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Emergency care and emergency care research
Jesse M. Pines, MD, MBA, MSCEAssociate Professor of Emergency Medicine and Health Policy
George Washington UniversitySeptember 27, 2010
Demographics
Quality of emergency care
Future directions
Overview
124 million ED visits in 2008 (CDC)
Demographics of emergency care
Who are all these people?
Myth: ED patients are just poor and uninsured, there for minor ailments that could have been treated by a primary doctor
Demographics of emergency care
Realities
◦ Most ED patients have insurance (CDC)
◦ Recent increases in visits by Medicaid & uninsured patients (JAMA 2010)
Demographics of emergency care
Realities
◦ According to most recent estimates, on 8% of ED visits were non-urgent
Demographics of emergency care
Why increased visits?
◦ Primary care access Higher visit rates for
Medicaid, Uninsured
◦ Appeal of the ED One-stop shop Comprehensive service
◦ EMTALA
Demographics of emergency care
At what cost?
◦ Cost of an off-hours visit is no higher than a PCP (NEJM 1996)
◦ There may be few economies of scale (Ann Emerg Med 2005)
◦ But certainly, the “price” is higher
Demographics of emergency care
At what cost?
◦ More gets “done” in the ED
◦ There is a balance Sometimes diagnoses
that are “missed” in doctors’ offices are diagnosed in the ED
Demographics of emergency care
But EDs are a victim of their own success
Higher demand + Less Space = ED crowding
Demographics of emergency care
Demographics of emergency care
•
Crowding matters
◦ Longer waits◦ Poorer quality◦ Higher
complications◦ Boarding
Higher medical errors
Higher mortality rates
“The state of emergency care affects every American. When illness or injury strikes, Americans count on the emergency care system to respond with timely and high-quality care. Yet today, the emergency care and trauma care than Americans receive can fall short of what they expect any deserve.”
- Harvey Fineberg, MD, PhD, President, IOM 2006
Institute of Medicine Reports…
“The state of emergency care affects every American. When illness or injury strikes, Americans count on the emergency care system to respond with timely and high-quality care. Yet today, the emergency care and trauma care than Americans receive can fall short of what they expect any deserve.”
- Harvey Fineberg, MD, PhD, President, IOM 2006
Institute of Medicine Reports…
Building a 21st century system◦ Coordination, Regionalization, Accountability
ED & hospital flow◦ Boarding of admitted patients
Health information technology◦ EMRs, Interoperability
Workforce issues Disaster preparedness Emergency care research
The breaking point
The importance of quality (Romano)
The importance of timing (Carr)
Clinical focus: CO poisoning (Iqbal)
AHRQ’s emergency care portfolio
Large variety of case-mix
◦ Quality of care means something different to different people
◦ Depends on why you’re there
Focus on quality
Simple approach
◦ Deliver the right care, in a timely, patient-centered manner, and don’t send home anyone who you it apparently “ok” but turns out later to be really sick
Quality of emergency care
Value propositions of emergency care
◦ America’s 24-7 One-stop healthcare shop
◦ Convenience is patient-centered, but may not make anyone healthier or extend life
Real value
◦ Timely diagnosis and treatment of acutely ill Americans reduces morbidity and mortality
◦ This resource is available to Americans 24-7, regardless of the ability to pay
Emergency care research: Future
Trauma outcomes are similar at night and during the day, ?better on weekends◦ (Dr. Carr)
Delays in diagnosis is associated with poor outcomes◦ SAH, AMI, Stroke, Trauma
The future◦ Understanding the relationship between
timeliness and outcomes for more “urgent” conditions
Timeliness and outcomes
Proliferation of testing◦ Increased rate of abdominal CT in EDs◦ 2001: 10%, 2005: 22% (Pines Med Care 2009)
The future
Testing rates v. Missed diagnosis
Resource Consumption
Minimizing misses
Fixing the emergency care system
◦ Within the ED
Ensuring evidence based best-practices Streamlining operations Optimizing clinical service delivery
Moving beyond associations…
Fixing the emergency care system
◦ Between the ED and hospital
Reducing boarding Improving care transitions
Moving beyond associations…
Fixing the emergency care system
◦ Among EDs and hospitals
Regionalization of emergency services Coordination of care at the community-level
Moving beyond associations…
Fixing the emergency care system
◦ Between the ED and outpatient system
Sharing data, reducing duplicate testing Improving care transitions, coordination Reducing avoidable admissions by creating
alternative pathways Reducing resource consumption…safely
Moving beyond associations…
Interventions to Assure Quality in the Crowded ED
◦ Co-Chairs: Jesse Pines & Melissa McCarthy◦ Marriott Boston Copley Place◦ June 1, 2011
2011 SAEM Consensus Conference
Interventions to Assure Quality in the Crowded ED (Boston, June 1 2011)
◦ Review interventions that have been implemented to reduce crowding
◦ Identify strategies within or outside of the healthcare setting that may help reduce crowding or improve the quality of care during episodes of ED crowding
◦ Identify the most appropriate design and analytic techniques for rigorously evaluating ED interventions
2011 SAEM Consensus Conference
Questions?
