ED crisis presents a new set of quality challenges

Patient harm, delays in care major consequences

By its very nature and location, the emergency department (ED) inextricably is bound to the rest of the hospital; what occurs there has profound repercussions throughout the facility.

The same goes for what doesn't happen there, and what isn't happening today is adequate coverage by specialists - and sometimes even generalists - for patients in desperate need of immediate care.

According to a recent report from the Irving, TX-based American College of Emergency Physicians (ACEP), "The decrease in the number of medical specialists willing to be on call to the nation's emergency departments is a looming national health care crisis of supply and demand."1

There are myriad reasons, not the least of which is declining reimbursement and an increase in the number of underinsured and uninsured patients, but of greater concern for quality managers is the impact on patient care and safety.

In the ACEP study, respondents were asked to select the top three consequences of the shortages. No. 1 was "risk of harm to patients who needed specialist care."

"As you can well imagine, it sets off a cascade of events," notes Art Gruen, MD, FACEP, president and CEO of Emergency and Acute Care Medical Corp. (EA) in Rancho Santa Fe, CA, a management services organization that provides call panel compensation solutions to encourage specialist participation in ED call at client hospitals.

"If an emergency physicians spends 15 minutes making calls for a doctor to take care of a patient with a heart attack, that's 15 minutes he could have spent with the patient - not to mention the backlog of patients this creates.

"This cascade could actually end up shutting down the ED or preventing ambulances from delivering patients because of the backlog," he explains. "It can impair patient safety all the way down the line."

The type of care affected is virtually unlimited, adds Brad Zlotnick, MD, FACEP, a San Diego emergency physician and director of strategic development for EA.

"Even basic emergency services - i.e., general surgery, OB/GYN, cardiology, orthopedics - are often lacking or delayed," he asserts.

Clearly, not all emergency patients have life-threatening conditions, but they all need care - and fairly soon, stresses Joe Smith, EA's COO and former hospital CEO.

"The problem with the current system, where the on-call physician may not be compensated, is that if they are in their office, it detracts from their productivity to come see a patient," he observes. "If it's not a life-threatening emergency, their tendency is to say, `I'll see them in the morning.' For a hospital, that's bad not only from a care point of view, but also from a PR point of view."

Ultimately, the impact may not be restricted to a given hospital, Gruen says.

"Let's say an internist admits a patient with gastrointestinal bleeding," he poses. "If a specialist is not available, there may be a longer LOS. This creates a bed shortage, which impacts the ED, which, in turn, impacts the health of the community."

EA has sought to find a solution to filling understaffed call panel rosters by creating a program that, among other things, assures physicians they will get paid fairly. Their strategies include:

Implementing fee-for-service programs: When the physician provides a service, he or she receives a straight fee per unit of service (RVU or relative value unit). A hybrid model also is available, where a stipend pays for availability and the fee is based on actual services.

Paying physicians by stipend: A flat fee can be guaranteed whether the physician is called or not.

Establishing regional calls panels: Pre-arranged transfer agreements may be established among EA's hospital clients.

Providing specialized CPT on-call coding and billing expertise: Twelve years' experience with proprietary productivity analyses and electronic information transfer support accurate, prompt coding, and specialist payment.

"The bottom line is we want to promote a situation whereby a specialist will agree to take care of a patient," Gruen says. The key issues, he notes, are finances and lifestyle. "As you can imagine, a doctor does not cherish getting up at 3 a.m., but if the compensation is adequate and guaranteed, they will support the mission of the hospital."

"Hospitals spend tremendous resources to improve quality of care, and that includes ED throughput," Zlotnick adds.

"Care and satisfaction are quality measures. What we try do is work with the hospital; we are a resource to them for a manageable, predictable way for compensating specialists," he adds.

Being able to participate in such a program is not restricted by hospital size or budget, Smith notes. "This program works effectively pretty much at all hospital sizes," he says. "We have systems where every specialty is covered, and others where only one, or two, or three are covered. It has to do with carefully evaluating what issues really need to be resolved. Hopefully, we'll find solutions that mitigate the toughest of their problems; as time moves on, you will see those hospitals that only have a few specialties covered will begin to cover everyone."

Finally, Zlotnick says, when hospitals try to solve these problems on their own, they bear the extra burden of ensuring compliance with the regulatory requirements of the Centers for Medicare & Medicaid Services, Stark self-referral laws, and the Emergency Medical Treatment and Labor Act (EMTALA), which, among other things, governs conditions under which emergency treatment is provided. "EA is compliant with all of these," he notes. "So a lot of the background work has already been done."


1. American College of Emergency Physicians. On-Call Specialist Coverage in U.S. Emergency Departments. ACEP Survey of Emergency Department Directors. Irving, TX; September 2004. Web site: www.acep.org.

Need More Information?

For more information, contact:

Art Gruen, MD, FACEP, President and CEO, Emergency and Acute Care Medical Corp., P.O. Box 9350, Rancho Santa Fe, CA 92067. Phone: (858) 759-4765. E-mail: art.gruen@eamc.com.

Joe Smith, COO, Emergency and Acute Care Medical Corp., P.O. Box 9350, Rancho Santa Fe, CA 92067. Phone: (858) 759-4765.

Brad Zlotnick, MD, FACEP, Emergency and Acute Care Medical Corp., P.O. Box 9350, Rancho Santa Fe, CA 92067. Phone: (858) 759-4765. E-mail: Brad.Zlotnick@eacmc.com.