CRISIS IN EMERGENCY CARE, THE EMERGENCY MEDICINE PHYSICIANS PERSPECTIVE

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CRISIS IN EMERGENCY CARE, THE EMERGENCY MEDICINE
PHYSICIANS PERSPECTIVE

• John R. McPherson, M.D.

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Factors Leading to Over-Capacity

• Increasing patient volume
• Higher patient acuity
• Nursing shortage
• Bed shortage
• Insufficient ED Space/beds
• Hospital bed shortage
• On-call specialty physician shortage
• Admitted patients in ED beds

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Increasing Patient Volume

• ED visits up 46 from 1993-2003
• (4.8 - 7 million)
• Annual increase 220,000 visits/year
• 19,000 patients treated in Florida EDs daily
• ED visits per 100 up from 35.6/100 1993 to
  40.8/100 in 2003
• Florida population up 3.9 mil from 1993

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Demand for ED services in Florida growing at an
accelerated pace
ED Visits to Florida Hospitals 1993-2003

• ED visits to Florida hospitals reached 7 million
  in 2003, up 46 from 1993.
• This reflects an annual increase of 220,000 ED
  visits per year.
• 49 of patients admitted to Florida hospitals
  were first seen in the ED.
• ED visits per 100 grew from 35.6 per 100 in 1993
  to 40.8 per 100 in 2003.

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Higher Patient Acuity

• 49 of patients admitted to Florida hospitals
  first seen in ED
• Decreased access to primary care
• Increased severity of illness
• Elderly population with increased patient
  complexity
• Longer ED work-ups
• More imaging studies
• Decreased access to specialists

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Nursing Shortage
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RN Vacancy Rate in Florida Hospitals1988 - 2004
Percent of vacant budgeted RN positions
Notes Survey reflects vacancy information for
the last week in February. Survey was not
conducted in 1996. Source FHA Nurse Staffing
Supply Surveys, 1989-2005
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RN Positions in Florida HospitalsBy
Specialty2005
Total Vacant Positions 2,455
Total Budgeted Positions 31,671
Source FHA Nurse Staffing Supply Survey, 2005
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Vacancy Rates in Florida HospitalsBy Nursing
Specialty2005
Responses 24 55 49 20 19 43 63 50 23 26 57 62 50
Source FHA Nurse Staffing Supply Survey, 2005
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Impact of Nursing Shortage onHospital Operations
Source FHA Nurse Staffing Supply Survey, 2005
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By 2020, Demand for RNs Will Exceed Supply by
33 in Florida and 29 Nationally
Florida
U.S.
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Source Projected Supply, Demand and Shortages
of Registered Nurses 2000 - 2020, HHS, HRSA
Bureau of Health Professions, National Center for
Health Workforce Analysis, July 2002
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Insufficient ED Space/Beds

• Population up 3.6 mil in FL since 93 w/daily ED
  visits up from 13,000 to 19,000 daily
• Number of Emergency Depts down from 226 to 214
  since 1993
• 31 hospitals have expanded their Eds/per AHCA
• Increased length of time patients board in the
  ED leads to insufficient ED space
• Decreased ED space/available beds leads to
• increased waiting times/decreased patient
  satisfaction
• increased numbers of patients leaving before
  medical evaluation
• hallway emergency department
• Ambulance diversions

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Demand for ED services is up, supply is down

• Since 1993, 3.6 million more people live in
  Florida
• During this same period, the number of hospitals
  with emergency departments fell from 226 to 214,
  a loss of 12 EDs.
• According to AHCA Plans and Construction records,
  since 1994, approximately 31 hospitals
  expanded/added to their emergency department.
• Unfortunately, there are no data on how many
  additional treatment rooms or additional patients
  can be cared for due to those expansion
  activities.

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Hospital inpatient resources have not expanded

• Available hospital beds in Florida shrunk from
  56,160 in 1993 to 53,770 in 2003, a loss of
  almost 2,400 beds.
• The beds per 1000 population fell to 3.1 beds in
  2003, compared to 4.1 beds in 1993.
• Over the 10 year period, hospitals added 311 ICU
  beds, but the ICU beds per 1000 population fell
  to .27 from .32 in 1993.

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Hospital Bed Shortage

• Critical care beds/Telemetry beds
• Increased hospital LOS
• radiology delays
• lab delays
• consultation delays
• inefficient/inappropriate bed utilization
• diminishing outpatient psych and SNF beds

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Admitted Patients in ED Beds

• GAO 2003 report - Best indicator ED overcrowding
  is extended length of time patients board in ED
• Hallway treatment of patients
• decreased privacy
• decreased quality
• decreased safety
• increased malpractice risk
• Decreased nursing morale/Increased nursing
  turnover
• Increased difficulty in recruiting good ED
  physicians to work in unsafe/hostile environment
• EM residency graduating class U of F - none
  plan to remain in Florida

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On-Call Specialty Physician Shortage

• EMTALA on-call requirement changes
• Call simultaneous for multiple hospitals
• Perform elective surgery while on call
• No Rule of 3
• Specialists uncomfortable with certain
  procedures
• Sub-specialty shortages
• Ortho hand - Plastics
• Oral/maxillary/facial - Pediatric anything
• Neurosurgery - Urology
• OB/gyn
• Tertiary referral centers are being crushed

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Hospitals Without Crisis Over-Capacity Plans

• JCAHO ED overcrowding standards
• Existing ED/hospital crisis over-capacity plans
• SUNY over-capacity protocol - State Medical
  Training Centers in New York
• Lakeland Regional Medical Center patient flow and
  over-capacity plan
• Other in-patient over-capacity plans

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