Skip to content

Archives for

See all posts in the network tagged with

 

While the issue of Electronic Medical Records and physicians seems a little off base for an EMS blog, the reality is that their use and adoption is occuring throughout all levels of healthcare.   This includes the prehospital arena and intrafacility transport systems.  Insurance information capture is now stressed with most ambulance systems, both public and private.  The concerns and thoughts expressed by the below reposted blog by Dr Palestrant, therefore, I believe address the 911 community as well.

An added concern that I have as an Emergency Medicine physician is that most of the prehospital documentation systems don't integrate with the EMRs established in the Emergency Departments.   By and large, the EMRs which have been adopted reflect administrative decisions without consideration of the care provider's/Emergency Department's needs.  Specifically, it is absolutely obsured that charts produced via a 911 squad don't automatically populate and integrate with any giving receiving hospital's Emergency Department record.   Often hours to days pass without a hardcopy arriving (if ever provided).   What good does this do for the patient? Intrafacility transport services are forced to waste time extracting needed information from a hospitals system and hand keying it into their charts, mostly extracting demographics for billing purposes, while a patient awaits an airlift to a nearby cath lab or stroke center.   Where is the conductor who is orchestrating this adoption of Electronic Records?

The lack of harmony and consistency with EMRs, both facility based and prehospital is addressed in Dr Palestrant's post.  

The direct link to his post is here: http://par8o.com/wordpress/why-emr-is-a-four-letter-word-to-most-doctors/

The full and text follows below:

Don’t get me wrong, EMRs (Electronic Medical Records) are inevitable. Over the long-run they are almost certainly good for physicians, patients and the healthcare industry.

However, their origin and the ulterior motives currently driving their adoption is sowing the seeds of their failure.  First, what is ACTUALLY happening out there?  The most recent CDC data would seem to be encouraging for EMR adoption (http://1.usa.gov/vu8wiy), with EMR use (finally) passing 50%.

Too bad there is more to the story.

If you look at adoption rates for so called “fully functional EMRs” (http://bit.ly/uUQ3FV), the adoption rate remains in the low teens (full data for 2011 is not yet available).  So why is there an almost 4-fold discrepancy between “any EMR” and “fully functional EMR”?  If EMRs are so great, why does the government have to essentially “bribe” physicians to adopt them through incentives such as the meaningful use incentive program (http://go.cms.gov/97BFXJ)?  Why is this so important to them that they didn’t even wait for the healthcare affordability act to implement this “incentive”? (They put it in the stimulus package after Obama had only been in office a few months.)

The 50% adoption rates seen in the first link reflect the presence of ANY type of an EMR-like technology. While it is a great headline for sure, the second link shows that this is an overly broad declaration.  When we look at “fully functional systems,” meaning they are being used for a full work-flow solution, we get numbers in the low teens instead. (When you subtract out unique situations such as Kaiser, the VA, and a few large independent doctor networks, I suspect the actual number is much lower.)

One reason that incentives and threats of decreased payment are necessary for EMR adoption is that the industry and physicians have known for years that EMRs do not improve productivity and that it is highly questionable that EMRs lead to better patient outcomes.  So why is all this taxpayer debt being accrued by throwing borrowed money at the healthcare industry to drive EMR adoption, if the end users are so disenchanted?  As Jonathan Bush, the Founder-CEO of AthenaHealth (a major EMR supplier) famously said, “It’s healthcare information technology’s version of cash-for-clunkers”(http://bit.ly/9ZgUa7), and,

Because it is actually all about control.

The goal of EMRs is to wrestle control of healthcare away from the doctor-patient relationship into the hands of third parties who can then implement their policies….by simply removing a button or an option in the EMR.  If you can’t select a particular treatment option, for all intents and purposes the option doesn’t exist or the red tape to choose it is so painful that there is little incentive to “fight the system.”

For patients, this means that they will only be able to consume the healthcare that they “qualify” for or be forced to find another way to obtain the care that they want and need.  It is the second outcome, see previous post (Benjamin Franklin, Lightning & Ex-Communication) that is the most intriguing, because as “shoppers,” patients will want to be informed and have choices as they take on more responsibility for the cost and quality of their own care.  This approach works very well with Health Savings Accounts, which were conveniently deemphasized in the healthcare reform effort.  Like the lightning going to ground, this is the inevitable future for healthcare in this country (assuming the other alternative, an acceleration to a single payor system does not occur first).

For physicians…well, it isn’t hard to figure out where this is all heading.  EMRs are quickly becoming the instrument by which we are controlled and managed.  As an example, many organizations are already starting to restrict diagnostic testing and therapies via EMR.

What’s next? Patient referrals?  It will be the final step in subjugating physicians.

So why is genuine EMR adoption struggling so much?  After all, one may argue that the accessibility of instant data that technology now enables is the greatest single advance in patient care so far this century.  With so much money being thrown at the problem, one might expect a much greater adoption. Why hasn’t it played out in a much more positive way?

This comes back to the origin and ulterior motives of EMRs.  First, EMRs have been largely a top down effort.  Rather than working with physicians to design the technologies and drive adoption, the experience (and almost universally the perception) is that the technology has been thrust upon physicians by administrators.  Compounding this is the unintended consequences of the meaningful use government incentives (or cash-for-clunkers program to use Jonathan Bush’s, more colorful language).  Having left the guidelines vague and largely written by a small group of industry insiders, most products have become a Tower of Babel with atrocious user interfaces and user experiences that….well, I don’t blame my fellow physicians for not wanting to use them. In addition to being expensive, they are complex, inefficient, and do not make physicians or their staff more productive.

Widespread adoption of an EMR (or multiple compatible EMRs) that is intuitive and easy to use, that empowers the end user and patients, and that actually helps to make the healthcare system more efficient would be a good thing for doctors, patients, and the industry.  However, unless we recognize what the ultimate goals are and better involve the people most critical to their effective use (physicians), I believe Jonathan’s prediction will be true and cash-for-clunkers applied to the healthcare sector will turn out about as successful as that other government program…TARP.

 

Adam Sharp, MD
Founder par8o & SERMO

Posted in Emergency Communications, ems-health-safety, ems-topics, health care reform, healthcare reform, technology-communications, technology-communications-ems-topics, Uncategorized

No comments Posted by on March 1, 2012

Repost from MSNBC – Interesting read!

http://vitals.msnbc.msn.com/_news/2011/11/09/8705246-swearing-spitting-choking-er-nurses-endure-this-and-more#.TrrEmrjyA5o.email

 

 

 

Posted in Uncategorized

No comments Posted by on November 9, 2011

Creating and Maintaining Drug Addictions in the EMS/ED Setting

Some background:

 

I have a very good friend who is a nurse who recenty admitted to me that the reason s/he "dropped off the face of the Earth," was s/he had an addiction problem.   This person is on the road to recovery and offerred to write about what occurred.  Interestingly, over the years, I have come across many healthcare workers in EMS with addictive problems.  Some with alcohol, some with other substances.  Regardless – please read and share comments.   This clearly is an important topic to discuss

 

 

Creating and Maintaining Drug Addictions in the EMS/ED Setting

Addiction and associated drug-seeking behaviors have reached, to use a cliché, epidemic proportions. The sad thing is that patient satisfaction surveys, patient “rights”, and lack of support from administrators when confronting behaviors has contributed to this problem far more than the addicts themselves. In days gone past, we had our heroin junkies, our pot smokers, and our valium-grandmas; these patients we could see coming from a mile away. Today’s addicts come from all walks/occupations, all age groups, and are less easily identified than in the past. They can be lawyers, hamburger-flippers, homemakers, mechanics, car salesmen; or in my case, an ER nurse.

 

No one was more surprised than I was the day I entered rehab for opioid dependence. An experienced ED nurse of 15 years,  with a great reputation as a leader, teacher, mentor; I was a junkie. Popping or snorting oxycodone or shooting up dilaudid was my daily routine, in between taking care of patients. But as with all addicts, I could rationalize, minimize, or bullshit my was out of any situation. Until I hit the bottom. I tell this not for sympathy, understanding, or shock value; but to underscore my understanding of these addicts which I always hated taking care of. After all, they were taking up my time, lying to me and expecting be to believe their pain scores, and generally being a waste of space.

 

Our role in the problem is creating the addict, maintaining the addict, then condemning the addict. First we create them. Unlike the days of gateway drugs leading to heroin, today we prescribe Percocet and oxycontin for pain. Legitimate drugs for legitimate reasons, we keep giving these meds and keep writing the refills… Then one day the patient tries to cut down or stop and get “dope-sick”, a horrible withdraw constellation of pain, anxiety, cramps, shakes, nausea, and feeling of impending doom. All these go away as soon as another “oxy 30” hits the GI tract.

 

When I was in rehab, I met many addicts, some as young as 19, who were addicted to narcotics secondary to a back injury, a surgery, or other legitimate illness/injury. It would be impossible for me to count the number of prescriptions for percocet, vicodin, oxycontin that I handed over for a sprained ankle, broken finger, or even a peritonsilar abscess. Imagine how many more are given upon discharge from an inpatient setting after injury or surgery. Oxycontin is so powerful and addictive that one 21 year old addict that I spoke with turned to heroin after his doctor cut him off from oxycontin, if given the choice between IV heroin or snorting an oxy 30 would take the oxy every time. Heroin was what he turned to when he couldn’t get his drug of choice. Imagine that; heroin is second best to a pill.

 

The second problem is maintaining the addict. We’ve all gotten calls for patients with intractable back pain who can’t drive to the hospital, after they’ve run out of their narcotics. So we roll our eyes, load them on the litter, and dump “another drug-seeker” into the ED. Then the ED doc, who knows that his paycheck is based, at least in part, on his “patient satisfaction scores, is torn between giving a shot of dilaudid and a script for “enough narcotics until you can see your doc”, and dealing with a negative patient survey than translates to less dollars in his/her paycheck. Add to this a crazy busy night in the ED, overloaded, and its often just easier to give them what they want and get them out of the ED “so we can take care of real patients”. 

 

If we call the patients on their drug-seeking behavior, then we’re called to the carpet from a director, a manager, or a charge nurse who quotes something from an ancient text; “Pain is subjective, it’s whatever the patient says it is..”. After all, the ED/EMS setting is a business, and “we have to keep the customers happy”. I’m guilty of this myself. Many times I’ve told a doc “Look, this morons is just drug-seeking, but causing all kinds of ruckus. He’s tying up two of my nurses, the tech, and three security guards, and I just got a call from the ‘patient advocate’. And there’s thirty patients in the waiting room to come back. Can you just write for whatever he wants so I can empty the bed and get back to the patients who are really sick? Please…”

 

Then we condemn them. I’m as guilty of this as anyone, perhaps more so. Addiction is a disease, right? What a load of crap! It’s just a lack of willpower or some loser who wants a free high. Or they come in to get into detox and rehab, perhaps legitimately wanting help or just making their parole office or family happy, and we let them sit for hours, in pain, while waiting for social services to find a bed for them at some rehab facility. To keep them comfortable, we “might” give them 1mg PO ativan and some zofran. Then we wonder, after sitting for eight hours in withdraw, the sign out AMA while yelling “you people don’t want to do anything for me”. I sat in the intake office at a detox for five hours while waiting for insurance to clear, in full blown withdraw, and believe me it was not fun. Only the thought of permanently losing my nursing license and fear of my wife kept me there.

 

Why don’t we treat the withdraw while waiting for placement? If someone is withdrawing from narcotics, who are we not giving them narcotics? Detox centers use a tapering program of Subutex to bring patients down over a period of three to five days. Patients are using upwards of 240mg of oxycontin a day or 4-10 bags of heroin, yet we thing nothing of giving them a little ativan and zofran, thinking that will keep them quiet until we can get them placed. Are we withholding the narcotics to punish them? Would we withhold D50 from a diabetic whose blood sugar was 20? Are we not withholding medical treatment?

 

So what is the answer? If I knew that, I’d be heading up the presidential council on drug addiction, rather than going to Cocaine, narcotics, and alcoholics anonymous. Perhaps, rather than condemning the addict, we need to look at our own behaviors and attitudes towards them. We created many of them, then we crush them and withhold care. Perhaps we need to worry less about patient satisfaction surveys driving our standards of practice, and more about the patient. While its true that “if we don’t give them what they want, they’ll just go somewhere else”, that can’t be our guiding principle. If a patient wanted another medication, say a cardiac med that they heard was good, would we give it to keep the patient satisfied?

 

Somehow, and I’m still trying to figure out how, I crossed the line from social drinker and occasional Percocet user for back pain to a full-time junkie, shooting up between patients in the bathroom. Yet still able to provide care for the most critically ill patient. Only through the grace of God did I not harm anyone other than myself. I’ve reached the bottom of a hell that I wouldn’t wish on anyone (other than a nursing administrator or two). But if there is a good side to this addiction of mine, I’m becoming a better person than I was before; less selfish, self-centered, grandiose and ill-tempered. And when the state decides it’s time for me to begin practicing as an ED nurse again, I’ll have a very different perspective for this unique group of patients who can be very challenging to care for. Perhaps God made me an addict to allow me to care for other addicts. Stranger things have happened.

Posted in ems-health-safety, ems-topics, patient-management

4 comments Posted by on October 3, 2011

Health Care Reform Hits Mainstreet

I had the wonderful pleasure this Wednesday and Thursday to attend the Neuroscience Conference hosted by Capital Health Center at the Borgata, in Atlantic City, New Jersey.    One of the speakers was Mr. David Knowlton.  Mr Knowlton is the President and CEO of the New Jersey Health Care Quality Institute. He is a fantastic speaker who is driven to improve health care delivery for the state of New Jersey.

A major element of his talk had to do with the recently passed Health Care Reform Bill. It we be affecting all of us over the next couple of years.  He showed a video, whose link is provided below, which explains this bill.   While not an expected topic for publication in a blog centering around EMS, I urge you to watch. 

As always, comments and discussion appreciated!

 

Click the highlighted link below!

Health Reform Hits Main Street

Posted in health care reform, healthcare reform, Uncategorized

No comments Posted by on May 7, 2011

New Jersey’s Two Tier ALS System. Time to Advance?

I had missed dinner and was heading in for my first of three night shifts. I made excellent time on the highway, and pulled into a local strip mall just several blocks from the hospital to grab a bite to eat before tackling my shift. Off along the curb a quarter mile back along the state highway was a local ambulance. The lights were flashing, the doors open, with a paramedic chase truck having clearly stopped the vehicle to assist with a patient in the rear. Where the ambulance was stopped is literally less than one mile to the Emergency Department entrance. Expecting the paramedic to have climbed aboard of the ambulance and to be off in moments, I entered the fast food establishment, grabbed my sandwich and soda and sat down to eat. Fifteen minutes later I exited and the ambulance was still sitting there. With New Jersey Highways being the way they are, the only way to assist would be to drive another half mile down the road, find a jug handle, wait for a light, drive in the opposite direction and find another jug handle to return. With only minutes to the start of my shift, I figured I would find out soon enough what was going on.

I arrived at the hospital, put my bags down, hung up my coat, and proceeded to receive sign-out from the dayshift doctor. After receiving report, I asked if the department had been alerted via HASTE for any inbound ambulances. I explained that there was a unit along the road a mile or two back with a MICU unit behind it for a least twenty minutes. At that moment, the squad rolled through the door. An approximately 60 year old was sitting upright on the stretcher, apparently quiet comfortable, wearing a 100% non-rebreather mask, smiling, and looking around. I asked if this was the same unit stopped on the state highway just up the road. The squad gave report of the various treatments and interventions initiated in field curbside along the highway.

Southern New Jersey has a very unique two tier EMS system which, after fifteen years, I am still getting use to it. It is predominantly a volunteer BLS system with ALS being provided by “chase-units”, consisting of Ford Explorers. The ALS units have no transport capability. Typically, the medics would climb aboard the BLS ambulance and provide higher level of care when needed or provide such on scene. Unfortunately, this system has lead to several issues, including the one addressed above.

The opening vignette, in my experience, is not at all unique. Prolonged transports from nursing homes only two or three miles down the road from one of the hospitals I work at for respiratory and cardiac arrests or from neighboring residential developments is not uncommon. There is a very strong motivation to provide advanced life support on-scene care despite the close proximity of a fully staffed Emergency Department. The concept of “scoop and run” by BLS units when close proximity to hospital care is at hand is often mistakenly misplaced for delayed scene times to await the arrival of ALS.

Another product of the two-tier system in New Jersey is a dangerous race of emergency vehicles and civilians in a long, “vehicular parade” to the hospital. The ambulance is followed by the paramedic chase unit, which is often followed or lead by a police car or two. Racing up the rear is usually family in their car despite being told not to try to follow the ambulance to the hospital. Other drivers, when hearing the sirens, usually only expect a single emergency vehicle. Two vehicles, especially if driving fairly tightly behind one another, can easily be unanticipated by motorists. With families trying to keep up with “the parade,” the potential for additional injuries is very real.

With state economics being what they are, funding to advance New Jersey volunteer crews to having ALS level of care is limited. The ideal would be to bring all squads up to the capacity of having a medic available for all runs if needed. Fewer rescue vehicles on the road would have the financial benefits of lower costs in equipment, fuel, and insurance for cash strapped municipalities. This system has been proven to work in New York State for decades. Nassau and Suffolk Counties in New York provide financing to train their volunteers to ALS level of care and limit the number of vehicles on the road for any individual call. Prolonged scene times are a rarity. Meanwhile, New Jersey has not managed to learn from it’s sister states how to manage within the constraints of finances to advance its volunteer EMS system and limit public risk.

I suspect the current system in New Jersey, with the paramedic chase units, represents a product of local politics, limited funding, billable ALS care by these chase units, combined with a hold over from when New Jersey was predominantly farmland with long distances between medical facilities. Southern New Jersey is increasingly not rural. As such, the current system is only adding to the financial costs to townships.

I invite others who read this blog to discuss their volunteer systems. Specifically, how do your systems manage to keep the public safe, provide ALS care, while dealing with the economic austerity affecting all municipalities today?

Comments from paramedics I work within this system are pending. At their request, I will post their thoughts regarding this blog’s subject matter anonymously and without editing.

ADDENDUM: All comments received have been posted provided objectionable language was not included. I have made every attempt to answer as many of the comments posted as I can.

Thank you to everyone who has contributed!

Posted in ems-health-safety, ems-topics, funding-staffing, in-the-line-of-duty, patient-management, rescues, training-development, training-fire-rescue-topics, vehicle-operation-ambulances

Tagged , , , ,

67 comments Posted by on April 26, 2011

My Superstition about Compliments



I have become superstitious regarding compliments at work. Being an ED physician, “thank-yous” are certainly few and far between. Most of the time if someone approaches me from an administrative position or from another department with the opening line “do you have a minute?” or “do you remember that case?” my defenses go up immediately. Other ED physicians I have spoken to say they have the same reflex. It is rarely good news. Emergency Medicine is like being a race car driver. You are on a high-speed track and will eventually be stuck in the pit or hit the wall. Complaints and patient care issues are inevitable when facilitating care of a high volume of patients, usually under highly stressful conditions, often fatigued, while handling a wide range of patient acuity. So, I was ecstatic this past week when an administrator provided a back handed compliment. He stated that he had recently been contending with patient complaints in regards to the care provided by my colleagues and added that it had been a seemingly long time since anyone complained at all
about me. I should have known at that point in the conversation that I was a doomed!
>

The shift started simply enough. The full moon outside should have been my additional warning. I had gone to my computer station, cleared out charts that needed to be completed, and printed up the nurse’s sheet for the first patient of my shift. As I was standing at my computer terminal, to my left I overheard the voice of a very animated woman conversing across the desk to a nurse. I printed up the nurse’s sheet for the first patient of my shift, assured that by the time I came back she would be gone. When I returned to my work area, I noticed the increasingly boisterous woman still in the same spot, sandwiched between the suture cart, the desk, and me, such that she was essentially on top of me. In an attempt to be polite, I let her finish her discussion for several generous minutes. I attempted to focus on my documentation and execute a few orders.  I found it increasingly difficult to concentrate with this woman’s voice echoing from such a close distance. I finally turned to her and cordially explained that I would appreciate it if she continued her conversation a few feet down at the other end of the desk. She suddenly lashed out at me. “You are rude and inconsiderate!” “This is the worst hospital I have ever been at!” I tried to explain that this was my work area and explained I had to protect the patient data I was working with as required by law. She would hear nothing of it. I, on the other-hand got to “hear” all of “it” from the nursing supervisor twelve hours later! Apparently, the woman in question later contacted the offices of nursing administration to complain. The woman made it clear to the supervisor that she felt that I made the presumption that she was “white trash,” as she stated “because I didn’t have time to do my hair!” Not only that, but this woman actually recommended that I be slapped for making her feel that way. -And this was just complaint number one of the evening.

I wish I could say that my night improved much after that. The shift consisted of multiple patients brought in by police in handcuffs, crisis patients needing immediate psychiatric intervention, with several being exceptionally violent. I let the few less complex patients linger in the fast track area just to stabilize the escalating psych patients and appropriately manage those that were medically unstable. My plan was to subsequently move on to see some of the non acute patients in fast track.

I prepared to see a young woman with back pain and printed the nurse’s note. Figuring this would be an easy case, I quickly reviewed the triage information. Vitals all looked good and the narrative discussed how she walked from the waiting room down the hallway and into the room without difficulty. I then decided to take a quick look in our chart records to see if she had presented to the hospital in the past and if there were any further helpful details in her history regarding today’s complaint. Multiple presentations were present for dental pain and ankle pain, with prescriptions being provided every week or so for Vicodin and Percocet. I was suspicious but was going to give her the benefit of the doubt. I introduced myself from the doorway and immediately noticed an absolute discrepancy in her movement as compared to the triage note. She was ambulating with overt difficulty to such a degree that she could have doubled as a female version of Lurch from the movie The Addams Family.  Her movements were all slow, exaggerated, with hesitating motions, wincing and moaning. I obtain her complaint history and performed the physical examination.  Subsequently I explained  I wanted to get a few tests. I reassured her that based on the lack of risk factors for bony pathology, I expected the result would be a negative workup and most likely the diagnosis of lumbar strain. I added that we could most likely manage her well with some muscle relaxants and anti-inflammatories until she could she her doctor the next day.
>
“I’ve tried those, and they don’t work,” she responded.
I offered her a generous IM dose of Toradol, explained it’s benefits, and recommended subsequent doses of muscle relaxants as well. She scoffed at my suggested plan of care.
>
“You can see your primary doctor in the morning for further workup if we find no significant pathology tonight.”
“Can’t you give me anything stronger?” She asked.
>
I explained my concerns for the freqeuncy of presentations over the last several weeks, including multiple prescriptions for narcotics. I impressed once again that the discharge plan with Toradol would be effective and her primary doctor’s office could proceed with further management the next morning. The next few minutes consisted of the patient trying to convince me that my plan of care would not work because every medication I recommend was not strong enough. I finally had to excuse myself and proceed to other patients.
>
A few hours passed and the x-ray order column never lit up as completed on the computer terminal for this patient. I wondered what had happened.
The nurse’s narrative said it all. “The patient refused the x-rays and left.”   Furthermore,  I was rude and called her a drug addict!  While I did express concerns regarding the frequency that she had presented and received narcotics, the words “drug addict” never were uttered. Fortunately, during the patient’s stay she did provide a urine specimen for a drug screen. As I reviewed the result, I noticed that the patient was positive for opiates despite her claim that she was not taking any medication at triage. Do I believe I said anything in an even remotely rude manner? No. However, I then imagined yet another complaint for me to address with administration on the horizon.
>
Things continued along the same vein for most of the evening. It was as if the forces of darkness were out to squash what good graces I had left with that mighty administrative complement.
Several patients who were regulars with psychiatric histories were “holds” in the department. The nurses were approaching me with requests for pain medications for several of these patients. At one point, without my mentioning a patient’s name, I verbalized at the work station to a nurse how I didn’t want to write for any pain medications for one particular patient as I wanted a chance to reassess her. I explained without mention of identifiers how this particular patient is frequently in the ED for various complaints and has multiple psychiatric issues. For whatever reason, I immediately afterwards seized the opportunity to show a newly hired nurse nearby how to pull up old records on our chart documentation program. I proceeded to show her without verbally mentioning any names or identifiers, how to pull up old records using a patient for which she was the primary nurse. Several minutes later, this same nurse approached me a few minutes later stating “You know, that lady in room K thinks you were talking about her! I apologized to her for you!”
>
Great!  I new I was in trouble.
>
I reviewed the nurse’s notes and scanned the last several presentations. Sure enough, this woman had a psychiatric history as well as a substance abuse history.
Entering room K, the patient laid into me. “I have had a problem but it is taken care of!” I explained that I had not been speaking about her and she overheard a partial conversation not related to her at all.
>
“Miss, I don’t think I have ever seen you before. I only now accessed what is documented in your old records.”
>
I further explained that, as such, there was no way I therefore could have been referring to her. At the time, she seemed satisfied. Care was rendered appropriately. Nevertheless – a complaint was filed. While only a conversation was held without any identifiers at normal voice modulation at a designated work area, administration was alerted to a HIPAA violation complaint.
Lovely.

So there you have it…. I’ve become superstitious.

While I have had a black cat for years, along with a house number that happens to be 13, I never gave credence to superstition in the past. For now on, if I dare ever receive an administrative complement again I am going to immediately see if I can switch shifts with someone. Clearly such a happening is a sign for an ER physician that the forces of darkness are out to get him!

Posted in Uncategorized

5 comments Posted by on February 3, 2011

Hiding In The Nursing Lounge

Recently my feathers became ruffled when my nursing staff shared with me that two EMT students decided to sleep in the nursing lounge rather than to introduce themselves and “dive right in.”   Despite my nurses trying to “protect” these kids, I insisted on getting details and calling the EMT instructor to make sure hell was raised in class.  I requested that these students return to perform their observation time all over again.

The two nurses who shared with me the events of that day are angels.   Both were feeling incredibly guilty over “ratting out” these two kids.  They saw my anger upon my hearing about the total disregard for learning that was displayed.  “They aren’t learning to be fry cooks – they will be responsible for peoples lives!”  I explained to my nurses that the observation time provided to these students to see what the Emergency Department staff actually does is crucial.   The students need to be aware of what information we need, how we need patient histories presented, and how EMTs and Paramedics are our “eyes and ears” in the field.  The rotation is more than just about “watching,” it is about honing skills and gathering a feeling of what processes proceed upon their bringing the patients through our sliding glass doors.

Many EMTs that I have seen over the recent years lack effective communication skills.  The ability to communicate pertinent information in a concise and efficient manner is paramount.  In no other hospital environment does rapid transmission of data in an effective matter hold such a high priority.  Did the child have access to medications before he arrested?  Was the accident victim’s car displaying a spidered windshield?  How long ago was it that the stroke victim was last seen acting normally by his family?  There have been several occasions where I personally feel like pulling my hair out  trying to tease this data out of the rescue personnel bringing in patients.

I believe the solution to the effective data transmission problem is two pronged.  First, the minimal observation time in the Emergency Department needs to be extended to more than the minimum of ten hours with emphasis on patient presentations.  A rolling four-week rotation might make more logical sense, with students actively following a physician, physician-assistant, and nurse.  Secondly, minimal standards in language skills and public speaking should also be a requirement.  Testing should be mandatory to assure these skills are present prior to be entered into an EMT program. Failure to meet these standards represents a disservice to the EMT student and to the public for which they are training to serve.

ADDENDUM:

I have created a lot of conversation/controversy  with this piece as can be viewed in the comments.  There seems to be some general themes which I would like to share based on the responses.

First off, I wish to apologies to anyone who I offended with this blog post.  The intent was never to be insulting, but rather to start a conversation regarding the issue of  effective patient care reporting and student education.  I strongly feel that effective public speaking and communicating patient reports in an efficient manner is a paramount skill needed in the Emergency Medicine/EMS arena.   As such, all comments which were submitted, both positive and negative,  have been posted as of my logging in today on 1-19-11 at 1900 EST

For clarification to those who don’t follow my blog and expressed concern that I have no in-field experience, I was a New York City EMS provider.  I was initially stationed out of Bedford-Stuyvesant, (Woodhall Hospital) and subsequently out of Queens General Hospital  (worked a tactical unit) .   I have worked in the field in EMS for years (both public and private sector),  volunteer my time as a proctor for EMS examinations, actively teach EMT programs, and was a volunteer firefighter.  I have worked both the suburban and urban arenas.  I started this blog as an effort to promote positive change and as well as  advancement of Emergency Medical Services.

Of further note, a substantial number of the  nursing staff with whom I work are EMTs, flight nurses, and paramedics themselves.  We all put in a great deal of effort whenever an EMT student rotates through our ER to teach.   I have the students follow me on a rotating basis listening to heart sounds, breath sounds, and perform examinations.   We actively discuss and teach pathology .  The nurses help the students splint, take vitals, and assist in care.  We take our roles with these students very seriously.  We aren’t mandated to do this.   We do this because of  genuine concern for the education of these students and our patients.  In this context, I believe it becomes obvious why I was so angry regarding these two individuals who were found sleeping in the lounge.

To address some key points which were made:

1)  There are communication issues on both the hospital and prehospital side of EMS care.  As was noted in one of the responses listed below, most ED personnel are overworked and there are incidences where EMS personnel are ignored.   I agree that ignoring our infield colleagues is absolutely wrong.   A vicious circle, however, ensues.   ED staff who are met with ineffectively communicated reports  tune out the prehospital provider.  This, in-turn, leads to the prehospital care provider feeling unappreciated.   A negative feedback loop is created.

Since this blog is intended to discuss issues in prehospital/EMS care and look for solutions, my suggestion is that if you are dealing with a hospital environment where you or your staff are being ignored, discuss this with the ED nurse manager or ED director.   Find out how to correct this problem!  Offer ride-alongs.   Offer teaching in turn.  Meanwhile, the initial premise which I was trying to convey, being that of  assuring exposure to effective patient reporting to the EMT student, might be augmented by extended ED rotations and education in honing communication skills.

2)  The issue of pay and salary was raised by several individuals.  I agree that in many areas EMS isn’t even considered an essential service.  This is absolutely wrong and does need to be changed.  I have addressed this concern in a prior blog.  However, pay and the responsibility inherent to accepting a job where people’s lives are involved are two separate issues.   There are towns where police are paid horribly and their lives are constantly at risk.  Should they, therefore not protect the public?  Since the blog addressed two of my students who were caught sleeping in the nurses lounge, should police cadets who know they will be serving in poorly paid dangerous cities not bother to learn?  Obviously not.

3) Someone raised the issue of difficult staffing in volunteer squads.  This is a tough topic.   I would argue that maintaining a standard would be of greater value than pure staffing.

4) Another individual raised the issue of how, as a medical student, he routinely has to present cases as part of his training.   He referenced how little didactic coverage is included in the current EMT course work.  He makes a valid point! I would argue that this should be addressed in EMT core curriculum

5) For clarification, my statement regarding the need for effective communication skills does not imply being a native English speaker.  Being able to relay a concise detailed report with pertinent information is my concern.

I truly like the response from paramedic George

“It’s a skill that communication should be simultaneously efficient and effective. There are only benefits in seeking better cooperation between ER nurses and EMS. And between SNF nurses and EMS. Between any and all healthcare providers transferring care or working as a team. It’s everyone’s duty to keep improving their skills, for supervisors to support and encourage development of providers’ skills, including communication skills. Don’t wait until there’s a problem involving a patient outcome to recognize this. Thank you all.”.

Posted in ems-health-safety, ems-topics, training-development, training-fire-rescue-topics, Uncategorized

52 comments Posted by on January 19, 2011

EMS System in NJ

With permission – the following is an email from a paramedic with whom I have a great deal of respect for.   He and I have had conversations regarding the state of EMS in New Jersey.   Fear of reprisals from his employer is the reason his identity having been removed from this email.   This Paramedic has also discussed the number of other New Jersey paramedics with similar frustrations.  We have also discussed the issue of this individual coming on-board under an alias and using this blog as a conduit and public forum to help institute change to a very broken system.

This paramedic’s email follows:

Hey Jordan,

I thoroughly enjoyed reading your blog.  I can certainly understand your frustrations with the system since you are a direct recipient of the final product as the squads roll into the ED each and every day.  I myself am appalled by the way things are run, particularly in clinical oversight, education length and quality, as well as policies and procedures. Unfortuneatly, there is nothing, you, I, nor anyone at the Department of Health level can actually change, due to the restrictive legislature that gives us the authority to operate is antiquated and limiting in it’s wording, rather than being enabling and progressive.

What really blows my mind is that the system we currently operate in does not mandate any minimum standards for providers (mainly BLS, as ALS is in my opinion OVER regulated), does not require an ambulance to be licensed by the Department of Health nor meet any minimum standards, nor mandate minimum response times.  Better yet, EMS in New Jersey isn’t even considered an essential service like police, fire, and municipal services are.  It’s simply, sickening.

Like I told you, there is a bill that we are trying to pass which will overhaul the EMS system in NJ, and change A LOT of things.  This is in response from a outside consulting company that spent quite some time in the state, auditing the way our EMS system is running, and what we can do to improve it.  I have included a copy of the report as well as a copy of the bill, which is a response to the system report in this e-mail.  In a nutshell, the report stated that the NJ EMS system in a “state of near collapse.”

The main opponent to this overhaul bill is the New Jersey State First Aid Council, which we so affectionately call “The First Grade Council.”  I am thoroughly convinced that they are the sole reason EMS in NJ is so backwards and antiquated.  If they are allowed to maintain any type political or lobbying power, there is no way we can progress into the 20th century here, let alone the 21st century.  They oppose a two EMT minimum standard, increasing the amount of time an EMT class takes to complete (we’re trying to comply with the new National Scope of Practice with this bill), allowing the Dept. of Health full authority over the operation of an ambulance, as well as many other things.  Too many to list actually. However, if this passes, the Council will basically be rendered powerless, and we can finally move on, without them.

Here is a link to the TriData report that was done on the EMS system a few years back. Verrrry interesting.

http://www.state.nj.us/health/ems/documents/ems_study_report.pdf

Here is a link to the bill they want to pass.  They’re hoping to put it in front of the governor by the end of the month. But don’t hold your breath.

http://www.njleg.state.nj.us/2010/Bills/A2500/2095_I1.PDF

Here is a link to the website that all the stakeholders in the new bill setup in support of the bill.

On the “The Issue” page, there is a short commentated video that explains what the bill is going to accomplish.

http://www.supportnjems.com/

I hope this gives you some interesting reading.  Talk to you soon!

->Signature and Name withheld.

Posted in 911, ems-health-safety, ems-topics, healthcare reform, patient-management, training-fire-rescue-topics, Uncategorized

10 comments Posted by on January 10, 2011

Time for Intelligence in Implementing EMS

During the recent snowstorm, the governor of New Jersey declared a state of Emergency closing all roads to nonemergency vehicles.  As luck would have it, I was on shift at one of the hospitals where I work.  My colleague received a call from a local EMS squad.   A stabbing was inbound.   The EMT on the phone relayed no valuable details except she didn’t care how bad the wounds were. While she hadn’t even arrived at the scene yet, with the weather being bad as it was, she was coming to us  “no matter what”.   The hospital where I worked that day is a small community hospital without in house surgery, no trauma team, and a physician staff for the entire hospital that evening which probably consisted of two ER physicians, an anesthesiologist, and two hospitalists.   Several miles down the road is a larger hospital with significantly more resources.   While the above vignette alone can generate significant discussion, this is only one item in my ire over local prehospital care

The literature is full of studies how the Europeans will actually divert ambulances with acute MI patients from local hospitals to those with catheterization labs.  Two Emergency Physicians whom I enjoy listening to on their Emergency Medicine literature review CDs, Doctors Jerry Hoffman and Richard Buckata, not long ago discussed how patients having acute coronary events in the driveways of European hospitals would be told not to unload their patients, travel to the next facility with the appropriate interventional resources, and how much better the outcomes are for these patients.   This is certainly not the practice in the region where I work.

Where is the logic of a pediatrician sharing in clear language her high clinical suspicion for acute appendicitis in a child with an EMS team and then those same EMTs making the decision to bring that child to a hospital without pediatrics or pediatric surgery?  This defies any logic.  What is accomplished?  Delay in definitive care, added unnecessary expensive, additional transport time, and psychological trauma to the child and her family.

At another hospital where I also work, local EMS squads historically will ignore bypass requests.  Responses by EMTs to questions regarding their rational for ignoring critical care divert and bypass requests as the nurses share with me that they have run out of pumps and cardiac monitors, “The patient insists on coming here”.  Other responses I have received from these same EMTS and medics as they bypassed two and three hospitals (incidentally, all within the same hospital system with the same physician groups) on their 25 mile trek to this particular hospital are “ divert is a courtesy request only,” and, this is my personal favorite,  “ we don’t want to be accused of kidnapping patients”.   Kidnapping patients? ! I understand completely that while on divert a hospital cannot expect all EMS inflow to stop and critical care patients will still arrive. Bypassing multiple hospitals that aren’t overwhelmed due to a family request is endangering ALL patients in that ER – including the one being “Kidnapped!” When someone is calling 911, they are calling for a rescue service and not a taxi ride.  Of course, I should share that this problem has been partially “solved.”  Many hospital administrators regionally are refusing to allow the ED Attending physicians to warn EMS squads of strained resources by forbidding bypass requests.

I have been in the streets myself for many years working for EMS systems.  I helped pay my way through school working in Brooklyn and Queens. I am very proud of my background with New York City EMS.  I am currently actively involved in EMS education.  Hence, I don’t believe anyone can say I do not know what I am talking about in regards to “being in the field.”    Under most circumstances, when I worked in New York, you were taken to the closest hospital.  No “special trips” taking a rescue unit out of it’s assigned region because the family likes the décor at a different hospital better.  It was simple.  Burns?  Burn unit.   Trauma?   The nearest trauma hospital. If the local hospital in our “PAR” was over whelmed, we tried to “share the burden” with the next closest facility

Going back to that snowstorm shift and the trauma patient, the blade missed the femoral artery on CT angiography.   The child who had been taken past a facility with pediatrics by local EMS had no difficulties in being transferred to another pediatric surgical hospital by ground three hours later after I had back all the studies to make a convincing argument to the surgeon at this other hospital to accept transfer. CT confirmed acute appendicitis.  As far as the local roads were concerned that night, while I am sure some portions of New Jersey were hit hard, I enjoyed listening to Jimmy Buffett on the radio as I took my time driving the some odd twenty-five miles home in my car without any difficulties.

Posted in 911, command-leadership, ems-health-safety, ems-topics, patient-management, special-operations, training-fire-rescue-topics

4 comments Posted by on January 1, 2011

Christmas Eve in the ER

As my thirteen year old daughter would put it,  “it bites” being stuck working on Christmas Eve in the Emergency Department.  Considering how busy we normally are on a typical work day, the fact that I am able to sit here with the nurses at the computer typing this entry I find thoroughly amazing.   Since 2:00 pm today, my staff and I have been keeping a tally of what pathology has shown up so far.  The tally is as follows:

1 ) Varicose vein that bleed and stopped bleeding  before arrival.   Bandaid applied

2 )Elderly lady.  Syncope in the closet.   Etiology unclear.  Admitted

3 ) The diabetic husband of the elderly lady who fell into the closet (see #2 above)  felt his blood sugar was low while trying to pick his wife up out of the closet.  Sandwhich provided.  Discharged

4 ) A nonbleeding, nonthrombosed hemorrhoid.  Tucks Medicated pads suggested. Discharged

5 ) A chronic alcoholic who was brought in because feeling short of breath for days.  Medics described new onset afib.  Turned out to be an MI who had already “Qed” out inferiorly.  Transfered to facilitiy with cath lab.

6 ) Cardiac Arrest in a cardiac transplant patient.  (Horrible!   Trying to be nice, we shut off all the Christmas music until family left)

7 ) toothache

8 ) Back sprain after a motor vehicle accident

9 ) A scrotal bleed (Don’t ask.  Really.   Just don’t)

10) Intoxicated alcoholic

11) A panic attack

12) A violent patient with dementia arguing with my 5 foot ED colleague.   Demented patient won!  (Staff taking bets at nursing station whether five foot tall doctor would win.  Not so much. )

13) An ankle sprain.

14) Another toothache.

15) Another minor MVA

16) “I’m out of town and I am out of my oxycodone, percocet 15, ambien, and lorazepam”    Discharged unhappy

17) Packing removed from a recent I&D of an abscess

18) STD check (really? On Christmas Eve?   Yep .  You have one! Discharged.  Really.  Pun intended. )

19 -22) Assorted lacerations.

23) Knee sprain from three days at work. ( Just ask for the work note!  You told us you were do in and we saw you walk into the ER without a problem. )

24) Shingles out of meds.

25) Another alcoholic psych patient.  Every racial slur .  Where is my five foot physician colleague?  This has his name all over it.

26) MVA  – refusing evaluation.  Brought in by BLS

27)  Chronic back pain – seen recently.   PMD won’t treat pain.  “Nobody understands me”

28)  Another drunk. “I want to go to Kosovo so I can fight for my country….I want to be a hero…..I don’t know where Kosovo is….do you know?”   Patient can barely stand up straight let alone be trusted with a rifle.

Thus, in an Emergency Department which has a volume usual of 120 patients or more a day, since 2:00 pm today, that is our total census.  Of this census, 5 via ambulance  total.

I dare say that after the salt ladened ham, seven fishes, alcohol, and over eating, none of us will be able to make a similar entry tomorrow.

Merry Christmas to everyone from my staff and colleagues at the Emergency Department!

ADDENDUM:   The above represented the time window from 2pm to approximately 8pm.    The ER exploded at about 9pm.  There were probably more police with people in custody in the ED that night than were manning the local stations.  The psych unit exploded.

As I head in to work now, I expect no different.  The doctor’s offices have been closed, those that should have been in yesterday probably have delayed to the point that they can’t hold out much longer, and, of course, the usual weekend crowd.

Posted in ems-topics, patient-management, Uncategorized

No comments Posted by on December 24, 2010

The Free Taxi Ride

Years ago I was working with New York City as an EMT out of Queens General Hospital.  I remember being in shock after picking up an otherwise non-ill appearing man who gave a complaint that I currently cannot recall.  We took him in a city ambulance to the local hospital.  The part that shocked me was that he never entered the hospital.  He thanked us and proceeded to go across the street to do his shopping. He never was sick and never intended to enter the ED doors.   We served as free transportation for him.   He expressed no qualms regarding his actions.  The only conclusion I can draw today was that, in his eyes, it cost him nothing.   He was able to get away with it.   He had a complete disconnect not only from the ethical issues of what he did, but the costs being eaten by the city government for the taxi ride.

The same issues apply daily in the care I provide in the Emergency Department.   There are multiples of patients who use the ED as primary care who are donning the latest Iphones, wearing expensive leather jackets, downed in expensive Aeropostel and Uggs clothing.  They are at a lost when I ask them who provides their primary care.  “I just go to the hospital!” Attempts to explain to these people the importance of routine primary care by an appropriately trained individual falls on deaf ears.  They will openly admit that the use of clinics and primary care facilities will cost them money.  They have nothing in the game.  Hence, using one of the most expensive forms of medical care, which often isn’t the best care, continues to be used and abused.

I recently questioned an administrator regarding the potential logic of opening up various clinics.   Perhaps a pediatric clinic on Tuesdays staffed with board certified pediatricians, Wednesday an adult primary care clinic staffed by Internists, and so on.  It seemed like a perfect solution to me to guarantee good follow up with individuals most appropriately trained to assure convalescence and preventive care.  “We looked into this, and financially it isn’t viable.”  In other words, my translation of this statement is that the hospitals can collect more state money for emergent care for non emergent patients than they would receive if they set up and established local clinic care.  Follow the dollar signs.   The current government bureaucracy continues to do a disservice to the very individuals they are supposed to protect.

Emergency care being a safety net and providing primary care is something that will never end.  However, I wonder how much general abuse would stop if the general public had to send in their taxes monthly rather than not realize that they are disappearing from their paychecks until April 15th.  In other words, each month a payment would have to be sent in no differently than a payment to a cell phone carrier.  The statement of “let the government do it” would be reconnected to the concept that the government is us.  Abuse local services? – Your taxes go up.   Your monthly payment to the local government-taxing agent goes up.   Don’t pay?  Sorry – your garbage will no longer be collected.  Don’t pay?  Sorry, your mail service stops.

Will this ever happen.  Of course not.  Still, free taxi rides are destroying the system.

Posted in 911, ems-health-safety, ems-topics, healthcare reform, patient-management

Tagged , , , , , , ,

10 comments Posted by on December 22, 2010

The Perception of Care Versus Quality of Care

Recently, I received a letter “Thanking me” for servicing my car at a local dealership. Scripted words stated how they were looking forward to my having a “fantastic” ownership experience indicates that I will be receiving a survey in the mail. It is obvious that the dealership, based on guidance from the outside survey firm, hopes that these key phrases will become embedded in my mind as I fill out their forthcoming mailing. I believe that I am like most people and throw most of these surveys away. The real motivators for my paying attention to these flyers and letters is either boredom, frustration or, rarely, anger. The later usually generates from me a letter and a phone call.

The reason for bringing up this topic of surveying and scripting has to do with how their use has permeated hospital care. The staffs in most ERs are now taught to use scripting during all patient encounters to help boost scores on subsequent third party surveys. The phrases sound artificial and forced to my ear. I was raised by my parents with the adage that “actions speak louder than words”. Hence, with the amount of effort my colleagues, staff and I display in our patient care, have to state these phrases (referred to in the lexicon of these companies as “key drivers”) seems very disingenuous. I use them as has been requested of me. However, this is not my prime concern with the current means of surveying acute hospital care. Being polite and courteous is something that everyone should expect. I try to be such in all my endeavors, including my work as an Emergency Medicine physician. In this regard, I absolutely agree with these surveys. There are a variety of issues which I see developing from the over reliance and misapplication of the survey data

Roses and gift baskets often stream past me in the ER to the nursing station in the ICU. In a recent case, a 45-year-old father of three that we sedated and intubated on arrival in fulminant cardiac failure remembers nothing of his ordeal in the Emergency Department. Near death, my colleagues and I performed as we were trained and delivered excellent care. This patient woke up in the intensive care unit. No survey for the care we provided in the ER will be generated for this individual. Any collected data will reflect strictly the care provided in the Intensive Care Unit. Interestingly, this is precisely the type of patient that is central in the curriculum in Emergency Medicine residencies. In other words, the Emergency Department is ignored in surveys for providing the type of care the physician staff is most qualified to provide.

Recently, a physician assistant confided in me that her department head at another emergency department chastised her. She explained how she was trying to explain to a young, otherwise healthy patient with a viral illness that antibiotics are thoroughly ineffective for her and can actually be harmful. Apparently, a negative survey or phone call was the product of her trying to practice good medicine. She was told that in the future she was to provide these medications whether indicated or not because that is what the “customer wants”. The “hospital is running a business”. Her experience is not a unique vignette. This type of patient represents the focus of many of these surveys. Urgent and nonemergent patients, often with an expectation of rapid “one stop McDonald’s shopping” for care and an expectation of an immediate “cure”, often receive these surveys in the mail. Combine the acquiescing to patient demands for unnecessary tests and medications despite it being poor medicine, with the push to rapidly see and discharge low acuity patients, inappropriate and substandard care is often being provided. Unnecessary and repeat studies involving ionizing radiation, especially to children, often occur.

Television shows have given the public the belief that Emergency Departments have specialists just waiting to come out of the back room to solve any problem at a moment’s notice. Not only is that not true, but also patients have no idea what Emergency Physicians are trained to do or their fund of knowledge. It is not a uncommon experience for a patient with a chronic, nonacute illness to show up in my emergency department which has confounded their specialist. Obviously, my two weeks of residency training, for instance, in dermatology, is not going to swiftly provide an answer for such a patient. After potentially multiple hours waiting to be seen, these patients are often unhappy being informed that I will not be able to answer their concerns.

To push up satisfaction scores, narcotics are being administered and prescribed with increasing frequency regardless of the true nature of the injury or complaint. I have witnessed my colleagues prescribe Percocet and other narcotics often without checking to see how many times in the last six months an individual showed up with the very same toothache. Addiction is a large enough issue already. As mentioned before, the push to move patients through rapidly and to drive up survey scores is only adding to this problem.

Another failure of the current hospital survey system has to do with morbidity and mortality reports published in various magazines and newspapers. To the layperson, one surgeon may inappropriately be seen as a “butcher” or a hospital may seem “like a death trap”. Not taken into account is how many of the more aggressive, higher quality surgeons will take on more difficult case with, as a result, higher morbidity and mortality scores. Usually, these highly skilled individuals are located at teaching and university hospital settings. Often, they do not have a choice to accept these transfers from community hospitals. These surgeons and institutions end up being penalized in the public’s eye in published websites and print media. Their community based potentially less skilled counterparts appear better in the public eye in these publications.

An entire industry has been erected to measure the public’s perception of services offered by various forms of business. Unfortunately, the survey industry’s product doesn’t translate well for specific niches in healthcare. Emergency services selects for a unique “customer” base. This customer base is comprised of the truly ill and the desperate, those who have no where else to turn for care, as well as those with poor coping skills and a naiveté regarding emergency care realities and, on occasion, those with secondary gain interests. What is being measured is the perception of quality in care and not quality of care. The survey industry has duped the hospital administrators who are trying to promote their “businesses”. Kind, considerate, thoughtful care, with a focus on the patient is absolutely paramount. Inappropriate prescribing of antibiotics and addictive narcotics, exposure to potentially harmful unnecessary studies, especially in developing children, as well as further straining an already economically burdened health care system are just some of the products of blinding following these surveys. The survey industry has duped hospital administration into believing that the same system used to evaluate customer service at my auto dealership translates to all niches of hospital care. Obviously, it doesn’t. Blind focusing on these surveys without true reflection on their source and meaning will lead to many patients becoming victims.

Posted in ems-topics, healthcare reform, patient-management

Tagged , , ,

2 comments Posted by on October 29, 2010

Emergency Department Overcrowding

I found the following on a general search for a project I’m working on. Interesting points. The google search simply led to a download with no listed author. If you know who wrote this, please let me know!

Emergency Department Overcrowding: Right diagnosis, wrong etiology, no treatment

There’s been a lot of hoopla about the phenomenon of emergency department overcrowding in recent years. This has been an issue worthy of Time magazine, CNN, and Nightline. Do we know the solutions? Are we on message? Or have we done ourselves harm?

Emergency departments are overcrowded because of the large number of patients seen in the ED who could better be seen elsewhere.

Wrong! Count the times you left work thinking “Gee, if only those acne cases hadn’t come in, it would have been an easy day.” Sore throats are not what grind our system to a halt. Admissions are. Admissions fill our examining rooms, and fill our hallways. Treatment of heart attacks is not delayed because of sore throats. Treatment of sore throats is delayed because of patients with heart attacks, who may “enjoy” a substantial portion of their hospitalization in our hallways. Any delay in the treatment of the next heart attack entering the emergency department is due almost solely to the previous heart attacks, pneumonias, and traumas already admitted, but still remaining in the emergency department and consuming staff time, space, and resources.

The narcotizing notion that overcrowding is caused by sore throats and the flu suggests that the problem is temporary, and that the problem is not a hospital problem. The popular issue of the “unnecessary” ED visit has so overtaken the ED as a topic of discussion that one forgets that we actually see sick patients. It is an issue seized by the legislature and all the insurers of the land, both of whom know that one guy from Kansas who was on his tractor when an airplane crashed into him represents the only appropriate visit to the nation’s emergency departments in 1999.

Thank God for the TV show, “ER.” At least they get it right – the patients are sick, and the personal lives of the staff are a mess. The next ED physician who walks to the podium to talk about overcrowding caused by the healthy happy masses looking for a good time in the emergency department should get a nice little curare dart in the deltoid. We see sick patients and make people’s lives better, and we’ve made a big damn mess of letting people know that.

When the emergency department is truly overloaded and cannot provide care to further patients, the hospital can divert ambulances to other area hospitals.

Wrong! If our emergency department is full, so are the other area emergency departments. In some areas, there IS no other emergency department for miles. In some regions, entire hospital systems run at over 100% occupancy for months on end. If you’re full and they’re empty down the street, they must have a pretty scary ED.

When the emergency department is truly overloaded and cannot provide care to further patients, the hospital can transfer patients to other area hospitals.

Wrong! As noted above, entire regions can be overloaded with patients. The act of attempting to transfer a patient, should the patient agree to transfer, can literally consume hours of staff time in phone calls and paper work needed to arrange for the transfer of a patient to another facility. A nice swig of Ipecac is more palatable. An ED full of admitted patients is already out of control, pushing staff beyond their capacity to provide adequate care. In such circumstances, one can ill afford the time required to arrange for transfer.

When the emergency department is truly overloaded with admitted patients, the hospital should call in additional staff to provide care for these patients.

Wrong! A substantial number of emergency departments cannot fill positions needed for routine staffing of the emergency department, much less call in additional staff. In most places, additional staff simply does not exist. This sort of policy is another one of the “we tried we failed” policies which allows someone to show they really care. Of course, the proper staff to call in for admitted patients would be in-patient nurses and in-patient physicians, not additional ED staff. If you enjoy funny and contorted expressions on people’s faces, and want to test your job security at the same time, suggest that at your next medical board meeting.

When the emergency department is overcrowded with admitted patients, elective admissions should be canceled, and elective surgery should be rescheduled.

Wrong! First, the era of “elective admission” is no more. Patients get admitted to the hospital because they are acutely ill. Minor surgery has moved to the ambulatory setting. Also, the patient with the “elective” cholecystectomy has committed to detailed arrangements with work and family prior to undergoing the procedure. The “elective” surgery or procedure, such as cardiac catheterization, not performed today becomes the “emergency” procedure of tomorrow. In some regions where hospital occupancy runs chronically at 100%, following this rule would simply eliminate all elective procedures on a permanent basis. Since most patients admitted to a hospital are medical patients, this also allows the department of medicine to shut down the department of surgery. Thus, the best way to implement this policy is simply to declare that all surgery is emergent. In fact, admit them to a hallway bed in the emergency department.

Admitted patients held in the emergency department cannot be moved to the inpatient service until a bed is available.

Wrong! There’s far more square footage and hallway space on the in-patient units than in the ED. Don’t like the hallways? – Use conference rooms, waiting rooms, sunrooms. Put the patients on the wards where the appropriate nurses and physicians providing in-patient care exist. Spread out the overcrowding problem. Let multiple units absorb a small part of the larger crisis. If the patient is to be stuck in a hallway for lack of beds, why should they care which hallway they’re stuck in? Who doesn’t believe that beds would be found quicker for these patients if they were moved onto the units? Every objection to placing patients in hallways on floors pending a bed also applies, in spades, to the ED.

Can’t do it? There is no JCAHO policy that gives the ED hallway special status. We’re not Stonehenge. Bring in you local structural engineer to demonstrate the surprisingly observable fact that the ED is not built out of rubber bands that can infinitely stretch to provide never-ending space. They might also be able to point out the similar amenities available in any hallway, regardless of location.

If your hospital has a full-fledged OB department, take your administrators on a tour of the OB ward, that “other” area of the hospital with the magic rubber-band hallways. Ever hear of an OB department that refuses a woman at the door in labor because of lack of space? Ever hear of an OB department calling the ED to let them know that the OB ward is taking a “time out”, and for the ED to play obstetrician for a while? Ever hear the OB chief suggest that you keep the woman in the ED and let her deliver in the hallway? (I have no doubt that someone reading this probably has had this experience, but I think the exception proves the rule.)

Of course, one could always find more available beds if only change-of-shift came more often.

Admitted patients should receive the same standard of care, regardless of their location in the hospital.

Wrong! How many times have you held your fifth or sixth ICU patient in the ED (without additional staff, of course) when the ICU won’t take a patient because it would mess up their “staffing ratios”? Where is the in-patient physician specialist? I mean, sure, we’re good. But who wants to pretend that we are the equal of the specialist in providing specialty care to in-patients (assuming, of course, that we had the time to stop and do so)? Where is the in-patient nurse specialist? Where is the warm food and the discharge planner?

The worst perversion of this requirement is forcing the already overtaxed ED nurse to complete a 10-page comprehensive admission form on all patients admitted but held in the ED. This has four measurable effects. First, the ED nurse is pulled away from providing real care to emergent patients, and is instead completing mind-numbing admission forms. Second, the in-patient unit, which now will not have to complete the form, is rewarded for whatever delays they have contributed to the obstruction to moving the patient to the in-patient unit. Third, the primary nursing provider on the in-patient unit never has to really get to know the patient, since the ED already does all the paperwork. Fourth, the patient doesn’t benefit from this – not even a tiny bit.

Currently, the only way to truly implement this policy during ED overcrowding is to move all of the in-patients out of their rooms into the hallways and have their treatment rendered by someone other than their personal physician. Now you have a uniform standard of care.

The hospital should have a policy to facilitate early discharge in circumstances where the emergency department is holding admitted patients.

Wrong! Well, they may have a policy. But a well-run hospital is going to have early discharges anyway. Of course, “early” can be interpreted as “shortly after the afternoon change of shift”. What incentive is there for the in-patient staff and admitting physician to disrupt THEIR day when the emergency department can so easily bunk patients in the emergency department? Why spread the “mess” to other areas, when it’s so nicely contained in the emergency department? All the more patients to fill out those patient satisfaction surveys!

Sudden and unusual ED overcrowding gets everybody’s attention. But when it’s a day-to-day phenomenon, “disaster fatigue” sets in, and it becomes simply business as usual. Others don’t care, not because they’re uncaring, but because, as long as patients can be held in the ED, it’s just not their problem. This reflects institutional culture, not individual preference. I don’t involve myself in the problems of the operating room, or whether or not warm food is delivered to the OB suite. Why? Because it’s not my problem. Why does OB take any woman who presents in labor? Because they believe that this is their patient, and it is their problem. Unless admitted patients are delivered to the floors, bed or no, the problem will remain ours.

Of course, this doesn’t preclude meetings to discuss the problem, get the data, look into different options, and have further meetings. That’s why the “C” in CQI stands for “continuous” and not “completed.”

We should quit discussing solutions that don’t work, because they impede the implementation of solutions that CAN work.

Well, of course! The solution to ED overcrowding is to get rid of the crowd. Admit them and put them on an in-patient unit. Get JCAHO to mandate it. Clearly, nothing else has, will, or can work.

Posted in ems-topics, patient-management

Tagged , , , , , , , , ,

1 comment Posted by on October 23, 2010

Advancement of EMS Oversight For BLS Arena

Beginning January, 2011, a Medical Director is required for all ambulance services in the Commonwealth of Pennsylvania. Additionally, the ability to contact Medical Command is required of all ambulance services as well. This seems as if we are heading in the right direction regarding oversight. Up until now, AEDs were optional for BLS ambulance services. The mandate that they are onboard has prompted the need for having a Medical Director. Hopefully, this will generate some quality control. Hopefully, this will not be a localized step forward in one individual state.

Posted in ems-health-safety, ems-topics, fire-rescue-topics, training-development, training-fire-rescue-topics

Tagged , , ,

No comments Posted by on October 23, 2010

EMS After 911: The State of Prehospital Care

Recently, I was offered an opportunity by the Burlington County Health department to serve on the New Jersey Medical Reserve Corps. The New Jersey Medical Reserve Corps is an outgrowth of the national mandate for disaster preparedness from the September 11th terrorism attacks.  This offer and the ninth anniversary of the terrorist attacks caused me to reflect on the realities of the preparedness of our current medical system in the event of another disaster.

The laundry list of the number of hospitals that have closed in the recent past in the Philadelphia region, where I practice, is outrageous.   Neumann, Parkview, City Line, Northeastern and The Medical College of Philadelphia are just a few names which come to mind.  A large result of these closures is a result of the red ink of insolvency.  I’m absolutely sure these hospital closures are not a unique event to my local area of practice as an Emergency Medicine physician.   Combine the number of hospital closures, the overcrowding of Emergency Departments and the treatment of the concept of “divert status” as taboo by hospital administration, the question arises, what would happen if another plane was hijacked and flown into a city center?

My grim view of our post 911 state of affairs for emergency medical services is further compounded by my perceived changes in pre-hospital training.  In the 1980s, in New York State, I was an Emergency Medical Technician. New York required my sitting for a recertification exam every two (2) years.  As an Emergency Medicine Physician, I am required to take a recertification exam to maintain my board certification status on a regular basis (Every ten years a proctored written examination, eight out of ten years online examinations based on materials from mandated articles, amongst other requirements). This same level of certification which assures a minimal standard of knowledge appears not to be required by the rescue personnel that we depend on.  Random continuing education credits, without assurance to their content, have replaced the reinforcement and assessment of basic skills and knowledge in many jurisdictions.  It seems as if the retention of personnel has become more important than the quality of the volunteer system.

While appropriate triage and scene command is a central subject discussed and taught in EMT programs, I see and hear of numerous hospital systems where the local EMS personal lack an understanding or a willingness to practice this act.  If local squads have no understanding that bringing ten to twelve auto accident victims into a single coverage community hospital concurrently at three in the morning, without sharing the burden with other nearby local hospitals, effectively shuts down that Emergency Department, what will occur with a major disaster?  Perhaps the overall problem is a refusal of a central government agency to take ownership of the volunteer EMS system.

My experience has lead me to believe that most metropolitan systems have mechanisms in place to contend with the volume resulting from a mass casualty incident. The only volunteer system I have personally witnessed years ago that centrally managed triage well was Nassau County, New York.  Back in the 1980s, I was a volunteer fire fighter and EMT with the Garden City Park Fire Department.  Routinely, our ambulances would call into Nassau County Medical Center with our patient reports, were given medical command, and were diverted and directed to a destination hospital based on a variety of factors.  In essence, “NCMC” not only oversaw the medical care provided, but also served as a “traffic control center”.  At least this region had, and hopefully still has, the mechanisms in place to handle the volume associated with a large calamity.

It seems as if the overall system for Emergency Medical Care is in need of reinvention.  A centrally controlled scene command, an assurance of minimal skill and proficiency for EMTs and first responders, and an ability of hospitals to have a built in cushion to absorb patients, are all core components of an effective disaster preparedness system.  This reinvention must be realized on a state or regional level.  Failure to address these issues could prove disastrous in the future if such circumstances ever reoccurred

Posted in 911, command-leadership, ems-topics, fire-rescue-topics, major-incidents, news, patient-management, rescues, training-fire-rescue-topics

Tagged , , , , , , ,

No comments Posted by on October 23, 2010