National Emergency Care Enterprise Advancing Care Through Collaboration: Workshop Summary (2009) / Chapter Skim
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3 Quality and Patient Safety
3 Quality and Patient Safety
Pages 25-36
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From page 25... ...
of Parkland Health & Hospital System in Dallas, began the panel discussion by describing a comprehensive effort Parkland had undertaken to address emergency department (ED) crowding and patient flow.
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Nedza said we need to think more broadly in terms of community health priorities because these are sometimes different than acute health priorities. Nedza observed that acute care providers typically focus on individual patients when making decisions about resource allocation.
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As measurement organizations have created -- and CMS has adopted -- performance indicators to measure door-to-needle times in select tertiary care hospitals, community hospitals with limited resources have less incentive to handle patients who walk in with an acute myocardial infarction and other measured conditions. Nedza observed that patients are sometimes transferred because there is no on-call M.D.
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From page 28... ...
This information has been used to support the trauma quality improvement project, which provides risk-adjusted comparisons of patient outcomes at individual centers and within various cities, counties, states, and the country as a whole. Standardizing Quality in EMS Dia Gainor, bureau chief of EMS for the state of Idaho and past president of the National Association of State Emergency Medical Services Officials, said there is no universal culture of quality in EMS.
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Hospitals have stood up to the challenge and realized ED crowding is a problem for the entire hospital, not just the ED. Yeh's presentation also highlighted the impact that mental health patients have on hospital emergency departments.
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Enacting a statewide ban on boarding more than 4 hours in the ED would be the best way to improve quality, Johnson said. Finding Quality by Connecting the Links of the Chain The AMA's Nedza described a cultural issue surrounding quality measurement that must be overcome: Medical providers often do not want to be measured on what happens to a patient after the patient has left their control.
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Others include aligning financial incentives and public reporting. In addition, she said, it is important to recognize that implementing strict rules will not succeed unless technical assistance is provided to facilities.
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The objective would be to promote a less fragmented team approach among hospitals, physicians, and postacute providers and improve problem areas, such as hospital throughput. Anderson agreed that to improve patient outcomes, "We have to all be aligned to the same incentives." Currently, financial outcomes for emergency medicine physicians and trauma surgeons are not matched up with those of the hospital, because they do not receive Medicaid disproportionate share payments or upper payment limit reimbursements.
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From page 33... ...
For example, EMS systems have used interstate compacts, so that licensure of an ambulance service is recognized at the state line, and there is no additional red tape upon repatriation. Recommendations to Federal Partners In the United Kingdom, Kellermann observed, the National Health Service considers an overcrowded emergency department an institutional failure, and management suffers the consequences.
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From page 34... ...
"When I drive from New York to Los Angeles, 80 percent of the time I am not in a coverage area." What is needed is a national trauma system to provide federal oversight to ensure that the level across all 50 states is consistent and essentially the same. Parkland's Anderson said that right now, providing trauma care is a bad business decision.
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From page 35... ...
Finally, Sandra Schneider, vice president of the American College of Emergency Physicians, noted that, in a survey of a thousand emergency physicians, emergency department crowding ranked as their top patient safety issue. Crowding has been associated with delays in care, increased morbidity, and increased mortality.
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