- Email: [email protected]
7: The Next Big Thing?
CORRESPONDENCE
Guidelines for Letters to the Editor Annals welcomes letters to the editor, including observations, opinions, corrections, very brief reports, and comments on published articles. Letters to the editor will not be accepted if they exceed 500 words and 5 references. They should be submitted using Annals’ Web-based peer review system, Editorial Manager (http://www.editorialmanager.com/annemergmed). Annals no longer accepts submissions by mail. Letters should not contain abbreviations. A manuscript submission agreement, signed by all authors, must be faxed to the Annals office at the time of submission. Financial associations or other possible conflicts of interest should always be disclosed. Letters discussing an Annals article must be received within 8 weeks of the article’s publication. Published letters will be edited and may be shortened. Unpublished letters will not be returned. Authors of articles for which comments are received will be given the opportunity to reply. If those authors wish to respond, their reply will not be shared with the author of the letter before publication. Neither Annals of Emergency Medicine nor the Publisher accepts responsibility for statements made by contributors or advertisers. Acceptance of an advertisement for placement in Annals in no way represents endorsement of a particular product or service by Annals of Emergency Medicine, the American College of Emergency Physicians, or the Publisher.
0196-0644/$-see front matter Copyright ª 2005 by the American College of Emergency Physicians.
24/7: The Next Big Thing? Throughout the last several decades, we practitioners of emergency medicine have been charged with numerous impositions and mandates that have fundamentally changed our practice. These rules and regulations come from Congress, Centers for Medicare and Medicaid Services, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Institute of Medicine, and other federal, state, and local agencies. Examples include the Health Insurance Portability and Accountability Act (HIPAA), pain scales, nurse staffing ratios, the Emergency Medical Treatment and Active Labor Act (EMTALA), regulatory and educational efforts to reduce medical errors, the JCAHO standards, and others. Although these well-intended efforts have yielded mixed blessings, it is fair to say that, as a result, the emergency department (ED) is more fully engaged in issues of quality, patient safety, and access to care than many other parts of the health care system. It is time we got help repairing the remaining gaping holes in the safety net. Thus, it is with great trepidation and a healthy respect for the ‘‘Law of Unintended Consequences’’ that I propose a candidate for ‘‘the next big thing.’’ In my humble opinion, the next big thing should be regulatory attention to the 24-hour, 7-day-a-week availability of various hospital diagnostic and therapeutic services and the recognition of the impact of lack of such availability on the overall health of the population. Decades of personal experience, reviews of medical malpractice cases, some medical literature, and common sense tell me that emergency patients admitted on weekends, nights, and holidays are at greater risk for adverse outcomes than those admitted during business Volume 46, no. 1 : July 2005
hours. Does anyone besides us pay more than lip service to the fact that critical illness is not a 9-to-5 problem? We have identified and to some extent addressed financial and racial inequities in care. ‘‘Temporal discrimination’’ has still not been addressed. It should not be that in 2005 the probability of inhospital mortality and morbidity for emergency patients should vary with the day and time of admission. That is as great an inequity as the ones we have tried to correct with EMTALA. The literature supports the notion that weekend and holiday mortality is higher1-3 and urgent procedures are less available.4 Little work has been done to define or identify problems of availability in the thousands of community hospitals nationwide. The public has been led to expect and depend on the 24-hour, 7-day-a-week safety net that is emergency medicine. My patients generally believe that all hospital services are available at all times. As a specialty, we are constantly striving to improve our service. Bedside ultrasonography and chest-pain observation units are excellent examples of our meeting this demand. However, our ability to serve stops where others need to pick up the slack: at the door to the ICU, the door to the angiography suite, endoscopy, the operating room, etc. Huge holes still remain in that safety net. Beyond the doors of the ED, the requirements continue for patients whose outcomes will vary with the time of day and day of the week. The benefits of intervention within 1 to 2 hours for certain conditions is well recognized and has driven the idea of regionalization (initially for trauma and later for stroke and interventional cardiology). Other urgent but less common problems requiring timely intervention may be served by expanding on-call services or having transfer Annals of Emergency Medicine 95
Correspondence arrangements in place. Waiting ‘‘until (Monday) morning’’ should not be an option for a hospitalized patient. One consideration might be something resembling a JCAHO standard that says: ‘‘All hospitals must yearly assess the needs of their patients for emergency therapeutic and diagnostic services on dates and times when they are not available. When there are services for which there is a significant medical need at times when those services are unavailable, hospitals should: (a) make them available, (b) have appropriate arrangements in place to secure such services promptly on demand, or (c) have agreements to expeditiously transfer patients to facilities where such services are available.’’ Certainly making services more available has the potential to increase direct costs; however, avoiding morbidity and malpractice liability saves money and promotes patient safety. Shortening hospital and ICU stays, and thereby reducing crowding and diversion, can have a positive impact on total hospitalization costs and costs for hospitals, insurers, and patients. Patients and their insurance companies may be unaware of temporal disparities in inpatient care and may welcome the opportunity to make more informed choices. To solve this problem, facilities and consulting physicians have to change. The ability to pull the trigger on the timing of such services should not be left to the sleepy consultant alone. There is undoubtedly a need for research in these areas, particularly at the community hospital level. We should not, however, allow the practice parameters for ‘‘how long to wait before ___’’ to be written by the plaintiff’s bar or by unthinking adherence to traditional staffing patterns. I would hope that patient and physician advocacy groups, professional organizations, hospital associations, and research and regulatory interests would begin to assess the need and acquire data on new ways to approach and fund this problem. Physicians of all affected specialties should voice their concerns to their professional organizations and educate the public. Professional organizations should use their liaison relationships with regulatory and government organizations to promote the study of this issue. Patient advocacy groups, along with employers and other purchasers of health care services, should learn about the problem and discuss it. Academic physicians should provide the data that will move these concerns forward, particularly as they relate to the community hospitals caring for the majority of our citizens. Representatives of the health care and insurance industries must reexamine the foundations for current staffing patterns and funding of ancillary services and seek creative alternatives to current entrenched patterns of behavior. Cost-benefit analyses should take into account the value of prevention and shortened hospital stays. Kenneth Frumkin, PhD, MD Chesapeake General Hospital Chesapeake, VA doi:10.1016/j.annemergmed.2005.01.041
96 Annals of Emergency Medicine
1. Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Engl J Med. 2001;345:663-668. 2. Barnett MJ, Kaboli PJ, Sirio CA, et al. Day of the week of intensive care admission and patient outcomes: a multisite regional evaluation. Med Care. 2002;40:530-539. 3. Cram P, Hillis SL, Barnett M, et al. Effects of weekend admission and hospital teaching status on in-hospital mortality. Am J Med. 2004; 117:151-157. 4. Bell CM, Redelmeier DA. Waiting for urgent procedures on the weekend among emergently hospitalized patients. Am J Med. 2004; 117:175-181.
Is the Initial Diagnostic Impression of ‘‘Noncardiac Chest Pain’’ Adequate to Exclude Cardiac Disease? To the Editor: Analyzing data from the i*trACS chest pain registry, Miller, et al. (Ann Emerg Med 2004;44:565-474) found that emergency department (ED) patients for whom the initial diagnostic impression was ‘‘noncardiac chest pain’’ nevertheless experienced a significant (2.8%) rate of adverse cardiac events. However, the ambiguous nature of the population in question severely limits the interpretability and generalizability of their findings. An admission rate of over 25% would seem to be at odds with the usual practice pattern for simple ‘‘noncardiac chest pain’’ patients. One has to wonder whether low-level concerns for myocardial ischemia motivated the decision to admit some patients or to send off cardiac biomarkers from the ED in the first place (in 53% of cases). Such cases should have been more fairly termed ‘‘low-risk chest pain,’’ because adverse cardiac events are rare but not non-existent in this population. On the other hand, for more complicated patients (with severe pneumonia, for example) who required hospitalization apart from concerns for myocardial ischemia, one suspects that the designation ‘‘noncardiac chest pain’’ was clinically irrelevant, and that the rate of adverse cardiac events (typically nonSTEMI) in this population simply reflected the severity of illness. Joshua M. Kosowsky, MD Brigham and Women’s Hospital Boston, MA doi:10.1016/j.annemergmed.2004.12.034
In reply: The comments by Dr Kosowsky regarding our article are appreciated, and I am pleased at the opportunity to respond. Without doubt, there is some ambiguity in defining a population of patients with noncardiac chest pain. In fact, this is a reflection of clinical practice. Every day, clinicians must grapple with ambiguous presentations. Often, the line between Volume 46, no. 1 : July 2005
Guidelines for Letters to the Editor Annals welcomes letters to the editor, including observations, opinions, corrections, very brief reports, and comments on published articles. Letters to the editor will not be accepted if they exceed 500 words and 5 references. They should be submitted using Annals’ Web-based peer review system, Editorial Manager (http://www.editorialmanager.com/annemergmed). Annals no longer accepts submissions by mail. Letters should not contain abbreviations. A manuscript submission agreement, signed by all authors, must be faxed to the Annals office at the time of submission. Financial associations or other possible conflicts of interest should always be disclosed. Letters discussing an Annals article must be received within 8 weeks of the article’s publication. Published letters will be edited and may be shortened. Unpublished letters will not be returned. Authors of articles for which comments are received will be given the opportunity to reply. If those authors wish to respond, their reply will not be shared with the author of the letter before publication. Neither Annals of Emergency Medicine nor the Publisher accepts responsibility for statements made by contributors or advertisers. Acceptance of an advertisement for placement in Annals in no way represents endorsement of a particular product or service by Annals of Emergency Medicine, the American College of Emergency Physicians, or the Publisher.
0196-0644/$-see front matter Copyright ª 2005 by the American College of Emergency Physicians.
24/7: The Next Big Thing? Throughout the last several decades, we practitioners of emergency medicine have been charged with numerous impositions and mandates that have fundamentally changed our practice. These rules and regulations come from Congress, Centers for Medicare and Medicaid Services, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Institute of Medicine, and other federal, state, and local agencies. Examples include the Health Insurance Portability and Accountability Act (HIPAA), pain scales, nurse staffing ratios, the Emergency Medical Treatment and Active Labor Act (EMTALA), regulatory and educational efforts to reduce medical errors, the JCAHO standards, and others. Although these well-intended efforts have yielded mixed blessings, it is fair to say that, as a result, the emergency department (ED) is more fully engaged in issues of quality, patient safety, and access to care than many other parts of the health care system. It is time we got help repairing the remaining gaping holes in the safety net. Thus, it is with great trepidation and a healthy respect for the ‘‘Law of Unintended Consequences’’ that I propose a candidate for ‘‘the next big thing.’’ In my humble opinion, the next big thing should be regulatory attention to the 24-hour, 7-day-a-week availability of various hospital diagnostic and therapeutic services and the recognition of the impact of lack of such availability on the overall health of the population. Decades of personal experience, reviews of medical malpractice cases, some medical literature, and common sense tell me that emergency patients admitted on weekends, nights, and holidays are at greater risk for adverse outcomes than those admitted during business Volume 46, no. 1 : July 2005
hours. Does anyone besides us pay more than lip service to the fact that critical illness is not a 9-to-5 problem? We have identified and to some extent addressed financial and racial inequities in care. ‘‘Temporal discrimination’’ has still not been addressed. It should not be that in 2005 the probability of inhospital mortality and morbidity for emergency patients should vary with the day and time of admission. That is as great an inequity as the ones we have tried to correct with EMTALA. The literature supports the notion that weekend and holiday mortality is higher1-3 and urgent procedures are less available.4 Little work has been done to define or identify problems of availability in the thousands of community hospitals nationwide. The public has been led to expect and depend on the 24-hour, 7-day-a-week safety net that is emergency medicine. My patients generally believe that all hospital services are available at all times. As a specialty, we are constantly striving to improve our service. Bedside ultrasonography and chest-pain observation units are excellent examples of our meeting this demand. However, our ability to serve stops where others need to pick up the slack: at the door to the ICU, the door to the angiography suite, endoscopy, the operating room, etc. Huge holes still remain in that safety net. Beyond the doors of the ED, the requirements continue for patients whose outcomes will vary with the time of day and day of the week. The benefits of intervention within 1 to 2 hours for certain conditions is well recognized and has driven the idea of regionalization (initially for trauma and later for stroke and interventional cardiology). Other urgent but less common problems requiring timely intervention may be served by expanding on-call services or having transfer Annals of Emergency Medicine 95
Correspondence arrangements in place. Waiting ‘‘until (Monday) morning’’ should not be an option for a hospitalized patient. One consideration might be something resembling a JCAHO standard that says: ‘‘All hospitals must yearly assess the needs of their patients for emergency therapeutic and diagnostic services on dates and times when they are not available. When there are services for which there is a significant medical need at times when those services are unavailable, hospitals should: (a) make them available, (b) have appropriate arrangements in place to secure such services promptly on demand, or (c) have agreements to expeditiously transfer patients to facilities where such services are available.’’ Certainly making services more available has the potential to increase direct costs; however, avoiding morbidity and malpractice liability saves money and promotes patient safety. Shortening hospital and ICU stays, and thereby reducing crowding and diversion, can have a positive impact on total hospitalization costs and costs for hospitals, insurers, and patients. Patients and their insurance companies may be unaware of temporal disparities in inpatient care and may welcome the opportunity to make more informed choices. To solve this problem, facilities and consulting physicians have to change. The ability to pull the trigger on the timing of such services should not be left to the sleepy consultant alone. There is undoubtedly a need for research in these areas, particularly at the community hospital level. We should not, however, allow the practice parameters for ‘‘how long to wait before ___’’ to be written by the plaintiff’s bar or by unthinking adherence to traditional staffing patterns. I would hope that patient and physician advocacy groups, professional organizations, hospital associations, and research and regulatory interests would begin to assess the need and acquire data on new ways to approach and fund this problem. Physicians of all affected specialties should voice their concerns to their professional organizations and educate the public. Professional organizations should use their liaison relationships with regulatory and government organizations to promote the study of this issue. Patient advocacy groups, along with employers and other purchasers of health care services, should learn about the problem and discuss it. Academic physicians should provide the data that will move these concerns forward, particularly as they relate to the community hospitals caring for the majority of our citizens. Representatives of the health care and insurance industries must reexamine the foundations for current staffing patterns and funding of ancillary services and seek creative alternatives to current entrenched patterns of behavior. Cost-benefit analyses should take into account the value of prevention and shortened hospital stays. Kenneth Frumkin, PhD, MD Chesapeake General Hospital Chesapeake, VA doi:10.1016/j.annemergmed.2005.01.041
96 Annals of Emergency Medicine
1. Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Engl J Med. 2001;345:663-668. 2. Barnett MJ, Kaboli PJ, Sirio CA, et al. Day of the week of intensive care admission and patient outcomes: a multisite regional evaluation. Med Care. 2002;40:530-539. 3. Cram P, Hillis SL, Barnett M, et al. Effects of weekend admission and hospital teaching status on in-hospital mortality. Am J Med. 2004; 117:151-157. 4. Bell CM, Redelmeier DA. Waiting for urgent procedures on the weekend among emergently hospitalized patients. Am J Med. 2004; 117:175-181.
Is the Initial Diagnostic Impression of ‘‘Noncardiac Chest Pain’’ Adequate to Exclude Cardiac Disease? To the Editor: Analyzing data from the i*trACS chest pain registry, Miller, et al. (Ann Emerg Med 2004;44:565-474) found that emergency department (ED) patients for whom the initial diagnostic impression was ‘‘noncardiac chest pain’’ nevertheless experienced a significant (2.8%) rate of adverse cardiac events. However, the ambiguous nature of the population in question severely limits the interpretability and generalizability of their findings. An admission rate of over 25% would seem to be at odds with the usual practice pattern for simple ‘‘noncardiac chest pain’’ patients. One has to wonder whether low-level concerns for myocardial ischemia motivated the decision to admit some patients or to send off cardiac biomarkers from the ED in the first place (in 53% of cases). Such cases should have been more fairly termed ‘‘low-risk chest pain,’’ because adverse cardiac events are rare but not non-existent in this population. On the other hand, for more complicated patients (with severe pneumonia, for example) who required hospitalization apart from concerns for myocardial ischemia, one suspects that the designation ‘‘noncardiac chest pain’’ was clinically irrelevant, and that the rate of adverse cardiac events (typically nonSTEMI) in this population simply reflected the severity of illness. Joshua M. Kosowsky, MD Brigham and Women’s Hospital Boston, MA doi:10.1016/j.annemergmed.2004.12.034
In reply: The comments by Dr Kosowsky regarding our article are appreciated, and I am pleased at the opportunity to respond. Without doubt, there is some ambiguity in defining a population of patients with noncardiac chest pain. In fact, this is a reflection of clinical practice. Every day, clinicians must grapple with ambiguous presentations. Often, the line between Volume 46, no. 1 : July 2005