Emergency care in some states in critical condition,’ warns ACEP’s report
Publication identifies barriers to improvement in key areas
The national emergency health care system is in serious condition, with many states in a critical condition.
This warning jumps off the page from the first-ever "National Report Card on the State of Emergency Medicine," just released by the Dallas-based American College of Emergency Physicians (ACEP). The report covered all 50 states and the District of Columbia.
This main "headline" surprises no one intimately involved with emergency medicine. What may be particularly disappointing, however, is the fact that not a single state received a grade of A, and the vast majority received a C. (See list by state, below.) The national average grade was a C-.
The ACEP Report Card scores each state in four main categories: access to emergency care, quality and patient safety, public health and injury prevention, and medical liability environment. It then assigns an overall state grade of A, B, C, D, or F. The report was compiled from data collected by health-related groups such as the American Medical Association and the American Hospital Association, federal agencies, and state governments.
For ED managers, however, it is only by digging beyond the overall grades that they will find the most valuable information, according to those most familiar with the report. For example, a state may have a high overall ranking compared with the other 51 states, yet lag woefully behind in one particular area. It is only by studying the numbers behind the grades that they will learn — or confirm — the greatest threats to quality emergency care in their state, they say.
"Each state should be looking at where they scored well and where they scored poorly, and maybe the reasons for doing so in each specific area, and use that to learn where they need to improve," says Bruce Bonano, MD, an attending emergency physician at Bayshore Hospital in Holmdale, NJ. "Or, more importantly, give it to their legislators in order to help improve the emergency medical system."
It’s about the system, not the staff
This report is not an indictment of the personnel that staff EDs, but how the system of emergency care in the state is lagging or forging ahead in providing better service, say industry sources.
Another issue in the report is that there are many forces at work impacting emergency care that have very little to do with how well or how poorly ED managers and their staffs perform. "This is an effort to try to get our arms around some very large problems, most of which extend beyond our direct control," says Wes Field, MD, FACEP, a member of the emergency medicine clinical faculty at the University of California Irvine, past chairman of the board of California Emergency Physicians, based in Emeryville, CA, and a member of ACEP’s Report Card Task Force. "It’s an attempt to start to control quality at a level beyond emergency department care."
This report is a "road map for change," asserts Roneet Lev, MD, FACEP, director of operations for the ED at Scripps Mercy Hospital in San Diego, past president of Cal-ACEP, which is the California chapter of ACEP, and chairperson of the Emergency Medicine Oversight Commission, which oversees the 20 EDs in San Diego County.
The report has four categories, but under each there are more specifics, notes Lev. "So, you should take any state you are interested in and go specifically down the rows to see what you’re good at and what you need to fix," she suggests. Emergency leaders who are not familiar with the details may not be able to give policy-makers effective guidance for solutions.
It’s only by this "drilling down" process that you will truly understand what’s impacting your ED, she continues. "California’s overall grade is a B, but we know we have tremendous problems in our state," Lev notes. While California has good protection under medical liability, where it received an A+, and public health, because of laws regulating seatbelts and child restraints, it ranked 51st in EDs per million and 50th in nurses per population in access of care, she says.
"People can’t get in to see us, because we are 46th in hospital beds per patient," Lev says. "So, if you do not have EDs, nurses, or hospital beds, no matter how good your providers are, you don’t have access."
The impact of outside forces on the ED is perhaps the most dramatic revelation of the report, and it is one the authors hope will spur action on several levels.
"I think what the report reflects is that there are still unacceptable levels of variation from state to state in terms of quality of care," says Field. Money is part of the reason, "but I think it’s really more complicated," he says.
A good example is the part of the report card about the medical liability environment, he says. "There are states where docs in any specialty can’t get affordable coverage and have almost no willingness to participate in backup panels."
This issue is in the realm of health care policy-makers, he says. "We hope to inspire state legislatures and governors to recognize they have serious issues they need to address, and as much as possible, be a launching point for ad hoc groups or task forces to try to attack some of these problems," Field says. ED physicians should join these groups, he adds.
Lev recognizes that while most ED managers will find at least some of the statistics disturbing, not all of them will pick up the torch of protest and then march down to their state legislatures. For those not so inclined, she says, there still is much of value to be derived from the report.
Find the page for your state, Lev suggests. "Then, I would go and read the details offered in the little boxes," she says. "Chances are whatever problems you’re seeing, all the rest of the EDs in your state are seeing."
It also can help explain a "poor" performance on the part of your ED, Lev continues. "A big thing managers have shoved down their throats is throughput," she notes.
It would help in California, for example, to know they are the 51st state in the number of RNs, Lev says. "We are understaffed and have few EDs, which would help explain why our Press Ganey [patient satisfaction] scores are down."
Such statistics "give us legitimacy and quantifies our concerns," she says. "It also helps explains things to patients when your ED is absolutely full."
Should ED managers share the report with their staff? "Absolutely," Lev answers. "This Friday, I have my commission meeting and I plan to share it. This is something nurses and physicians like to know."
This first report card is just the beginning, adds Field. "In future, we want to get close to ED managers with more compelling data."
The temptation they tried to avoid was doing original research, Field says. "As future report cards are developed, we will try to drill down on practice management issues, and critical issues that surround crowding," he says.
For example, he says, the whole issue of overcrowding and boarding is still unchartered territory, he says. The Joint Commission on Accreditation of Healthcare Organizations is just beginning to understand this is a problem and just starting to ask hospitals to address it, he says. "But to make a lot of headway, you have to at least compel hospitals to report data on the amount of time EDs are saturated and overcrowded, and whether diversion is an issue," Field says. "Just to get everybody to look at same issues would be a step up."
Sources/Resource
For more information on the national report card, contact:
- Bruce Bonano, MD, Attending Emergency Physician, Bayshore Hospital, Holmdale, NJ. Phone: (732) 739-5924.
- Wes Field, MD, FACEP, Emergency Medicine Clinical Faculty, University of California Irvine. Phone: (949) 452-3569.
- Roneet Lev, MD, FACEP, Director of Operations, Emergency Department, Scripps Mercy Hospital, San Diego. Phone: (619) 203-7190. E-mail: [email protected].
For a free interactive version of the ACEP national report card, go to www.acep.org/webportal. Move your cursor to "Check the Grades" and click on the "go" arrow. For a free hard copy, contact: American College of Emergency Physicians, 1125 Executive Circle, Irving, TX 75038-2522. Phone: (800) 798-1822.
This warning jumps off the page from the first-ever National Report Card on the State of Emergency Medicine, just released by the Dallas-based American College of Emergency Physicians (ACEP). The report covered all 50 states and the District of Columbia.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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