State of emergency medicine in Spain

Spain has universal public health care coverage. Emergency care provisions are offered to patients in different modalities and levels according to the characteristics of the medical complaint: at primary care centers (PCC), in an extrahospital setting by emergency medical services (EMS) and at hospital emergency departments (ED). We have more than 3,000 PCCs, which are run by family doctors (general practitioners) and pediatricians. On average, there is 1 PCC for every 15,000 to 20,000 inhabitants, and every family doctor is in charge of 1,500 to 2,000 citizens, although less populated zones tend to have lower ratios. Doctors spend part of their duty time in providing emergency care to their own patients. While not fully devoted to emergency medicine (EM) practice, they do manage minor emergencies. However, Spanish EMSs contribute hugely to guarantee population coverage in all situations. These EMS are run by EM technicians (EMT), nurses and doctors, who usually work exclusively in the emergency arena. EDs dealt with more than 25 million consultations in 2008, which implies, on average, that one out of two Spaniards visited an ED during this time. They are usually equipped with a wide range of diagnostic tools, most including ultrasonography and computerized tomography scans. The academic and training background of doctors working in the ED varies: nearly half lack any structured specialty residence training, but many have done specific master or postgraduate studies within the EM field. The demand for emergency care has grown at an annual rate of over 4% during the last decade. This percentage, which was greater than the 2% population increase during the same period, has outpaced the growth in ED capacity. Therefore, Spanish EDs become overcrowded when the system exerts minimal stress. Despite the high EM caseload and the potential severity of the conditions, training in EM is still unregulated in Spain. However, in April 2009 the Spanish Minister of Health announced the imminent approval of an EM specialty, allowing the first EM resident to officially start in 2011. Spanish emergency physicians look forward to the final approval, which will complete the modernization of emergency health care provision in Spain.     

A Qualification Course in an International Emergency Medicine Intervention

Background: The Tuscan Emergency Medicine Initiative is a comprehensive training program for physicians designed to create a lasting infrastructure for training in emergency medicine (EM) in a region of Italy. A “Train-the-Trainers” model was utilized to prepare physicians who were working in the emergency department (ED) to become the teachers of EM, and a master's program was created to train the next generation of emergency physicians as well as to put in place a structure into which residency training in EM will be placed. This model has been used in other projects as well; however, the dilemma of what to do with physicians who are already in practice remained an unsolved problem. Objectives: We wished to create a qualification course in EM for this important group of physicians. Methods: Didactic lectures, workshops, simulations, and clinical rotations were utilized to standardize current emergency care delivery in the region's EDs. Results: Between 2005 and 2008, 488 physicians completed the program. Conclusions: We propose this model as a way of training and including the physicians caught in the transition to specialty training in any area developing the specialty of EM.     

Child Health Insurance Outreach through the Emergency Department A Pilot Study

In 1997 the U.S. government funded the Children's Health Insurance Program (CHIP), but the 48 billion dollars initiative has had limited success in finding and enrolling uninsured children. While such children are more likely to receive care in emergency departments (EDs), no national initiative has targeted EDs for child health insurance outreach. OBJECTIVE: As a pilot study for a national multicenter study, this study evaluated the effectiveness of child health insurance outreach in an ED setting. METHODS: This was a prospective observational study of the outreach efforts of a single case manager from August 1998 to July 1999, performed at Foote Hospital ED in Jackson, Michigan (45,000 visits/year). All patients 相似文献   

Analysis of Factors Affecting U.S. Emergency Physician Workforce Projections

Objectives: To use existing data sources to refine prior estimates of the U.S. emergency medicine (EM) workforce and to estimate effects of proposed changes in the U.S. health care system on the EM workforce. Methods: Relevant data were extracted from the American College of Emergency Physicians (ACEP) 1995 Membership Activity Report, the American Medical Association (AMA) publication "1995/96 Physician Characteristics and Distribution in the U.S.," the American Hospital Association (AHA) 1994 hospital directory, a written survey of each state's medical licensing board and state medical society, and the American Board of Emergency Medicine (ABEM) annual activity report for 1995. These data were used to project workforce supply and demand estimates applicable to workforce models.
Results: None of the available information sources had complete data on the number and distribution of emergency physicians (EPs) currently practicing in the United States. Extrapolating the limited reliable statewide EP numbers to make nationwide projections reveals a shortage of EPs needed to fully staff the nation's existing EDs. At least 22 states had an average ratio of <5 EPs per existing ED. Additional national projections incorporating a decreasing number of U.S. EDs indicate that the current annual number of EM residency graduates will not eliminate the deficit of EPs for at least several decades, given that projected numbers of retiring EPs annually will soon equal the total annual EM residency graduate production. Conclusions: Although the current data on EPs in practice in the United States are incomplete, the authors project a relative shortage of EPs. More accurate and complete information on the numbers and distribution of EPs in America is needed to improve workforce projections.     

Critical procedure performance in pediatric patients: Results from a national emergency medicine group

Study objectiveWe sought to examine the frequency of pediatric critical procedures performed in a national group of emergency physicians.MethodsWe performed a retrospective analysis of an administrative billing and coding dataset for procedural performance documentation verification from 2014 to 2018. We describe and compare incident rates of pediatric (age <18 years) patient critical procedure performance by emergency physicians in general emergency departments (EDs), pediatric EDs, and freestanding ED/urgent care centers. Critical procedures were endotracheal intubation, electrical cardioversion, central venous placement, intraosseous access, and chest tube insertion.ResultsAmong 2290 emergency physicians working in 186 EDs (1844 working in 129 general EDs, 125 in 8 pediatric EDs, and 321 in 49 freestanding EDs/urgent cares), a total of 2233 pediatric critical procedures were performed during the study period. Many physicians at general EDs and freestanding EDs/urgent cares performed zero pediatric procedures per year (53.9% and 89% respectively). Per 1000 ED visits seen (All patient ages), physicians working in general EDs performed fewer pediatric critical procedures than physicians in pediatric EDs (0.12/1000 visits vs 0.68/1000 visits; rate difference = 0.56, 95% confidence interval [CI] 0.51–0.61). Per 1000 clinical hours worked, physicians working in general EDs performed 0.26 procedures compared to 1.66 for physicians in pediatric EDs (rate difference = 1.39; 95% CI 1.27–1.52).ConclusionPediatric critical procedures are rarely performed by emergency physicians and are exceedingly rare in general EDs and freestanding EDs/urgent cares. The rarity of performance of these skills has implications for ED pediatric readiness.     

Airway management practices in emergency medicine residencies

The Core Content for Emergency Medicine (EM) recommends that all emergency physicians be trained to manage the airway, including administering paralytic agents for endotracheal intubation. This study analyzed compliance with the recommendations by reviewing airway management practices at EM residencies. All 96 EM residency directors were sent a 10-item survey characterizing airway management practices at residency-affiliated emergency departments (EDs). The 91 respondents (95%) represented residencies with 120 affiliated hospitals. Paralytic agents routinely were used during intubations in 114 of the EDs (95%). Forty-nine of the EDs (41%) never requested an anesthesiologist for intubations, and 8 EDs (7%) mandated anesthesiology presence during paralytic agent administration. The Department of Anesthesiology never performed quality assurance (QA) evaluations in at least 64 EDs (53%). The Department of Emergency Medicine performed QA checks less than two thirds of the time in at least 44 EDs (36%). The majority of EM residencies are complying with the Core Content recommendations by actively performing intubations using paralytic agents. Anesthesiologists are infrequently consulted in residency-affiliated EDs. Quality assurance of ED intubations is not rigorously monitored by emergency and anesthesiology departments.     

A study of the workforce in Emergency Medicine in Israel: 2003

Emergency Medicine (EM) was officially recognized as a specialty in Israel in 1999. In 2003 the first nine Israeli trained emergency physicians (EPs) were certified. This survey was undertaken to assess current staffing of Emergency Departments (ED) in Israel and to attempt to estimate future staffing needs for EPs. A survey was sent to all ED directors at general hospitals in Israel. We asked questions relating to staffing by number of physicians, type and level of training, and differential staffing by time of the day and week. In addition, we inquired as to the census, structure, hospital resources available, and size of the ED. Twenty-four of 25 (96%) EDs responded. There were 59 EM specialists registered in Israel; there were 37 EM residents. EDs reported a total of 1,872,500 visits annually. Emergency care is otherwise given by specialists and residents in other fields, and non-specialist physicians. At large hospitals there is an average of 2.5 EM specialists during daytime hours, and another four specialists of other types on duty. During the night in large hospitals, there is an average of <1 specialist of any kind (typically not EM) on duty. In most EDs, care is turned over to non-specialists (residents and others) during evenings and nights. The recognition of the need for Emergency Medicine as a specialty in Israel has not as yet translated into care of emergencies by EPs for most patients. To adequately staff EDs with physicians trained in EM, an emphasis needs to be placed on increasing EM staff and resident positions. The need seems most acute in medium-sized hospitals and during off hours and weekends.     

Workforce Projections for Emergency Medicine: How Many Emergency Physicians Does the United States Need?

Objective: To mathematically model the supply of and demand for emergency physicians (EPs) under different workforce conditions.
Methods: A computer spreadsheet model was used to project annual EP workforce supply and demand through the year 2035. The mathematical equations used were: supply = number of EPs at the beginning of the year plus annual residency graduates minus annual attrition; demand = 5 full-time equivalent positions/ED X the number of hospital EDs. The demand was empirically varied to account for ED census variation, administrative and teaching responsibilities, and the availability of physician extenders. A variety of possible scenarios were tested. These projections make the assumption that emergency medicine (EM) residency graduates will preferentially fill clinical positions currently filled by EPs without EM board certification.
Results: Under most of the scenarios tested, there will be a large deficit of EM board-certified EPs well into the next century. Even in scenarios involving a decreasing "demand" for EPs (e.g., in the setting of hospital closures or the training of physician extenders), a significant deficit will remain for at least several decades. Conclusions: The number of EM residency positions should not be decreased during any restructuring of the U.S. health care system. EM is likely to remain a specialty in which the supply of board-certified EPs will not meet the demand, even at present levels of EM residency output, for the next several decades.     

Introduction of emergency medicine in China

Over the past 20 years, emergency medicine (EM) in China has been through a period of rapid development. This included the formal establishment of professional association of EM in 1986 and the establishment of ED in all county‐level hospitals across the country in the late 1990s. In line with the rapid economic development of China, ED have been equipped with appropriate ‘hardware’ equipment, but the ‘software’ part of the ED system remains underdeveloped. Doctors do not usually work exclusively in ED, but on a rotational basis, while also working as specialists in their own departments, such as medicine and surgery. EM in China remains underdeveloped, at least partly, for two main reasons: the current financial status of the health‐care system and lack of sufficient numbers of qualified EM specialists. Chinese education and training systems are now beginning to produce high‐quality emergency specialists, although there is not yet consistency across all courses. In Australia, the specialty of EM is well developed and, as such, this country is well placed to contribute to the development of ED in China.     

Optimal Older Adult Emergency Care: Introducing Multidisciplinary Geriatric Emergency Department Guidelines From the American College of Emergency Physicians,American Geriatrics Society,Emergency Nurses Association,and Society for Academic Emergency Medicine

In the United States and around the world, effective, efficient, and reliable strategies to provide emergency care to aging adults is challenging crowded emergency departments (EDs) and a strained health care system. In response, geriatric emergency medicine (EM) clinicians, educators, and researchers collaborated with the American College of Emergency Physicians (ACEP), American Geriatrics Society (AGS), Emergency Nurses Association (ENA), and the Society for Academic Emergency Medicine (SAEM) to develop guidelines intended to improve ED geriatric care by enhancing expertise, educational, and quality improvement expectations; equipment; policies; and protocols. These “Geriatric Emergency Department Guidelines” represent the first formal society‐led attempt to characterize the essential attribute of the geriatric ED and received formal approval from the boards of directors for each of the four societies in 2013 and 2014. This article is intended to introduce EM and geriatric health care providers to the guidelines, while providing proposals for educational dissemination, refinement via formal effectiveness evaluations and cost‐effectiveness studies, and institutional credentialing.     

Emergency Medicine Public Health Research Funded by Federal Agencies: Progress and Priorities

The emergency department (ED) visit provides an opportunity to impact the health of the public throughout the entire spectrum of care, from prevention to treatment. As the federal government has a vested interest in funding research and providing programmatic opportunities that promote the health of the public, emergency medicine (EM) is prime to develop a research agenda to advance the field. EM researchers need to be aware of federal funding opportunities, which entails an understanding of the organizational structure of the federal agencies that fund medical research, and the rules and regulations governing applications for grants. Additionally, there are numerous funding streams outside of the National Institutes of Health (NIH; the primary federal health research agency). EM researchers should seek funding from agencies according to each agency's mission and aims. Finally, while funds from the Department of Health and Human Services (HHS) are an important source of support for EM research, we need to look beyond traditional sources and appeal to other agencies with a vested interest in promoting public health in EDs. EM requires a broad skill set from a multitude of medical disciplines, and conducting research in the field will require looking for funding opportunities in a variety of traditional and not so traditional places within and without the federal government. The following is the discussion of a moderated session at the 2009 Academic Emergency Medicine consensus conference that included panel discussants from the National Institutes of Mental Health, Drug Abuse, and Alcoholism and Alcohol Abuse and the Centers for Disease Control and Prevention (CDC). Further information is also provided to discuss those agencies and centers not represented.     

Demand for hospital emergency departments: a conceptual understanding

BACKGROUND:

Emergency departments (EDs) are critical to the management of acute illness and injury, and the provision of health system access. However, EDs have become increasingly congested due to increased demand, increased complexity of care and blocked access to ongoing care (access block). Congestion has clinical and organisational implications. This paper aims to describe the factors that appear to influence demand for ED services, and their interrelationships as the basis for further research into the role of private hospital EDs.

DATA SOURCES:

Multiple databases (PubMed, ProQuest, Academic Search Elite and Science Direct) and relevant journals were searched using terms related to EDs and emergency health needs. Literature pertaining to emergency department utilisation worldwide was identified, and articles selected for further examination on the basis of their relevance and significance to ED demand.

RESULTS:

Factors influencing ED demand can be categorized into those describing the health needs of the patients, those predisposing a patient to seeking help, and those relating to policy factors such as provision of services and insurance status. This paper describes the factors influencing ED presentations, and proposes a novel conceptual map of their interrelationship.

CONCLUSION:

This review has explored the factors contributing to the growing demand for ED care, the influence these factors have on ED demand, and their interrelationships depicted in the conceptual model.KEY WORDS: Emergency department, Demand, Crowding, Risk factors, Emergency services, Emergency medicine, Emergency room     

Supply and Demand of Board-certified Emergency Physicians by U.S. State, 2005

Objectives:  The objective was to estimate the emergency medicine (EM) board-certified emergency physician (EP) workforce supply and demand by U.S. state.
Methods:  The 2005 National Emergency Department Inventories-USA provided annual visit volumes for U.S. emergency departments (EDs). We estimated full-time equivalent (FTE) EP demand at each ED by dividing the actual number of visits by the estimated average EP visit volume (3,548 visits/year) and then summing FTEs by state. Our model assumed that at least one EP should be present 24/7 in each ED. The number of EM board-certified EPs per state was provided by the American Board of Medical Specialties (American Board of Emergency Medicine, American Board of Pediatrics) and the American Osteopathic Board of Emergency Medicine. We used U.S. Census Bureau civilian population estimates to calculate EP population density by state.
Results:  The supply of EM board-certified EPs was 58% of required FTEs to staff all EDs nationally and ranged from 10% in South Dakota to 104% in Hawai'i (i.e., there were more EPs than the estimated need). Texas and Florida had the largest absolute shortages of EM board-certified EPs (2,069 and 1,146, respectively). The number of EM board-certified EPs per 100,000 U.S. civilian population ranged from 3.6 in South Dakota to 13.8 in Washington, DC. States with a higher population density of EM board-certified EPs had higher percent high school graduates and a lower percent rural population and whites.
Conclusions:  The supply and demand of EM board-certified EPs varies by state. Only one state had an adequate supply of EM board-certified EPs to fully staff its EDs.     

System dynamics and dysfunctionalities: levers for overcoming emergency department overcrowding

Overcrowding of U.S. emergency departments (EDs) is a widely recognized and growing problem. This presentation offers the perspectives of a primary care physician (PCP) examining the problem at three levels: global health policy, quality process improvement, and more intimate clinical caring. It posits that ED overcrowding is actually a symptom of 10 more fundamental problems in U.S. health care and EDs: variations/supply-demand mismatch; primary care provider shortfalls; limited after-hours access; admission throughput challenges; clinical challenges related to discontinuity patients; clinical challenges related to those with special needs; interruptions; testing logistical challenges; suboptimal information systems; and fragmented/dysfunctional health insurance system, leaving many un- and underinsured.     

Time analysis of consult service emergency department admission process compared with emergency medicine service admission process.

This prospective case-controlled study was performed to compare the time intervals of a consult emergency department (ED) admission process with an emergency medicine (EM) service admission process. During March 1994, the consultant services admitted 307 patients for hospitalization at an urban tertiary academic ED with an EM residency; in April 1994, the EM service admitted 264 patients. The times measured were: 1) triage to examination room; 2) room to first physician contact; and 3) emergency physician contact to admit request. Data analysis was by mode and Wilcoxon tests. We analyzed 537 evaluable admissions. The mode for consultant process was 205 min, and the mode for emergency medicine admissions was 158 min from first physician contact to admit request, for a 47-min difference. All patients arrived stable to an inpatient bed; none was transferred to the Intensive Care Unit or to an operating room in the first 24 h. Concordance of the ED admitting impression and the hospital discharge diagnosis was 99% (259/264). We conclude that in selected tertiary academic EDs, admission of all patients by the EM service is more efficient than a consultant-admission process. Outcomes show the EM admission process may be employed safely and with accurate patient diagnosis.     

Emergency medicine in India: Why are we unable to ‘walk the talk’?

The largest democracy on earth, the second most populous country and one of the most progressive countries in the globe, India, has advanced tremendously in most conventional fields of Medicine. However, emergency medicine (EM) is a nascent specialty and is yet to receive an identity. Today, it is mostly practised by inadequately trained clinicians in poorly equipped emergency departments (EDs), with no networking. Multiple factors such as the size of the population, variation in standards of medical education, lack of pre-hospital medical systems and non-availability of health insurance schemes are some of the salient causes for this tardy response. The Indian medical system is governed by a central, regulatory body which is responsible for the introduction and monitoring of all specialties--the Medical Council of India (MCI). This organisation has not recognized EM as a distinct specialty, despite a decade of dogged attempts. Bright young clinicians who once demonstrated a keen interest in EM have eventually migrated to other conventional branches of medicine, due to the lack of MCI recognition and the lack of specialty status. The Government of India has launched a nationwide network of transport vehicles and first aid stations along the national highways to expedite the transfer of patients from a crash site. However, this system cannot be expected to decrease morbidity and mortality, unless there is a concurrent development of EDs. The present article intends to highlight factors that continue to challenge the handful of dedicated, full time emergency physicians who have tenaciously pursued the cause for the past decade. A three-pronged synchronous development strategy is recommended: (i) recognise the specialty of EM as a distinct and independent basic specialty; (ii) initiate postgraduate training in EM, thus enabling EDs in all hospitals to be staffed by trained Emergency physicians; and (iii) ensure that EMs are staffed by trained ambulance officers. The time is ripe for a paradigm shift, since the country is aware that emergency care is the felt need of the hour and it is the right of the citizen.     

Assessment of Emergency Physician Workforce Needs in the United States, 2005

Objectives: The objective was to estimate emergency physician (EP) workforce needs, taking into account the diversity of U.S. emergency departments (EDs) and various projections of EP supply and demand. Methods: The 2005 National ED Inventory‐USA ( http://www.emnet‐usa.org/ ) provided annual visit volumes for 4,828 U.S. EDs. The authors calculated annual supply based on existing emergency medicine (EM) board‐certified EPs, adding newly board‐certified EPs, and subtracting board‐certified EPs who died or retired. Demand was estimated at each ED by dividing the number of visits by the average EP volume (based on 2.8 patients/hour, 40 hours/week, and 34% nonclinical time). The models assumed that at least 1 EP should be present 24/7 in each ED, which would require at least 5.35 full‐time equivalents (FTEs) per ED. Based on annual EP attrition estimates, results for best‐case, worst‐case, and intermediate scenarios were calculated. Results: In 2005, there were approximately 22,000 EM board‐certified EPs, but 40,030 EPs would be needed to staff all 4,828 EDs (55% of demand met). A total of 2,492 (52%) EDs had a visit volume that required the minimum number (5.35) FTEs, of which 47% were rural. In the unrealistic (no attrition), best‐case scenario, it would take until 2019 to staff all EDs with board‐certified EPs. In the worst‐case scenario (12% attrition), supply would never meet demand. Our intermediate scenario (2.5% attrition) suggested that board‐certified EPs would satisfy workforce needs in 2038. Conclusions: Supply of EM residency‐trained, board‐certified EPs is not likely to meet demand in the near future. Alternative EP staffing arrangements merit further consideration.     

Need for Standardized Sign-out in the Emergency Department: A Survey of Emergency Medicine Residency and Pediatric Emergency Medicine Fellowship Program Directors

Objectives
To determine the existing patterns of sign-out processes prevalent in emergency departments (EDs) nationwide. In addition, to assess whether training programs provide specific guidance to their trainees regarding sign-outs and attitudes of emergency medicine (EM) residency and pediatric EM fellowship program directors toward the need for the development of standardized guidelines relating to sign-outs.
Methods
A Web-based survey of training program directors of each Accreditation Council for Graduate Medical Education (ACGME)–accredited EM residency and pediatric EM fellowship program was conducted in March 2006.
Results
Overall, 185 (61.1%) program directors responded to the survey. One hundred thirty-six (73.5%) program directors reported that sign-outs at change of shift occurred in a common area within the ED, and 79 (42.7%) respondents indicated combined sign-outs in the presence of both attending and resident physicians. A majority of the programs, 119 (89.5%), stated that there was no uniform written policy regarding patient sign-out in their ED. Half (50.3%) of all those surveyed reported that physicians sign out patient details "verbally only," and 79 (42.9%) noted that transfer of attending responsibility was "rarely documented." Only 34 (25.6%) programs affirmed that they had formal didactic sessions focused on sign-outs. A majority (71.6%) of program directors surveyed agreed that specific practice parameters regarding transfer of care in the ED would improve patient care; 80 (72.3%) agreed that a standardized sign-out system in the ED would improve communication and reduce medical error.
Conclusions
There is wide variation in the sign-out processes followed by different EDs. A majority of those surveyed expressed the need for standardized sign-out systems.