Archives for June 2006

Bring It On

Hello, GruntDoc readers! This is my first guest-blogging stint, but I’m a big fan in general of neighborly community behavior. We have friends pick up the mail for you when you’re away, maybe feed the cat, so why not maintain the online presence, as well?

Especially when the online presence is that of GruntDoc, who’s been a dedicated supporter of medical blogging in all its forms, including Grand Rounds (he is a three-time host, I interviewed him once for Medscape). GruntDoc has also been a source of tips and commentary to MedGadget, another blog I contribute to (in fact, when we got the tip about this cricothryroidotomy keychain, I immediately thought of him).

GruntDoc encouraged me to rant during my stint here — I think he’s trying to keep things lively, or maybe he knows how much I have to reign it in usually, as an intern blogging under my real name.

I’m not sure this is a rant, but I do want to address Symtym’s assertions on what’s really an emergency. He quotes a figure I’ve heard, and verified — 100 million visits to US Emergency Departments each year (I’m getting numbers from Richardson AEM Vol 40, p 388).

100 million A huge number, to be sure, especially given the US population of 300 million. So it’s easy to say we’re in crisis now, everything is an emergency, forces have conspired to make people think they should use the ED for hangnails and stuffy noses. right? guess Well, guess how many visits were logged fifteen years ago: 90 million.

OK, now maybe there was wild misuse of emergency services in the early 90’s, too (I wouldn’t really know,  I was in high school). It seems, though, that the problem isn’t that there are more people using ED’s  inappropriately, or at least, this isn’t a terribly new issue. Rather, it’s that there are fewer ED’s around, so we’re all feeling the crunch more.

As for those 100 million visits, does that really mean that one third of all americans go to the ER each year? Of course not. Me and my two friends sure don’t, least not yet this year. Meanwhile, I can personanly vouch that some of our "regulars" chronic homeless alcoholics use the ED 100 times a year. How big a problem is this? I’ve blogged about it before, it’s a big problem and accounts for a substantial fraction of ED expenditures.

What about all the 70-year old diabetic hypertensives with chest pain? They come in every three or four months with disturbing symptoms. The 80-year olds who feel week and dizzy, maybe they blacked out for a second. These are real complaints, real emergencies, they need workup, every time. 

As for the hangnails, the inappropriate use of ED services, it’s actually notoriously hard to calculate how many are seen inappropriately. People have tried (Richardson, again — maybe I’ve worked with her, once or twice). The bottom line is, it’s hard to measure inappropriate ED use, and efforts to deny care to non-emergent situations may end up costing more, and/ or causing bad outcomes. Researchers try to quantify it, but existing denial of care methods just don’t seem to be worth it, and the estimated savings may be exaggerated as well.   

You can blame "themes of entitlement" and whatnot, and I’ve found doing so provides some comfort when you’re stressed and feeling put-upon by those few demanding, unappreciative patients. But, when you really look at it, it’s hard to blame the patients.

And, you know, as an intern, I’m going to get paid the same living wage whether I see a dozen patients a shift, or two dozen. But I keep trying to move quickly, providing good care and pleasant bedside manner, because I want to see as much as I can, and I’d like patients to get a favorable impression of our hospital and ED. If they end up realizing that we, in the ED, can provide services faster and more completely than if they just showed up unscheduled to their primary care doc, well, good for us.

Look, I’m not trying to debate ED access or government incentives to waste — that argument sprouts up every few weeks on the blogosphere and there’s already a good iteration / continuation in progress over at Grahamazon. I’m just trying to, well, figure out the right mindset and perspective to approach my job, and avoid becoming as jaded, down the road, as some others appear to have become.

— Nick

Incentivized Behavior

To answer the question (“Hey you in the ER! Is this really an emergency?”)—of course not! Historically the utilization of the “ER” runs 35% of the US population, or roughly (and presently) 100M annually. We lives in an exceedingly dangerous and ill society if we believe that one-third of our society has a “true” emergency requiring the services of an “ER” every year. Additionally, in many urban settings, 25% of ER volumes are brought to the ERs by ambulances. Again, we live in a very dangerous and ill society if we believe that one-twelfth of our society is so impaired that an ambulance is required every year.

For many reasons, the ER is the US healthcare system’s equivalent to fast-food. Similarly, the ambulance, often referred to as a cabulance—is just a form of door-to-door public service. Addicting? Essential? Fundamental? A right? A waste? Why? All very fair observations and questions, and I believe all come down to what we have incentivized in our society, directly and indirectly.

For those that utilize the ER and truly perceive every pain, malady and bodily dysphoria (theirs or those they decide for) to be true emergencies it is hard to fault that as inappropriate. I consider that appropriate “overreads” for a kind society and related to all the PSAs that promote self-awareness of healthcare issues. They get an “A” for intent, but only a “C” for excution—but reasonable, when we want a system that should be based on sensitivity trumping specificity.

If you consider all governmental funding sources for healthcare equivalent to a zero-sum game, then I believe it is easy to understand why both the feds and the states are increasing the pressures on the Medicaid programs. It has nothing to do with state surpluses, because the feds and the states share equally in the Medicaid yoke. But (IMHO) has everything to do with where governmentally-derived healthcare spending will need to go—Medicare, boomers, and healthcare information (broadly construed). We are fast coming upon a true constituency-based phenomenon, the largest, single, and united constituency group the US has ever seen begins this year—those residing in both the Medicare and boomer demographics. Contrast that with the diverse constitutency groups composing the Medicaid demographics coupled with the strong negative stereotypes of Welfare, the poor, the immigrant, the illegal, etc. Funding Medicare will always be more politically acceptable over funding Medicaid. Granted the states are not responsible for Medicare funding, but they are responsible for the state and locally employed boomers (and dependents) that will be retiring and utilizing their state/locally funded healthcare.

In California, the Medi-Cal receipents have been placed into managed care Medi-Cal programs that at least in my area (Sacramento) has had four major problems. First, managed care has driven so many providers out of the area there exists long waiting times for any forms of health services. This creates a collateral pressure on the ERs—”managed Medi-Cal” just can’t be seen in a timely manner. Second, because of the inability for them to be seen in a timely manner their health problems are more complicated and more advanced—which snowballs even more ER utilizations.

Third, those not able to get into the managed Medi-Cal programs are pretty much disenfranchised from all providers, because almost all providers are aligned with existing managed plans—there are very few providers that will pickup “straight Medi-Cal.” This constitutes another collaterally pressured group of Medi-Cal receipents into the ERs.

Fourth, a catagory of Medi-Cal called “emergency Medi-Cal,” which was created to provide Medi-Cal coverage for emergency conditions. Whether intentional or not, it is widely perceived that “emergency Medi-Cal” is not for “emergency” as a condition but for “emergency” as a venue. The ER becomes the venue for all Medi-Cal services under this misinterpretation. A very typical dialog with members in this category of Medi-Cal starts with “I have my emergency Medi-Cal and I want….”

What would be the effect of limiting Medi-Cal funding in California—immediate proportional and incremental increases in ER volumes for true emergent needs, for those further disenfranchised from primary care providers, and for those that already believe “the system owes them.” For good and bad reasons, Medicaid programs have incentivized behaviors and expectations over time. Changes in “who is covered” and “what is covered” without credible alternatives and potent counter-incentives will just drive-up ER utilizations.

There is a profound misunderstanding in the US about “Emergency Room,” it is an oxymoron, because utilization of the ER for everything other than a true emergency has been pervasively incentivized.† We have created a near-entitlement in the form of Medicaid and we have created a general expectation that any medical condition may be addressed in an ER.

Aside, when I first started my EM practice I was very incensed at parents on Medi-Cal who would bring their febrile child to the ER to get a prescription for APAP and had a pack of cigarettes sticking out of their shirt-pocket or purse. Over the years, I’ve come to have two reflections on the matter, first, I can’t affect social and healthcare policy in the ER at 3 AM (the hair trying to wag the tail that wags the dog); and second, not writing the prescription only causes the child to suffer.

Glog Potpourri

Glogging while the cat’s away…


This post will be more like an emergency medicine (EM) potpourri sort of along the lines of “why are
fire engines red?
” You know random associations…

First, I’ve got to get use to the Movable Type interface again—I haven’t used a WYSIWYG editor since my blogging infancy, circa 4.04. I have the same version over at symtym, but it is just for looking at the “nuts and bolts.” So turn off the WYSIWYG editor and use my much preferred AR markup in XHTML.

Second, I try to collect EM relevant abbreviations/phrases/terms—we have a vast wealth of colloquialisms with bad pronunciation, grammar and spelling mixed in. Humor is always a good place to start this “guesting” relationship. Old favorites and a few new ones in no particular order, with commentary (of course):

  1. ground level fall: no one can fall from the ground to the ground
  2. mechanical fall: well of course it is mechanical, the only alternative is virtual
  3. GCS 16: one that calculates his/her own score
  4. 5–point restraints: leathers and a foley
  5. male bed: has a fifth wheel
  6. my child has whelps: are they house broken?
  7. I’m passing clogs: I like Bastad Monet in a 43
  8. penis: OK (actual triage complaint)
  9. vag spots: thousands of exams, but never seen a spotted one…
  10. WAD: weak and dizzy; see WAD panel
  11. WAD II: weak and dizzy and needs a CT
  12. DFO: done fall out, see #1
  13. AEIOU: acute ethnic illness otherwise unknown
  14. VM: vowel movement
  15. DBI: “dirt ball index,” calculated from the BAL × BSA (in tattoos) ÷ by the number of remaining teeth

Enough of that PC stuff…

Third, Press Ganey revving the engine while in park.

‘Patient’ says it all | USAT | 5.31.06

The average length of stay in U.S. emergency rooms is 3.7 hours, or 222 minutes. The state-by-state look at emergency department waiting times was conducted by Press Ganey Associates, which measures patient satisfaction for 35% of the nation’s hospitals.

The report on emergency-room times is based on about 1.5 million patient questionnaires filled out in 2005. And it shows wide state-to-state variations in the time between entering the hospital’s emergency department and being admitted or sent home.

Iowa (138.3 minutes) and Nebraska (146.1 minutes) had the shortest emergency-room stays, while Maryland (246.9 minutes), and Arizona (297.3 minutes) had the longest.

Press Ganey measures the perception of performance (subjective), which is the surrogate for actual performance (objective, if all biases can be truly identified and controlled) and even farther removed from production. If we desire the countries EDs to function like public safety (which is often the expectation)—then they must have a production model akin to public safety. There are worlds of differences between an average response and a percentile response. Take a typical marking ploy for hospitals, stating an average door-to-doctor time in the ER that averages 30 minutes, 50% will see the doctor in greater than 30 minutes (normal distribution). Contrast that with a paramedic ambulance provider that has a contractual requirement to provide an ambulance to the scene within 8 minutes 90% of the time (normal curve skewed markedly to the left). Such a degree of production (moving the whole curve to the left on the time axis) requires tremendous additional cost and infrastructure. Skewing the production to the left (moving the “hump”) will require even more cost and infrastructure. Anyone involved in a high performance EMS systems knows that all components must be at peaking staffing—i.e., to wax biochemical, we’re dealing with zero-order reactions, where production is constant and continuous. This can be achieved in EMS with 90% reliability, but healthcare and the payers have no such commitment or public mandate.

Press Ganey gets to rev the engine—and gets paid very well for doing it. It has very little to do with quality or the offering of credible solutions, but everything to do with the promotion of competition amongst healthcare entities.

Well not to be accused of maundering, that’s enough meandering.