ED Management ============= þ 2010-11 figures for UPMC - slightly less than 4% revenues > profits þ Malpractice: - in 2003, ED malpractice rates in PA ranged from <$10K-$90+K (mode was at $20K. - Newsweek said that the national average was $53,000. þ Emergency Physician Salaries - per Medical Group Management Association (MGMA), reported in ACEP News, August 2002: + 1999: medial salary $186,663; 2000: median salary $198,423 + by years of experience: 1-2 years: $173,834 3-7 years: $192,936 8-17 years: $205,665 18+ years: $212,228 + varied by region: East: $174,889 Midwest: $220,953 South: $228,014 West: $197,146 þ Efficiency - Standard ED sees 2.2 patients per physician service hour, at an ED with 16% admission rate. (Kaplan and Brennan, NJ, ACEP 2000 Chartmanship Lecture) - Use of a "scribe" showed increased physician satisfaction and increased efficiency in terms of patients per hour 2.2 to 2.4 over a 9 month period) þ Interpreters: ACEP EM Today September 2000 HHS Orders Translators for Those With Limited English Skills The Department of Health and Human Services (HHS) issued a new directive on August 30th instructing health care and social service facilities that receive federal funds to provide free interpreters to individuals with limited English language skills. The directive said that HHS was not imposing new requirements, but reiterating longstanding principles. It emphasized the HHS position that health care providers must take steps to ensure that people with limited English skills have meaningful access to programs and services. Federal law already requires federally funded health care and social service agencies to provide language assistance, but it is not uniformly enforced. The directive specifically warns against the use of family, friends or minor children as interpreters. The directive includes four keys to compliance: Assessment - the language needs of the population must be determined Development of a Comprehensive Written Policy of Language Access - a policy must be developed that will ensure meaningful communication Training of Staff - staff must understand the policy and be able to carry it out Vigilant Monitoring - regular oversight must be conducted The directive said that hospitals must post notices in lobbies and waiting rooms informing patients that such services are available. The HHS also wants hospital workers to note a patient’s primary language in that individual’s file. To read the directive, go to http://www.access.gpo.gov/su_docs/fedreg/a000830c.html, and scroll down to Health and Human Services Department. þ Statistics from 1998 (www.cdc.gov/nchs/data/ad313.pdf) - 100 million ED visits in 1998 - 19% emergent 31% urgent 14% semi-urgent 9% non-urgent 27% unkonwn - constant 8A-12MN, most during 4-8 PM, worst Sat, Sun, Mon - 13% admission rate - avg. 41 minute wait þ Emergency Physician Productivity þ Shift Work: - The industry literature clearly states that difficulties with shift work surface around age 45. Our survival may depend on creative solutions. [Akerstedt T. Ergonomics 1981;24:265.] þ Risk-Taking Personality Traits vs. Admission - [Pearson SD, Goldman L, Orav EJ, Guadagnoli E, Garcia TB, Johnson PA, Lee TH. Triage decisions for emergency department patients with chest pain: do physicians' risk attitudes make the difference? Department of Ambulatory Care and Prevention, Harvard Medical School, Boston, Massachusetts, USA. J Gen Intern Med 1995 Oct;10(10):557-64.] Abstract: þ EPs vs. PCPs vs. PAs þ Analysis of Various Potential Effects on ED patient census: (1) Brunette et. al. Correlation of Emergency Health Care Use, 911 Volume and Jail Activity with Welfare Check Distribution. Ann Emer Med: July 1991;20:729-742 (2) Christoffel KK Effect of season and weather on pediatric emergency department use. In: Am J Emerg Med (1985 Jul) 3(4):327-30 It is commonly believed that emergency department (ED) use is affected by extreme weather. To test this hypothesis, data concerning use of a pediatric ED during three seasonally diverse months was analyzed in the light of Weather Bureau information concerning daily conditions during the study months. Seven measures of extreme weather were defined: 1) extreme cold (daily high temperature less than or equal to 25 degrees F); 2) extreme heat (daily high temperature greater than or equal to 88 degrees F); 3) unusual cold (winter) with departure from normal of mean temperature less than -10 degrees F; 4) unusual heat (summer) with departure from normal of mean temperature greater than 10 degrees F; 5) precipitation greater than or equal to 0.25 inches (in water-equivalent inches); 6) stormy (thunderstorm, hail, ice, or blowing snow); 7) snow-covered (greater than or equal to 6 inches of snow on the ground). Seasonal use patterns were examined and the proportion of days with each weather factor was compared with the proportion of visits on days with the factor. The data indicate 1) season has a major affect on ED use because it affects prevalence of disease and injury; 2) extremely cold and stormy conditions significant reductions in ED use of approximately 5- 20%; 3) 80-95% of expected visits are made on days with very bad weather. The data indicate that weather is a minor factor in determining ED use. (3) Buesching DP Jablonowski A Vesta E Dilts W Runge C Lund J Porter R Inappropriate emergency department visits. In: Ann Emerg Med (1985 Jul) 14(7):672-6 Guidelines adopted in 1982 by the American Collegeof Emergency Physicians were used to determine appropriate and inappropriate emergency department (ED) utilization patterns at three community hospitals during a two-week period in August 1983. In all, 3,130 visits were examined. There was an overall inappropriate visit rate of 10.8%, although considerable variation was observed among the three hospitals. Subgroups with the highest inappropriate visit rates included the following: 1) persons with Medicaid as the primary payment source (17.3%); 2) children aged 5 years or younger (15.2%); 3) those unable to identify a personal physician (14.1%); 4) unemployed persons (13.1%); 5) patients making visits during regular office hours (12.6%); and 6) those failing to attempt to contact their personal physicians (12.4%). These variations in inappropriate usage were all statistically significant at the P less than .05 level or better. Inability to identify a personal physician emerged as the most pervasive influence on inappropriate ED visit rates (P less than .001). (4) Winstead DK Schwartz BD Mallott D Bertrand WE Biorhythms revisited: rhythm and blues? In: J Clin Psychiatry (1984 Oct) 45(10):426-9 In a previous study, no significant relationship was seen between date of psychiatric admission or psychiatric emergency room visit and various phases or critical days in the biorhythm cycle. The present study evaluated these relationships for date of admission of 313 patients--192 with major depression, 88 with bipolar disorder, and 33 with schizophrenia or other diagnoses. No significant relationship to critical days or any combination of critical/noncritical days was found. Two further analyses failed to reveal any significant relationship between admission date and ascendant versus recuperative phases or any combination of cycle and phase. No differences were seen between affectively ill and other patients on any measures evaluated. (5) Karas S Jr Patterns in the number of patients seen hourly in a community hospital emergency department. In: JACEP (1977 Oct) 6(10):449-52 The hourly and daily patient load data from Tri-City Hospital was analyzed using statistical and graphic analysis for the period between April 1, 1976 and October 31, 1976. This analysis revealed repetitive patterns in the patient load data, both in the daily data, with a seven-day cycle peaking on Saturday or Sunday, and the intraday data with a bimodal daily cycle with peaks between 10:00 am and 1:00 pm, followed by a high evening peak between 7:00 pm and 8:00 pm. Methods were introduced which, by simple calculation, can determine these cycles and those deviant days that exceed the norm early in the day. (6) Baker DW Stevens CD Brook RH Regular source of ambulatory care and medical care utilization by patients presenting to a public hospital emergency department [see comments] In: JAMA (1994 Jun 22-29) 271(24):1909-12 OBJECTIVE--To determine the regular source of care and the relationship between usual provider and use of medical services among ambulatory emergency department patients. DESIGN--Cross-sectional survey. SETTING--A public hospital in Los Angeles County, California. PATIENTS--A total of 1190 stable, ambulatory adults presenting to the emergency department during a 2-week period. MAIN OUTCOME MEASURES-- Self-reported regular source of care, usual health status, and recent physician visits. RESULTS--A total of 16% of the patients identified an emergency department as their regular source of care. One fourth of this group reported fair or poor health. African Americans and Latinos were more likely than whites to identify an emergency department as their regular source of care. Patients who identified an emergency department as their regular source of care had 25% fewer physician visits and were less likely to have seen a physician during the preceding 3 months than patients who were usually seen in an office or clinic (relative risk, 0.45; 95% confidence interval, 0.28 to 0.70). Of all patients, 56% identified a regular source of care other than an emergency department, but 24% to 36% of all their recent physician visits still occurred in an emergency department. CONCLUSION--Our patients rely heavily on emergency departments for ambulatory physician visits, regardless of their reported regular source of care. However, patients who identify an emergency department as their regular source of ambulatory care used physician services less frequently than patients with access to providers in other settings. These issues require further evaluation with population-based surveys. (7) Diehl AK Morris MD Mannis SA Use of calendar and weather data to predict walk-in attendance. In: South Med J (1981 Jun) 74(6):709-12 Hospital emergency rooms frequently provide routine health care to inner-city residents. Operating costs for such "walk-in" services might be reduced if staffing levels could be tailored to patient flow. To determine how calendar and meteorological factors affect attendance, we matched the daily visit records of a large ambulatory care center with concurrent calendar and weather data. Stepwise regression analysis resulted in a predictive equation that allows the projection of future attendance. In our facility, patient flow peaked on Monday and declined steadily during the remainder of the week. Fewer visits occurred during autumn and winter than during summer months. Higher temperatures were associated with more visits and daytime rainfall and glaze with fewer, once calendar variables were accounted for. The prediction equation has its greatest usefulness in projecting trends in walk-in attendance. Staffing levels can be adjusted to the predicted patient flow, allowing more cost-efficient operation. (8) Reich NT Moscati R Jehle D Ciotoli M The impact of a major televised sporting event on emergency department census. In: J Emerg Med (1994 Jan-Feb) 12(1):15-7 This study examines the effect of a major televised sporting event, the Super Bowl, on emergency department (ED) census. Daily patient census figures for the month of January 1988-1992 were obtained. Individual shift census was divided by monthly mean census to compare relative volume. Census figures for 4 of the 5 Super Bowl days were significantly lower than the remaining 143 days studied. The day of the Super Bowl was the month's slowest shift for 3 of the 5 days. When the local team was a playoff participant, a stronger association was noted. The results demonstrate a significant decrease in ED utilization coinciding with the Super Bowl broadcast. Major televised events can significantly decrease ED volume, especially when local interest is present. Staffing changes may then be made accordingly.