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EMERGENCY MEDICINE

LAC +USC MEDICAL CENTER


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