Solving the worldwide emergency department crowding problem - what can we learn from an Israeli ED?

ED crowding is a prevalent and important issue facing hospitals in Israel and around the world, including North and South America, Europe, Australia, Asia and Africa. ED crowding is associated with poorer quality of care and poorer health outcomes, along with extended waits for care. Crowding is caused by a periodic mismatch between the supply of ED and hospital resources and the demand for patient care. In a recent article in the Israel Journal of Health Policy Research, Bashkin et al. present an Ishikawa diagram describing several factors related to longer length of stay (LOS), and higher levels of ED crowding, including management, process, environmental, human factors, and resource issues. Several solutions exist to reduce ED crowding, which involve addressing several of the issues identified by Bashkin et al. This includes reducing the demand for and variation in care, and better matching the supply of resources to demands in care in real time. However, what is needed to reduce crowding is an institutional imperative from senior leadership, implemented by engaged ED and hospital leadership with multi-disciplinary cross-unit collaboration, sufficient resources to implement effective interventions, access to data, and a sustained commitment over time. This may move the culture of a hospital to facilitate improved flow within and across units and ultimately improve quality and safety over the long-term

Why Doctors Order Too Many Tests (It\u27s Not Just to Avoid Lawsuits)

Advanced radiology tests such as CT scans, MRIs and ultrasounds have dramatically changed how patients are diagnosed and treated. Just a decade ago, patients were still being subjected to exploratory surgery, in which a surgeon cuts open the abdomen to look for problems; today, CT scans allow doctors to make diagnoses without a scalpel

McDonald\u27s Medicine: Are We Too Impatient to Wait for Care?

The prospect of waiting for health care is not only distasteful to Americans, it\u27s downright threatening: indeed, the specter of Canadian-style waiting lists for certain tests and procedures evoked enough American-style fear that it became a key Republican talking point to challenge the concept of government-subsidized health care

The Role of the HEART score and Clinical Decision Units in ED Patients with Chest Pain

Every year, millions of patients present to Emergency Departments across the country complaining of chest pain. Even after traditional ED testing which includes electrocardiograms, laboratory testing, and chest radiography, chest pain patients still have a small but real risk of serious illness. The HEART score is a new tool that has been validated to help risk-stratify patients. Clinical Decision Units decrease cost and length of stay without compromising patient safety, allowing for complete evaluations of these patients

Comparing Emergency Department Resident and Patient Perspectives on Costs in Emergency Care

Objectives: Costs of care are increasingly important in healthcare policy and, more recently, clinical care in the Emergency Department (ED). We compare ED resident and patient perceptions surrounding the costs of emergency care, compliance, communication, and education. Methods: We conducted a mixed methods study using surveys and qualitative interviews in a single, urban academic ED. The first study population was a convenience sample of adult patients (\u3e17 years of age), and the second was ED residents training at the same institution. Participants answered open- and closed-ended questions on costs, cost-related compliance, and communication. Residents answered additional questions on residency education on costs of care. Closed-ended data were tabulated and described using standard statistics while open-ended responses were analyzed using grounded theory. Results: Thirty ED patients and 24 ED residents participated in the study. Both ED patients and residents felt neutral regarding the importance of cost discussions and generally did not have knowledge of medical costs. Patients were comfortable discussing costs while residents were less comfortable. Additionally, some patients had cost concerns restricting compliance with treatment. Limitations to discussing costs included lack of time and perceived irrelevance. Generally, ED residents took costs into consideration during clinical decision-making, most commonly because of a feeling of personal responsibility to control healthcare costs. Nearly all ED residents agreed they had too little education regarding costs, and the most common suggestion for enhancing education was inclusion of price lists. Conclusions: There were several notable differences in patient and resident perspectives on cost discussions in the ED in this sample. While patients do not see cost discussions to be important, they are generally comfortable discussing costs yet do not report having sufficient knowledge on what care costs. ED residents think costs are important, but are less comfortable discussing them, primarily because they lack education on medical costs

How the European Union Is Embracing Cross-border Telemedicine and what the U.S. State Medical Boards Can Learn From It

Despite the fact that there have been many advances in the field of telemedicine, the United States (U.S.) state and federal laws have not kept pace with these technological advancements and may operate as a barrier to growth in the field of telemedicine. On the other hand, the European Union (EU) has developed a robust legal framework for the practice of telemedicine. The aim of this research project is to evaluate what elements of the EU legal experience could be used to support efforts to better align telemedicine law with the practice of telemedicine in the U.S. Based on the 2015 EU Guidelines, by 2020, a French physician may be able to see a German patient online and have instant access to the patient’s medical record, automatically translated into the French language.1 The EU has prioritized the creation of a legal framework that fully supports cross-border telemedicine.2 As early as 2000, the EU broadened medical licensure requirements for telemedicine so that physicians licensed in one nation could provide telemedicine services to patients who reside in other EU nations without needing to obtain medical licenses from these nations.3 Furthermore, linguistic experts from several nations of the EU have been working together to develop ways of automatically translating and instantly delivering patient records to physicians as appropriate.1 The state medical boards of the U.S, however, have struggled with efforts designed to achieve similar legislative changes. In most states, physicians are required to be licensed in both the state where they practice and the state where the patient resides.4 For example, a Texas physician is required to obtain a Georgia medical license in advance of providing telemedicine care to a patient in Georgia to ensure that their services are legal and reimbursable by insurance.4 While some states now provide a telemedicine license or expedite multistate licensing, these measures are insufficient to support the widespread practice of interstate telemedicine.4 With current regulations, obtaining medical licenses in all 50 states for telemedicine practice is impractical and prohibitively expensive for healthcare providers and organizations. U.S. medical licensure requirements for telemedicine practice are comparable to EU regulations before 2000. Furthermore, U.S. telemedicine reimbursement regulations arbitrarily differ across state borders, and electronic medical record systems from various companies do not communicate properly with each other. At this time, physicians in the U.S. cannot retrieve patient records for unscheduled patient encounters in real-time unless the patient was previously treated using the same medical health records system, causing inconvenience to patients, treatment delays and duplicative medical testing.5 Similar to the European approach, we recommend that the state medical boards allow physicians licensed in one state to provide telemedicine services to patients in other states. Furthermore, we recommend collaboration among the state medical boards, industry leaders, and state legislatures to come up with uniform telemedicine reimbursement regulations and to design a uniform electronic medical record inter-operability standard to allow the U.S. telemedicine industry to keep abreast of the global developments in telemedicine

The Pediatric Emergency Department: A Substitute for Primary Care?

Objectives: Pediatric emergency department (PED) patients often present with non-urgent complaints. We attempted to estimate the perceived degree of urgency of the visit and to identify reasons for seeking non-urgent care in the PED by patients and parents. Methods: A prospective survey was completed by parents (for children 17 and younger) and patients (18-21) presenting to a suburban academic PED that sees approximately 15,000 patients per year. A convenience sample of participants was enrolled. Results: Three hundred and five of 334 surveys were completed (91% response rate) over a 3-month period. Twenty-four percent of the chief complaints were perceived by those surveyed as emergent or possibly life-threatening, 23% were felt to be very urgent, and 52% were deemed somewhat urgent or minor. Twenty-five percent of those with minor or somewhat urgent complaints arrived by ambulance. Weekend visits and minority race correlated with a lower degree of perceived urgency. Overall, 79% of those surveyed identified a primary care provider (PCP) for themselves or their child. Of those, 54% had attempted to contact the PCP prior to coming to the PED. Six percent of those who attempted to reach their primary care providers were able to contact them and 52% were told to come to the PED. Conclusions: More than half of patients and parents presenting to the PED believed they had minor or somewhat urgent complaints. While the majority of patients have a regular provider, limited access to timely primary care and convenience may make the PED a more attractive care option than primary care for many parents and patients

Bedside teaching on time to disposition improves length of stay for critically-ill emergency departments patients

Introduction: We tested the effect of a brief disposition process intervention on residents’ time to disposition and emergency department (ED) length of stay (LOS) in high acuity ED patients. Methods: This was a quasi-experimental study design in a single teaching hospital where ED residents are responsible for administrative bed requests for patients. Enrollment was performed for intervention and control groups on an even-odd day schedule. Inclusion criteria were ED patients triaged as Emergency Severity Index (ESI) 1 and 2. In the intervention group, the attending physician prompted the resident to make the disposition immediately after the evaluation of resuscitation patients. In the control group, the attending physicians did not intervene in the disposition process unless more than 2 hours passed without a disposition. Main outcomes were time to disposition and total ED LOS. Results: A total of 104 patients were enrolled; 53 (51%) in the intervention group and 51 (49%) in the control group. After controlling for ESI and resident training year, mean disposition time was significantly shorter in the intervention group by 41.4 minutes (95% CI: 32.6-50.1). LOS was also shorter in the intervention group by 93.3 minutes (95% CI: 41.9-144.6)

The use of mobile phone cameras in guiding treatment decisions for laceration care

Objectives: Mobile phone technology may be useful in helping to guide medical decisions for lacerations. We examined whether emergency department (ED) provider opinions on which lacerations require repair differed using mobile phone–generated images compared with in-person evaluations. Subjects and Methods: Patients presenting to an urban ED for initial and follow-up laceration care were prospectively enrolled. Patients took four mobile phone pictures of their laceration and provided a medical history. Cases were reviewed by ED providers who assessed image quality and made a recommendation about whether the laceration needed repair. The same provider then assessed the patient in-person. Concordant decision-making between mobile phone and in-person assessments was calculated as well as the degree of undertriage. Results: In total, 94 patients were included over an 8-month period. There was complete agreement in 87% of cases (κ statistic=0.65). Of the 13 patients with discrepant decisions, 6 were due to poor image quality, in 3 the images did not properly represent the problem, in 3 others there were historical findings that altered care, and for 1 the image looked worse than the actual injury in-person. In total, 5 of 94 (5%) of cases would have been undertriaged using only the mobile phone recommendation. Median image quality was 6 out of 10 (with 10 being the best) (interquartile range, 4–8). Conclusions: There are high rates of agreement when providers use mobile phone images to assess lacerations for possible repair in the ED. Image quality is in general good but highly variable and may drive incorrect assessments