- Email: [email protected]
EMF-7 EMTALA: Two decades later
RESEARCH FORUM ABSTRACTS
emergency physicians were certified as specialists. We undertake this survey to assess current staffing of emergency departments (EDs) in Israel and attempt to estimate the need for emergency physicians in the future. Methods: A survey instrument was sent to all ED directors in general hospitals having EDs in Israel. The ED directors were informed that the information would be kept anonymous and only used in the aggregate. We asked questions relating to ED staffing by number of physicians, type of specialty, resident or specialist, and differential staffing by time of the day and week. In addition, we inquired as to the census, structure, hospital resources available, and size of the ED. Results: We had a response rate of 96% (23 of 24 hospitals). There are 59 certified emergency medicine specialists working in EDs in Israel, caring for a total of 1,872,500 visitors annually. A minority are residency trained. There are currently 37 emergency medicine residents enrolled in 19 programs in Israel. Emergency care is otherwise given by specialists and residents in other fields and by nonspecialist physicians. Presence of emergency medicine specialists is not evenly distributed by hospital type or time of day. During the day shift at large hospitals, there is an average of 2.25 emergency medicine specialists and another 4 specialists of other types on duty. From midnight to 8 AM in large hospitals, there is an average of less than 1 specialist of any kind (typically not emergency medicine) on duty in the ED. Evenings and nights in most EDs, care is given by nonspecialists (residents in various specialties and others nonspecialists) working 16-hour shifts. The shortage of emergency physicians is greatest in medium-sized hospitals (average ED census 88,000 visits per year) where there is an average of only 5.3 full-time physicians (of all types) employed, which is in contrast to large hospitals (average ED census 104,000) where there is an average of 9.3 full-time ED physicians (of all specialties). Nineteen of 23 responding hospitals have been recognized as potential training sites for emergency medicine residents. Conclusion: The recognition of the need for emergency medicine as a specialty in Israel by the medicopolitical establishment has not as yet translated into care of emergencies by emergency physicians for most patients. It is apparent that to adequately staff the existing EDs in Israel around the clock full time, there is a need for a large increase in the number of emergency specialists. This increase will require a policy emphasis on funding positions for emergency medicine staff and a concentrated effort directed at emergency medicine resident education.
377
Factors Contributing to Increased Emergency Department Use Among Patients With Chronic Conditions
Sorondo B, Zickgraf T, Fisher J, Minczak B/Philadelphia College of Osteopathic Medicine, Philadelphia, PA; Albert Einstein Medical Center, Philadelphia, PA; Thomas Jefferson University, Philadelphia, PA Study objectives: The purpose of the study is to identify risk factors for emergency department (ED) utilization among patients with chronic conditions. Methods: This is a descriptive, population-based study using data from the Medical Expenditure Panel Survey 2000. Individuals aged 18 years or older and with diagnoses of chronic obstructive pulmonary disease, congestive heart failure, diabetes mellitus, or hypertension were included as having chronic conditions. Those patients were classified as ED users and non-ED users. Variables representing characteristics such as demographics, socioeconomic status, health care utilization, and number of chronic conditions were used in the analysis. STATA software was used for Taylor-series approach to estimate SE for weighted survey estimates. Multivariable analysis (stratification) and regression model were used to compare the 2 groups and to assess the factors associated with visits to the ED. Confidence intervals were calculated in each analysis. Results: Of 25,095 cases reviewed, 3,997 (16%) were identified as having at least 1 of the 4 chronic conditions, and 18% of those were ED users. There were no statistically significant differences between ED users and non-ED users in variables such as age and insurance status. When the regression model was analyzed, statistically significant factors associated with ED users were being female, nonwhite, or unmarried; lacking prescription medical insurance; having a higher incidence of outpatient physician visits; and having a higher incidence of prescriptions drug refills (P\.01). Conclusion: Individuals who have chronic conditions and are poor, lack prescription insurance, are female, are nonwhite, have less than a college education, or have a poor perception of their mental and physical health status are more likely to use the ED for care.
OCTOBER 2004
44:4
ANNALS OF EMERGENCY MEDICINE
EMF-7
EMTALA: Two Decades Later
Ballard DW, Derlet RW, Rich BA, Lowe RA/University of California–Davis, Sacramento, CA; Oregon Health Science University, Portland, OR Study objectives: We determine whether emergency departments (EDs) continue to willfully deny screening and stabilization in violation of the Emergency Medical Treatment and Active Labor Act (EMTALA) and to examine the evidence used to justify EMTALA violations. Methods: Under the Freedom of Information Act, the Centers for Medicare and Medicaid was petitioned for the 200 most recent EMTALA citations requiring a corrective plan of action. Each violation was classified into 1 of 3 primary categories: (1) refusal to perform a screening examination or to stabilize; (2) possible refusal to screen or stabilize; and (3) no evidence of refusal to screen or stabilize. Citations were also classified into 10 additional subcategories, including actual or risk of harm to patient(s), screening or treatment decisions based on financial or insurance status, clinical judgment errors, procedural deficiencies, and documentation failures. Violations occurring in inpatient locations and not involving the ED were excluded. Three investigators independently reviewed a subset of data, and interrater reliability was computed (k). Results: We received 206 records from the period from November 1999 to September 2001. Of these 206, 174 (84%) violations met inclusion criteria and 57 (33%) were category 1 (clear instances of EDs refusing to screen or stabilize), 43 (25%) were category 2 (possible refusal), and 74 (43%) were category 3 (no refusal). Subcategory classifications included harm to patient(s) (17 [10%] of 174), financial (7 [4%] of 174), clinical judgment (26 [15%] of 174), procedural (93 [53%] of 174), and documentation (137 [79%] of 174). The interrater reliability k statistics for the ‘‘refusal to screen/treat’’ classifications (category 1 to 3) were 0.29 and 0.56 (fair to moderate agreement). Conclusion: Willful ED refusal to screen or stabilize still occurs despite EMTALA regulation and enforcement. However, a substantial number of violations reviewed contained no evidence of deliberate denial of care.
378
A Prospective Study Comparing Standard Laryngoscopy to the Trachview Videoscope System for Orotracheal Intubation by Emergency Medicine Residents and Medical Students
Roppolo LP, Brockman CR, Hattan B, Hynan LS/University of Texas Southwestern, Dallas, TX Study objectives: Flexible fiberoptic bronchoscopy is a skill that can be difficult for emergency physicians to use in the setting of an emergency intubation. The TrachView Videoscope (TV) consists of a narrow high-resolution fiberoptic cable whose tip is positioned at the distal end of the endotracheal tube. The image is displayed on a small portable bedside monitor. In this way, the TV does not alter the standard method of intubation but adds a second, possibly improved, view of the vocal cords. The TV has never been formally studied. We determine the ease of use and improvement in the percentage of glottic opening (POGO) score using the TV by individuals with various levels of intubation experience. Methods: The study was conducted in 2 phases on a mannequin model during an airway laboratory for emergency medicine residents and medical students in a university setting. Phase 1 consisted of a nonrandomized group sequential study design in which, after a 10-minute demonstration of the TV, emergency medicine residents assessed the POGO score using direct laryngoscopy (DL) and compared it with their observed POGO score using the TV. Part 2 consisted of a crossover study with first- and second-year medical students with no intubation experience. The students were randomized into 2 groups that differed by the method of intubation instruction given first: DL or TV. The students were given a 10-minute demonstration of each technique and had 2 attempts to return the demonstration. The POGO score noted by the student was recorded for each technique. The groups were then crossed and the process was repeated. Additional information collected from study subjects included ease of use of the TV and improvement in intubation using the TV. Results: In phase 1, the residents consisted of 4 postgraduate year (PGY)-1, 10 PGY-2, and 11 PGY-3 residents, and 3 participants whose level was not recorded, for a total of 28. Overall, the median POGO score for DL was 50%, and the median
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emergency physicians were certified as specialists. We undertake this survey to assess current staffing of emergency departments (EDs) in Israel and attempt to estimate the need for emergency physicians in the future. Methods: A survey instrument was sent to all ED directors in general hospitals having EDs in Israel. The ED directors were informed that the information would be kept anonymous and only used in the aggregate. We asked questions relating to ED staffing by number of physicians, type of specialty, resident or specialist, and differential staffing by time of the day and week. In addition, we inquired as to the census, structure, hospital resources available, and size of the ED. Results: We had a response rate of 96% (23 of 24 hospitals). There are 59 certified emergency medicine specialists working in EDs in Israel, caring for a total of 1,872,500 visitors annually. A minority are residency trained. There are currently 37 emergency medicine residents enrolled in 19 programs in Israel. Emergency care is otherwise given by specialists and residents in other fields and by nonspecialist physicians. Presence of emergency medicine specialists is not evenly distributed by hospital type or time of day. During the day shift at large hospitals, there is an average of 2.25 emergency medicine specialists and another 4 specialists of other types on duty. From midnight to 8 AM in large hospitals, there is an average of less than 1 specialist of any kind (typically not emergency medicine) on duty in the ED. Evenings and nights in most EDs, care is given by nonspecialists (residents in various specialties and others nonspecialists) working 16-hour shifts. The shortage of emergency physicians is greatest in medium-sized hospitals (average ED census 88,000 visits per year) where there is an average of only 5.3 full-time physicians (of all types) employed, which is in contrast to large hospitals (average ED census 104,000) where there is an average of 9.3 full-time ED physicians (of all specialties). Nineteen of 23 responding hospitals have been recognized as potential training sites for emergency medicine residents. Conclusion: The recognition of the need for emergency medicine as a specialty in Israel by the medicopolitical establishment has not as yet translated into care of emergencies by emergency physicians for most patients. It is apparent that to adequately staff the existing EDs in Israel around the clock full time, there is a need for a large increase in the number of emergency specialists. This increase will require a policy emphasis on funding positions for emergency medicine staff and a concentrated effort directed at emergency medicine resident education.
377
Factors Contributing to Increased Emergency Department Use Among Patients With Chronic Conditions
Sorondo B, Zickgraf T, Fisher J, Minczak B/Philadelphia College of Osteopathic Medicine, Philadelphia, PA; Albert Einstein Medical Center, Philadelphia, PA; Thomas Jefferson University, Philadelphia, PA Study objectives: The purpose of the study is to identify risk factors for emergency department (ED) utilization among patients with chronic conditions. Methods: This is a descriptive, population-based study using data from the Medical Expenditure Panel Survey 2000. Individuals aged 18 years or older and with diagnoses of chronic obstructive pulmonary disease, congestive heart failure, diabetes mellitus, or hypertension were included as having chronic conditions. Those patients were classified as ED users and non-ED users. Variables representing characteristics such as demographics, socioeconomic status, health care utilization, and number of chronic conditions were used in the analysis. STATA software was used for Taylor-series approach to estimate SE for weighted survey estimates. Multivariable analysis (stratification) and regression model were used to compare the 2 groups and to assess the factors associated with visits to the ED. Confidence intervals were calculated in each analysis. Results: Of 25,095 cases reviewed, 3,997 (16%) were identified as having at least 1 of the 4 chronic conditions, and 18% of those were ED users. There were no statistically significant differences between ED users and non-ED users in variables such as age and insurance status. When the regression model was analyzed, statistically significant factors associated with ED users were being female, nonwhite, or unmarried; lacking prescription medical insurance; having a higher incidence of outpatient physician visits; and having a higher incidence of prescriptions drug refills (P\.01). Conclusion: Individuals who have chronic conditions and are poor, lack prescription insurance, are female, are nonwhite, have less than a college education, or have a poor perception of their mental and physical health status are more likely to use the ED for care.
OCTOBER 2004
44:4
ANNALS OF EMERGENCY MEDICINE
EMF-7
EMTALA: Two Decades Later
Ballard DW, Derlet RW, Rich BA, Lowe RA/University of California–Davis, Sacramento, CA; Oregon Health Science University, Portland, OR Study objectives: We determine whether emergency departments (EDs) continue to willfully deny screening and stabilization in violation of the Emergency Medical Treatment and Active Labor Act (EMTALA) and to examine the evidence used to justify EMTALA violations. Methods: Under the Freedom of Information Act, the Centers for Medicare and Medicaid was petitioned for the 200 most recent EMTALA citations requiring a corrective plan of action. Each violation was classified into 1 of 3 primary categories: (1) refusal to perform a screening examination or to stabilize; (2) possible refusal to screen or stabilize; and (3) no evidence of refusal to screen or stabilize. Citations were also classified into 10 additional subcategories, including actual or risk of harm to patient(s), screening or treatment decisions based on financial or insurance status, clinical judgment errors, procedural deficiencies, and documentation failures. Violations occurring in inpatient locations and not involving the ED were excluded. Three investigators independently reviewed a subset of data, and interrater reliability was computed (k). Results: We received 206 records from the period from November 1999 to September 2001. Of these 206, 174 (84%) violations met inclusion criteria and 57 (33%) were category 1 (clear instances of EDs refusing to screen or stabilize), 43 (25%) were category 2 (possible refusal), and 74 (43%) were category 3 (no refusal). Subcategory classifications included harm to patient(s) (17 [10%] of 174), financial (7 [4%] of 174), clinical judgment (26 [15%] of 174), procedural (93 [53%] of 174), and documentation (137 [79%] of 174). The interrater reliability k statistics for the ‘‘refusal to screen/treat’’ classifications (category 1 to 3) were 0.29 and 0.56 (fair to moderate agreement). Conclusion: Willful ED refusal to screen or stabilize still occurs despite EMTALA regulation and enforcement. However, a substantial number of violations reviewed contained no evidence of deliberate denial of care.
378
A Prospective Study Comparing Standard Laryngoscopy to the Trachview Videoscope System for Orotracheal Intubation by Emergency Medicine Residents and Medical Students
Roppolo LP, Brockman CR, Hattan B, Hynan LS/University of Texas Southwestern, Dallas, TX Study objectives: Flexible fiberoptic bronchoscopy is a skill that can be difficult for emergency physicians to use in the setting of an emergency intubation. The TrachView Videoscope (TV) consists of a narrow high-resolution fiberoptic cable whose tip is positioned at the distal end of the endotracheal tube. The image is displayed on a small portable bedside monitor. In this way, the TV does not alter the standard method of intubation but adds a second, possibly improved, view of the vocal cords. The TV has never been formally studied. We determine the ease of use and improvement in the percentage of glottic opening (POGO) score using the TV by individuals with various levels of intubation experience. Methods: The study was conducted in 2 phases on a mannequin model during an airway laboratory for emergency medicine residents and medical students in a university setting. Phase 1 consisted of a nonrandomized group sequential study design in which, after a 10-minute demonstration of the TV, emergency medicine residents assessed the POGO score using direct laryngoscopy (DL) and compared it with their observed POGO score using the TV. Part 2 consisted of a crossover study with first- and second-year medical students with no intubation experience. The students were randomized into 2 groups that differed by the method of intubation instruction given first: DL or TV. The students were given a 10-minute demonstration of each technique and had 2 attempts to return the demonstration. The POGO score noted by the student was recorded for each technique. The groups were then crossed and the process was repeated. Additional information collected from study subjects included ease of use of the TV and improvement in intubation using the TV. Results: In phase 1, the residents consisted of 4 postgraduate year (PGY)-1, 10 PGY-2, and 11 PGY-3 residents, and 3 participants whose level was not recorded, for a total of 28. Overall, the median POGO score for DL was 50%, and the median
S 1 1 7