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Effective communication with deaf patients and awareness of the Americans with disabilities act among emergency department personnel: A nationwide survey
RESEARCH FORUM ABSTRACTS
prehospital and emergency department care of nursing home and adult long-term care facility patients. In addition, we attempted to identify the frequency of patients arriving with the Massachusetts "Comfort Care" AD docmnentation. Methods: Study design was a cross-sectional study of consecutive institutionalized patients over a 60-day period. All individuals 18 years or older who were nursing home or long-term care facility patients transferred by ambulance to the ED were included. Physicians evaluated AD status by transfer chart review or verbal request of the family on patient arrival to the ED. Physician/nursing personnel voluntarily completed study questionnaires addressing the patient's medical condition, immediate availability AD status, and impact on patient care as defined by prehospital and/or ED Advanced Cardiac Life Support (ACTS) intervention. The authors reviewed all adult ED charts during the study period to maximize capture of eligible patients. The authors subsequently conducted a chart review for evidence of preexisting AD on previous admissions. Results: There were a total of 176 encounters representing 13"/patients; 26 patients had multiple ED visits. One hundred forty-six (83%) ED encounters had no AD, whereas 30 (17%) ED encounters had unambiguous AD at time of ED arrival. We found 23 (13.1%) more ED encounters representing 17 patients with AD of "Do not resuscitate/Do not intubate" (DNR/DNI) and 17 (9.7%) ED encounters representing i6 patients with AD of "Full code," only on retrospective chart review of inpatient record. Of the 23 (13%) ED encounters that had previously documented AD of DNR/DNI but no AD at ED arrival, 12 (6.8%) had a clinical presentation that raised the issue of AD status. One of these patients received chest compressions, intuhation, and ACtS intervention. There were a total of 59 (33.5%) encounters in which the issue of AD status was raised and 29 (16.5%) encounters representing 29 patients for whom AD status was directly relevant to their care. Of these 29 patients, 20 arrived with no formal AD, whereas 9 arrived with AD of DNR/DNI. One patient with documented DNR/DN1 status on transfer records received prehospital chest compressions. No patients presented with "Comfort Care" documentation during the study period. Conclusion: A large majority of patients in our study arrived at the ED without AD documentation. Two of these patients received ACtS interventions despite previous AD of DNWDNI. Institutionalized individuals represent a potential group of patients in whom unambiguous AD could be relatively easily resolved by systematic documentation and interinstitutional communication.
6 AGuidelines Comparison of Emergency Medicine UltrasoundTraining With of the Society for Academic Emergency Medicine Witting MD, EuerleBD, KennethH, ButlerKH/Universityof MarylandMedicalCenter,Baltimore,MD Study objectives: To compare the current state of emergency medicine residency ultrasound training with guidelines for that training from the Society for Academic Emergency Medicine (SAEM). Methods: A brief questionnaire was sent to program directors from E19 emergency medicine residency programs in the United States. Responses were compared with the SAEM guidelines for clinical experience (150 total uhrasounds) and didactic experience (40 hours of didactic instruction). Results: Overall response rate was 92%. Seventy-six programs (69%) own an ultrasound machine (ownership meaning 24-hour availability and complete discretion over use). Of these, 12 (16%) indicated that their average 1998 graduate had done 150 or more total uhrasounds during residency, although none had average numbers that exceeded the minimum guidelines for all 4 procedure categories. Information on didactic curriculum was available from 74 ultrasound-owning programs: the duration was 0 to 20 hours in 49 (66%), 20 to 40 hours in 19 (26%), and 40 to 100 hours in 6 (8%). If one considers programs with at least 20 to 40 hours of instruction covering at least 80% of the SAEM curriculum as meeting the didactic guideline, 13 programs (18%) would meet this standard. Overall, the average 1998 graduate from a maximmn of 4 programs would be "trained in ultrasound" according to SAEM guidelines. Conclusion: Most programs own ultrasound equipment, but few currently meet SAEM training guidelines.
7 Americans Effective CommunicationWith Deaf Patients and Awareness of the With Disabilities Act Among Emergency Department Personnel: A Nationwide Survey LarsenTJ, Larsen MF, 8ough JE/East Carolina University, Greenville, NC Study objective: Recently, there have been a number of lawsuits brought against hospitals that were not in compliance with the Americans With Disabilities Act (ADA) in regard to deaf patients. Apparently, many deaf patients are not being furnished with
$ 24
qualified sign language interpreters. This leads to the potential of inappropriate medical care and lawsuits being filed. Emergency departments have not been immune to this. Rather than an intentional disregard of this federal law, it is the authors' belief that it is a lack of awareness of the federal requirements brought about by the ADA and misconceptions about the needs of deaf patients. The objective of this study is to investigate the magnitude of deaf patients being seen in an ED setting, the means of communication being used with deaf patients, the formal education of hospital personnel regarding communication with deaf patients, the hospital personnel's awareness of policies and regulations regarding this population, and the accessibility of sign language interpreters in EDs. Methods: Questionnaires pertaining to the above objectives were distributed to all 121 emergency medicine residency programs approved by the Accreditation Council for Graduate Medical Education (ACGME). Each packet included surveys for all emergency medicine residents, 10 attending physicians, and 10 nurses. Results: One hundred five of the i21 (86.8%) programs responded by returning at least 1 survey. Overall, 2,009 of the 6,097 (33.0%) of the surveys were returned. Of the 2,009 physicians and nurses responding, 1,623 (80.8%) had been personally involved in the care of deaf patients. The results indicate that physicians and nurses see an average of 3 to 4 deaf patients annually. Three hundred twenty-eight (21.7%) indicated the use of sign language interpreters as their primary mode of communication. Formal medical education included communication with deaf patients in 6.1% of those responding. Although 22.4% indicated they were aware of legal obligations regarding deaf patients, only 2.6% of those surveyed indicated awareness of the ADA. When asked whether access to sign language interpreters was available, 41.0% answered that they did not know. Conclusion: In spite of the heightened number of ADA lawsuits specific to deaf patients, there continues to be a lack of awareness pertaining to this particular problem among emergency physicians and nurses.
8
Patient Satisfaction Scores With or Without Resident Involvement
Shih RD, CochraneDG, Mandell M/Morristown Memorial Hospital, Morristown, NJ Patient satisfaction surveys are becoming benchmarks for evaluating emergency physician care by hospital administrators. Different survey methodologies are used with inherent limitations. The effects of resident participation in patient care has been poorly evaluated in the past. Study objective: The objective of this study is to evaluate the effect of patient satisfaction scores when residents are involved in emergency department patient care with one of the commonly used survey instruments, the Press, Ganey ED survey. Methods: A retrospective study design was used at a tertiary referral community hospital. Patient satisfaction survey results were obtained for a 6-month period. Cases were grouped by whether the patient was primarily managed by an ED attending or resident physician. Data were collected for a number of satisfaction variables (such as overall satisfaction and satisfaction with physician care), patient demographics, and final diagnosis. Satisfaction categories were compared between groups using Student t test and %2 tests where appropriate. Results: Five hundred five surveys were available for analysis of 3,607 that were sent to patients (14% response rate). Overall mean satisfaction scores with tim ED visit did not diEter between groups (attending 801, resident 81.4;/>.05). However, satisfaction with physician care was significantly elevated in the resident group (attending 66.0, resident 71.6; P<.05). No differences were found with respect to patient demographics or diagnosis. Conclusion: Resident involvement in patient care appears to improve patient satisfaction scores using Press, Ganey survey methodology. Further study to elucidate the reasons for these findings are needed.
9 ADepartment Comparison of Provider Self-Adjudicationof OutpatientEmergency Claims Using a Symptom-Based System With an MCO Claims Review Process That Uses a Diagnosis-Based Methodology Shesser R, Holterman K, Smith J, BraunJ/George Washington University,Washington, DC Study objectives: To determine the performance of a provider "self-adjudicating" outpatient ED claims using a "presenting symptom-based" system compared with the managed care organization (MCO) reviewing and adjudicating the claims using a "final diagnosis-based" system. Methods: Mt outpatient visits from I MCO to an urban, university hospital emergency department between September 1, 1998, and February 28, 1999, were included.
ANNALS OF EMERGENCYMEDrCINE 34:4 OCTOBER1999, PART 2
prehospital and emergency department care of nursing home and adult long-term care facility patients. In addition, we attempted to identify the frequency of patients arriving with the Massachusetts "Comfort Care" AD docmnentation. Methods: Study design was a cross-sectional study of consecutive institutionalized patients over a 60-day period. All individuals 18 years or older who were nursing home or long-term care facility patients transferred by ambulance to the ED were included. Physicians evaluated AD status by transfer chart review or verbal request of the family on patient arrival to the ED. Physician/nursing personnel voluntarily completed study questionnaires addressing the patient's medical condition, immediate availability AD status, and impact on patient care as defined by prehospital and/or ED Advanced Cardiac Life Support (ACTS) intervention. The authors reviewed all adult ED charts during the study period to maximize capture of eligible patients. The authors subsequently conducted a chart review for evidence of preexisting AD on previous admissions. Results: There were a total of 176 encounters representing 13"/patients; 26 patients had multiple ED visits. One hundred forty-six (83%) ED encounters had no AD, whereas 30 (17%) ED encounters had unambiguous AD at time of ED arrival. We found 23 (13.1%) more ED encounters representing 17 patients with AD of "Do not resuscitate/Do not intubate" (DNR/DNI) and 17 (9.7%) ED encounters representing i6 patients with AD of "Full code," only on retrospective chart review of inpatient record. Of the 23 (13%) ED encounters that had previously documented AD of DNR/DNI but no AD at ED arrival, 12 (6.8%) had a clinical presentation that raised the issue of AD status. One of these patients received chest compressions, intuhation, and ACtS intervention. There were a total of 59 (33.5%) encounters in which the issue of AD status was raised and 29 (16.5%) encounters representing 29 patients for whom AD status was directly relevant to their care. Of these 29 patients, 20 arrived with no formal AD, whereas 9 arrived with AD of DNR/DNI. One patient with documented DNR/DN1 status on transfer records received prehospital chest compressions. No patients presented with "Comfort Care" documentation during the study period. Conclusion: A large majority of patients in our study arrived at the ED without AD documentation. Two of these patients received ACtS interventions despite previous AD of DNWDNI. Institutionalized individuals represent a potential group of patients in whom unambiguous AD could be relatively easily resolved by systematic documentation and interinstitutional communication.
6 AGuidelines Comparison of Emergency Medicine UltrasoundTraining With of the Society for Academic Emergency Medicine Witting MD, EuerleBD, KennethH, ButlerKH/Universityof MarylandMedicalCenter,Baltimore,MD Study objectives: To compare the current state of emergency medicine residency ultrasound training with guidelines for that training from the Society for Academic Emergency Medicine (SAEM). Methods: A brief questionnaire was sent to program directors from E19 emergency medicine residency programs in the United States. Responses were compared with the SAEM guidelines for clinical experience (150 total uhrasounds) and didactic experience (40 hours of didactic instruction). Results: Overall response rate was 92%. Seventy-six programs (69%) own an ultrasound machine (ownership meaning 24-hour availability and complete discretion over use). Of these, 12 (16%) indicated that their average 1998 graduate had done 150 or more total uhrasounds during residency, although none had average numbers that exceeded the minimum guidelines for all 4 procedure categories. Information on didactic curriculum was available from 74 ultrasound-owning programs: the duration was 0 to 20 hours in 49 (66%), 20 to 40 hours in 19 (26%), and 40 to 100 hours in 6 (8%). If one considers programs with at least 20 to 40 hours of instruction covering at least 80% of the SAEM curriculum as meeting the didactic guideline, 13 programs (18%) would meet this standard. Overall, the average 1998 graduate from a maximmn of 4 programs would be "trained in ultrasound" according to SAEM guidelines. Conclusion: Most programs own ultrasound equipment, but few currently meet SAEM training guidelines.
7 Americans Effective CommunicationWith Deaf Patients and Awareness of the With Disabilities Act Among Emergency Department Personnel: A Nationwide Survey LarsenTJ, Larsen MF, 8ough JE/East Carolina University, Greenville, NC Study objective: Recently, there have been a number of lawsuits brought against hospitals that were not in compliance with the Americans With Disabilities Act (ADA) in regard to deaf patients. Apparently, many deaf patients are not being furnished with
$ 24
qualified sign language interpreters. This leads to the potential of inappropriate medical care and lawsuits being filed. Emergency departments have not been immune to this. Rather than an intentional disregard of this federal law, it is the authors' belief that it is a lack of awareness of the federal requirements brought about by the ADA and misconceptions about the needs of deaf patients. The objective of this study is to investigate the magnitude of deaf patients being seen in an ED setting, the means of communication being used with deaf patients, the formal education of hospital personnel regarding communication with deaf patients, the hospital personnel's awareness of policies and regulations regarding this population, and the accessibility of sign language interpreters in EDs. Methods: Questionnaires pertaining to the above objectives were distributed to all 121 emergency medicine residency programs approved by the Accreditation Council for Graduate Medical Education (ACGME). Each packet included surveys for all emergency medicine residents, 10 attending physicians, and 10 nurses. Results: One hundred five of the i21 (86.8%) programs responded by returning at least 1 survey. Overall, 2,009 of the 6,097 (33.0%) of the surveys were returned. Of the 2,009 physicians and nurses responding, 1,623 (80.8%) had been personally involved in the care of deaf patients. The results indicate that physicians and nurses see an average of 3 to 4 deaf patients annually. Three hundred twenty-eight (21.7%) indicated the use of sign language interpreters as their primary mode of communication. Formal medical education included communication with deaf patients in 6.1% of those responding. Although 22.4% indicated they were aware of legal obligations regarding deaf patients, only 2.6% of those surveyed indicated awareness of the ADA. When asked whether access to sign language interpreters was available, 41.0% answered that they did not know. Conclusion: In spite of the heightened number of ADA lawsuits specific to deaf patients, there continues to be a lack of awareness pertaining to this particular problem among emergency physicians and nurses.
8
Patient Satisfaction Scores With or Without Resident Involvement
Shih RD, CochraneDG, Mandell M/Morristown Memorial Hospital, Morristown, NJ Patient satisfaction surveys are becoming benchmarks for evaluating emergency physician care by hospital administrators. Different survey methodologies are used with inherent limitations. The effects of resident participation in patient care has been poorly evaluated in the past. Study objective: The objective of this study is to evaluate the effect of patient satisfaction scores when residents are involved in emergency department patient care with one of the commonly used survey instruments, the Press, Ganey ED survey. Methods: A retrospective study design was used at a tertiary referral community hospital. Patient satisfaction survey results were obtained for a 6-month period. Cases were grouped by whether the patient was primarily managed by an ED attending or resident physician. Data were collected for a number of satisfaction variables (such as overall satisfaction and satisfaction with physician care), patient demographics, and final diagnosis. Satisfaction categories were compared between groups using Student t test and %2 tests where appropriate. Results: Five hundred five surveys were available for analysis of 3,607 that were sent to patients (14% response rate). Overall mean satisfaction scores with tim ED visit did not diEter between groups (attending 801, resident 81.4;/>.05). However, satisfaction with physician care was significantly elevated in the resident group (attending 66.0, resident 71.6; P<.05). No differences were found with respect to patient demographics or diagnosis. Conclusion: Resident involvement in patient care appears to improve patient satisfaction scores using Press, Ganey survey methodology. Further study to elucidate the reasons for these findings are needed.
9 ADepartment Comparison of Provider Self-Adjudicationof OutpatientEmergency Claims Using a Symptom-Based System With an MCO Claims Review Process That Uses a Diagnosis-Based Methodology Shesser R, Holterman K, Smith J, BraunJ/George Washington University,Washington, DC Study objectives: To determine the performance of a provider "self-adjudicating" outpatient ED claims using a "presenting symptom-based" system compared with the managed care organization (MCO) reviewing and adjudicating the claims using a "final diagnosis-based" system. Methods: Mt outpatient visits from I MCO to an urban, university hospital emergency department between September 1, 1998, and February 28, 1999, were included.
ANNALS OF EMERGENCYMEDrCINE 34:4 OCTOBER1999, PART 2