The emergency department is, by definition, a place where patients can go to get urgent medical care.
Yet most of the nation’s emergency departments are unable to meet this most basic operational goal, according to a new study of on-call specialty care conducted by Robert Wood Johnson Foundation (RWJF) Clinical Scholar Mitesh Rao, M.D., M.H.S. (2007-2009) and colleagues.
Three-quarters of the nation’s emergency departments do not have enough on-call coverage by surgical specialists to meet the demand for round-the-clock specialty care, the study finds.
“We hypothesized that overall we would find a good amount of on-call coverage shortages, but we didn’t think the numbers would be that high,” says Rao, a resident in emergency medicine at the Yale University School of Medicine. “It really stunned us.”
The widespread shortage of on-call specialty care is a well-known problem, Rao says. He has personally experienced difficulties caused by shortages of on-call physician specialists. “I’ve seen patients [in the emergency department] who have critical, surgical needs that need to be addressed, and oftentimes have trouble finding a specialist physician for them,” he says.
Despite the ubiquity of the problem, little is known about its scope. The lack of data prompted Rao and his colleagues, Catherine Lerro, M.P.H., and Yale Clinical Scholar program site co-director and alumnus (1997-1999) Cary Gross, M.D., to conduct the survey of emergency department directors to explore the adequacy of on-call coverage in the nation’s emergency departments. The findings were published in the December 2010 print edition of Academic Emergency Medicine.
The survey covered hundreds of hospitals in every region of the country. Three in five respondents reported a loss in ability to provide “24-7” coverage for at least one specialty in the past four years. Particularly hard-hit are the fields of neurosurgery, hand surgery and plastic surgery.
Physician Specialist Shortages Bad News for Both Patients and Hospitals
A lack of specialists means emergency department patients often face delays in receiving care. A mother who slices her hand open while preparing dinner, for example, may have to wait for hours before needed surgery to repair damaged nerves. Or a motorcyclist with head injuries may not get immediate medical attention in the critical hours after a car accident. This can result in worse health outcomes.
Mounting wait times also mean more crowded emergency departments and more frustrated—and sometimes untreated—patients. In fact, in Rao’s survey, almost one-quarter of the emergency department directors surveyed said more patients are leaving before being seen by a medically needed specialist physician than in the past.
Hospitals that cannot provide the care patients need usually compensate by transferring patients to neighboring hospitals, which creates additional delays in treatment. Academic teaching hospitals tend to receive a large number of transferred patients because they have a reserve of residents and fellows who can step in for specialists. But even with these additional resources, more than 68 percent of teaching hospital emergency department directors reported problems with on-call specialist coverage.
In addition to the financial and resource costs associated with transferring and treating patients, Rao found that hospital ratings suffer as a result of specialist shortages. Twenty-three percent of the hospitals experienced a loss or downgrade in trauma center designation levels as a result of on-call specialist coverage problems.
“While not every hospital needs the capacity to provide higher-level trauma care, with almost one-quarter of our sample noting downtrends in their trauma capabilities, the ability of the overall system to manage trauma care could be threatened by problems with on-call coverage capabilities,” Rao and his colleagues write.
Problems with on-call coverage are not necessarily caused by workforce shortages, Rao says. His study cites financial and legal disincentives that might make specialists reluctant to stay on-call. These include lack of payment due to the high number of uninsured patients using emergency departments and legal liabilities that lead to higher insurance premiums for specialists.
“This is not a sustainable system,” Rao says. “I hope this encourages other researchers and government entities to look further into the problem. Hopefully this brings to light a serious issue that needs to be further addressed.”
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