Category Archives: Emergency Care
Adam L. Sharp, MD, MS is an emergency physician and recent University of Michigan Robert Wood Johnson Foundation Clinical Scholar (2011-2013). He works for Kaiser Permanente Southern California in the Research and Evaluation Department performing acute care health services and implementation research.
Violence is a leading cause of death and injury in adolescents. Recent studies show effective interventions can prevent violent behavior in youth seen in the Emergency Department (ED). Adoption of this type of preventive care has not been broadly implemented in EDs, however, and cost concerns frequently create barriers to utilization of these types of best practices. Understanding the costs associated with preventive services will allow for wise stewardship over limited health care resources. In a recent publication in Pediatrics, "Cost Analysis of Youth Violence Prevention," colleagues and I predict that it costs just $17.06 to prevent an incident of youth violence.
The violence prevention intervention is a computer-assisted program using motivational interviewing techniques delivered by a trained social worker. The intervention takes about 30 minutes to perform and was evaluated within an urban ED for youth who screened positive for past year violence and alcohol abuse. The outcomes assessed were violence consequences (i.e., trouble at school because of fighting, family/friends suggested you stop fighting, arguments with family/friends because of fighting, felt cannot control fighting, trouble getting along with family/friends because of your fighting), peer victimization (i.e., hit or punched by someone, had a knife/gun used against them), and severe peer aggression (i.e., hit or punched someone, used a knife/gun against someone).
An interview with Nicole Lurie, MD, MSPH, the assistant secretary for preparedness and response at the U.S. Department of Health and Human Services, and an alumna of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program. She is the co-author of “The U.S. Emergency Care System: Meeting Everyday Acute Care Needs While Being Ready for Disasters,” published in the December 2013 issue of Health Affairs, which focused on the future of emergency medicine. The interview is part of a series of posts featuring RWJF Scholars who authored articles in the issue.
Human Capital Blog: You write that the nation’s emergency care system is in trouble. What are the challenges facing emergency departments (EDs)?
Nicole Lurie: We’ve understood for at least a decade that the emergency system is in trouble. We ask a lot of this system, and as a result we have EDs that are really crowded and with long wait times, boarding times and throughput times. It’s become a de facto access point for many people who lack access to primary care or insurance, which wasn’t what it was originally set up for. Now, EDs have evolved to be more than places to treat life and limb threats and serve as default diagnostic and therapeutic entry points. But many people who end up in an emergency department may be willing to be treated in a different kind of environment. It is really up to us to build a system that accommodates their needs and ensure our emergency care system can do its important work.
And remember: We changed the way we deliver care in the U.S. from a hospital-based focus to an outpatient focus over the last few decades, but we never really built the infrastructure for it. Outpatient providers have had their visits shortened and group practice environments have changed the relationship between patients and their primary care providers. We hear about the shortage of primary care providers and the crisis of crowding and boarding in emergency departments, but we don’t always connect the dots to understand how we got here. It is a good time to start to have this conversation as payment models are encouraging us to recognize that generating health for our patients is a team effort.
HCB: How do you see the emergency care system evolving, particularly with respect to disaster preparedness?
An interview with Renee Hsia, MD, a Robert Wood Johnson Foundation Physician Faculty Scholars program alumna and associate professor of emergency medicine at the University of California, San Francisco. She is the co-author of “Emergency Care: Then, Now and Next,” published in the December 2013 issue of Health Affairs, which focused on the future of emergency medicine. The interview is part of a series of posts featuring RWJF Scholars who authored articles in the issue.
Human Capital Blog: Other than the obvious changes in technology, how are emergency departments (EDs) different today than they were 50 years ago?
Renee Hsia: We’ve had a dramatic transition since the 1950s, in terms of what emergency departments do, and the patient outcomes we expect. We mention in the article, for example, that years ago many emergency departments used funeral hearses to transport patients to the ED. Now transport is usually in vehicles with all sorts of life-saving equipment on board. That’s one reason the mortality rate is a lot lower now than it was then; death is much rarer in the emergency room today.
Another dramatic transition has been the rise of the specialist in emergency medicine. It used to be more common to have physicians trained in other specialties taking turns in the emergency room. You still see that in some rural areas, but it’s far less common. There’s been a gradual movement toward the understanding that we need people who are masters in the acute presentation of illness.
We’ve also seen the beginnings of a system transition, with a growing focus on regionalization. We have to account for the reality that not all community EDs and hospitals are equipped with the same technology as tertiary hospitals, such as a cardiac catheterization lab, for example. We need to be sure that we can get patients “the right care in the right place at the right time,” and that requires close coordination within the larger health care system.
HCB: You discuss the relationship between ED crowding and changes in primary care practice. Could you tell us about that?
Nicole Lurie, MD, MSPH, is the assistant secretary for preparedness and response at the U.S. Department of Health and Human Services (HHS), and Kacey Wulff, MPH, is special assistant to the assistant secretary, at HHS. An alumna of the Robert Wood Johnson Foundation Clinical Scholars program, Lurie is the co-author of “The U.S. Emergency Care System: Meeting Everyday Acute Care Needs While Being Ready for Disasters,” published in the December 2013 issue of Health Affairs, which focused on the future of emergency medicine. This is part of a series of posts featuring RWJF Scholars who authored articles in the issue.
As we approach the Affordable Care Act’s March 31 enrollment deadline, data is starting to emerge about how these reforms are making care more accessible, cost less, and, ultimately, Americans healthier. As these reforms take effect, and make our day-to-day health care system stronger, they also result in strengthening communities across the country to become more resilient and disaster-ready.
The gaps that inspired and propelled health reform like untreated chronic conditions and mental illness, and health disparities plague our health care system every single day. During a crisis, like a hurricane, earthquake, or attack, these issues can become magnified. As a result, the ability for individuals and communities to prepare, respond, and recover successfully is intrinsically linked to the strength of the underlying health care system.
The Affordable Care Act expands mental health and substance use disorder benefits and federal parity protections for 60 million Americans. As a result, many Americans who previously have not had coverage for mental health care will have greater access to this and other important aspects of health care. This will help to make the tools that support recovery from injuries sustained during disasters, whether illness, injury, or trauma, more accessible.
This boost in preparedness is important for responding to disasters big and small: the biggest indicator of how a person or community will fare during a disaster is how they were doing before the crisis struck. While health insurance doesn’t guarantee that you will be healthier, it does make health much more likely.
An interview with Sara Rosenbaum, JD, the Hirsh Professor in the School of Public Health and Health Services at the George Washington University, in Washington, DC, and a Robert Wood Johnson Foundation (RWJF) Investigator Awards in Health Policy Research recipient. She is the author of “The Enduring Role of the Emergency Medical Treatment and Active Labor Act,” published in the December 2013 issue of Health Affairs, which focused on the future of emergency medicine. The interview is part of a series of posts featuring RWJF Scholars who authored articles in the issue.
Human Capital Blog: Your article discusses the past, present, and future of the Emergency Medical Treatment and Active Labor Act (EMTALA), adopted in 1986. Could you tell us a little about what moved Congress and the President to create the law, and what its purpose was?
Sara Rosenbaum: The law had several roots. To begin, it was the outgrowth of a good deal of law that came before it, embracing the notion that hospitals should provide emergency care, even without the expectation of payment. So that idea wasn’t unique to EMTALA, but by the early 1970s the expectation that hospitals would provide the community benefit of emergency services had revved up, partly because states had adopted that expectation under their own common law and statutes. So EMTALA was the culmination of a lot of legal precedent. But what prompted passage of the law in 1986 was two things: First, a substantial number of news stories about patient-dumping, particularly in California; and second, on the heels of Medicare payment reform a few years earlier, there was a lot of concern that hospitals would start discharging Medicare patients in an unstable state – sicker and quicker, as the saying went.
HCB: What are the law’s key components?
Rosenbaum: The one everybody knows best is the screening component: If somebody comes to an emergency department and requests an examination, hospitals must examine the patient to determine if there's an emergency medical condition. And if they find one, they must provide stabilization treatment. Or, if the patient has an emergency condition that the hospital is unable to stabilize, it can seek the cooperation of another hospital with more specialized capabilities, and transfer the patient. And then that second hospital has a separate obligation; it can’t just say “no.”
HCB: What’s your sense of how the law operates in the daily life of a hospital?
Carli A. Culjat, BSN RN, is a staff nurse in the Emergency Department at Bryan Medical in Lincoln, Neb., and an alumna of the Robert Wood Johnson Foundation New Careers in Nursing program. She graduated with her BSN from the Creighton University School of Nursing. This post is part of the “Health Care in 2014” series.
As a new graduate and a young person, I am very eager to see what will happen to my country, my career, and my own future with the changes taking place in the U.S. health care system. As I walked across the stage receiving my diploma, my emotions developed and they included excitement, relief, and fear of the unknown. I believe our county is facing similar emotional complexity. As a new graduate and new employee – change can bring forth so many emotions, especially on the large scale that is taking place in health care today.
The media covers the controversy of the situation and as a former student, my class still uses social media to reach out and develop opinions on the changes and their possible effects. Fear creates controversy and with this, we see so many different perspectives and reactions. Even still, I believe our country is excited for a change and ready for the health care system to evolve into a system that we can be proud of and utilize.
There are many who are relieved, myself included. I am relieved that employment is an option at this time in this changing system, I am relieved that our country has taken the initiative to address a need, and I am relieved that I have an education and position that I can use to assist, in the best way a single person can, in health care reform—as a frontline person, a staff nurse in an Emergency Department.
Taura Barr, PhD, RN, is an assistant professor at the West Virginia University School of Nursing. Timothy Landers, PhD, RN, CNP, is an assistant professor at The Ohio State University College of Nursing. Both are Robert Wood Johnson Foundation Nurse Faculty Scholars. This post is part of the “Health Care in 2014” series.
This is the time of year when people consider how they are doing with their new year’s resolutions. The three most common resolutions are lose weight, improve finances, and exercise more. Two out of three of those resolutions involve health.
Sadly, most of these resolutions will fail.
While we rate our physical, emotional, and spiritual health as a top priority, in practice we often fall short. This seems to be especially true for us as health care providers and our health care system.
Kristi Henderson, DNP, NP-BC, FAEN, is the chief advanced practice officer and director of telehealth for the University of Mississippi Medical Center, where she holds dual appointments in the School of Medicine and School of Nursing. She has an administrative and clinical practice as a family and acute care nurse practitioner, and is a Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellow. This post is part of the “Health Care in 2014” series.
As we ring in the New Year, do any of these scenarios ring true for you or your family?
- There is someone who suffers from diabetes but lives an hour from a diabetes specialist. They can’t stay in the community where they live for treatment and an already-taxing diagnosis becomes a burden to treat. What if there was a way that the diabetes specialist, diabetes educator, pharmacist, ophthalmologist, and nutritionist could all be brought to this patient virtually by way of today’s technology? What if there was a way for a treatment plan to be customized to each patient and adjusted in real-time from information uploaded from a smartphone?
- There is someone who has heart failure and for every ‘flare up’ the only option is to go to the local emergency room (ER). Medication and check-up regimens are followed every year but the ER visits are the only way to see a health care provider at a moment’s notice. What if health stats, vital signs, and symptoms could all be tracked by the health care provider to identify subtle changes early on, or when symptoms begin to worsen, and interventions could avoid an ER visit? Imagine if symptoms, vital signs, weight and medication side effects were monitored while a patient with heart failure goes about their day, not just at their scheduled check-ups.
Sarah M. Miller is a Robert Wood Johnson Foundation (RWJF) Scholar in Health Policy Research (cohort 19). She has a PhD in economics from the University of Illinois at Urbana-Champaign. Her dissertation examines the effect of the 2006 Massachusetts health care reform on emergency room (ER) use. Miller will soon become an assistant professor of economics at the University of Notre Dame. Read all the blog posts in this series.
The Emergency Medical Treatment and Active Labor Act (EMTALA) guaranteed all patients the right to receive urgent care in an emergency department regardless of their ability to pay. While the intent of the EMTALA was to ensure no patient was refused emergency care simply because they did not have health insurance, by covering only emergency department care, and not primary or preventive care, the EMTALA created incentives for patients to use the health care system inefficiently. These incentives may be especially salient for low-income or uninsured patients who have limited access to health services outside of emergency departments and community health centers.
The law established that patients could always receive care in the emergency department even if they didn’t have the cash to pay upfront, or an insurance company picking up the tab, but the mandate did not extend to private physicians’ offices. Some state laws go so far as to dictate that uninsured patients can receive free care in the ER if they have sufficiently low incomes.
Italo M. Brown, MPH, is a rising third-year medical student at Meharry Medical College. He holds a BS from Morehouse College, and an MPH in epidemiology and social & behavioral sciences from Boston University, School of Public Health. He is a Health Policy Scholar at the Robert Wood Johnson Foundation Center for Health Policy at Meharry Medical College. Read all the blog posts in this series.
In 1986, Congress took a step in the direction of patient advocacy by passing the Consolidated Omnibus Budget Reconciliation Act (COBRA). One part of this act, the Emergency Medical Treatment and Labor Act (EMTALA), has served as the precedent for federally mandated care and has largely shaped our understanding of urgent care delivery in America. While some have touted EMTALA as a public health victory, many have scrutinized the federal mandate, citing its imperfection and labeling it as a strong contributor to the current ailments of our emergency medical system.
However, 27 years after EMTALA became law, a greater emphasis is placed on preventive measures and comprehensive care, rather than urgent care, as a means to reduce negative health outcomes. Naturally, champions of cost-efficient comprehensive care have suggested that a federal mandate should be explored.