arm open wounds (1.3 million visits)
7.) Headaches, including migraines (1.2 million visits)
8.) Nose and throat infections (1.1 million visits)
9.) Skin infections (1.1 million visits)
10.) Urinary tract infections (1.1 million visits)

The number one diagnosis among patients admitted to the hospital was pneumonia.

It would seem at first glance that many people come to the emergency department for “minor” complaints, but keep in mind that these statistics are based on the FINAL diagnosis. Most people would not choose to wait hours in a crowded waiting room if they knew for sure that the bone was not broken, the belly pain was gas, or the chest pain was reflux.

In fact, twenty to twenty-five percent of the patients with “non-cardiac” chest pain were admitted to the hospital from the emergency department for further evaluation and observation, and only received the “non-cardiac” diagnosis upon discharge.

Remember this: a “minor” emergency is what happens to someone else.

Dying To Get In......the Emergency Department

Christopher Jones, 33 years old
Edith Rodriguez, 43 years old
Brenda Vance, 49 years old

The list of patients who have died in emergency department waiting rooms while waiting to be seen could be much longer. These three names are the ones that have made the news. These three people died while waiting to get inside an emergency room to see a doctor.

The public is outraged and upset that these deaths occurred. As I read the news stories and the blogs, I see the finger of blame pointed at a nurse or a doctor or both, who failed to do something that should have been done. What I don’t see is the public outrage that our healthcare system has failed the people it should protect.

Long waiting times are not isolated to three hospitals in America. Every day in hospitals all across the country, dedicated emergency physicians and emergency nurses work long hard hours to provide care to the sick and injured. There are approximately 4600 emergency departments in America treating about 115 million people every year. That’s an average of 25,000 people per emergency department. Now, realize that some departments see many more patients, and some see fewer. However, if the average is 25,000 patients per year, that’s about 68 patients per department per day. If all 68 patients were averaged over the day, that would be 2.8 patients per hour.

Since the average emergency physician in ideal circumstances (enough nurses, enough hospital beds, enough specialists on call) can see 2.5 patients per hour, which leaves 7.2 patients every day who cannot be accommodated by the system. Added over the year, that is 2628 patients who cannot be seen by the current emergency healthcare system. These are 2628 PEOPLE who will not receive care for their illness or injury. It is easy to see why people sometimes have serious problems in the waiting room, and that the system is already full to capacity.

The calculations above are very simplistic and don’t reflect the reality of patient flow in real emergency departments, but trust me, the reality is NOT BETTER than the scenario I’ve developed above. Something must be done to increase the resources of emergency departments – nurses, on-call physicians, available hospital beds – before the stories of people like Christopher Jones, Edith Rodriguez, and Brenda Vance become the norm and not the exception.