Societal Impact on Emergency Care

Societal Impact on Emergency Care

Impact of Health Policy Changes on Emergency Medicine in Maryland Stratified by Socioeconomic Status

Laura Pimentel, MD, et al.

The insurance provisions of the Patient Protection and Affordable Care Act (ACA) began implementation and a major revision of MD’s Medicare waiver ushered in a Global Budget Revenue (GBR) structure for hospital reimbursement. Our objective was to analyze the impact of these policy changes on emergency department (ED) utilization, hospitalization practices, insurance profiles, and professional revenue.

Read More
Societal Impact on Emergency Care

Emergency Medical Treatment and Labor Act (EMTALA) 2002-15: Review of Office of Inspector General Patient Dumping Settlements

Volume 17, Issue 3, May 2016
Nadia Zuabi, BS et al.

Introduction: The Emergency Medical Treatment and Labor Act (EMTALA) of 1986 was enacted
to prevent hospitals from “dumping” or refusing service to patients for financial reasons. The statute
prohibits discrimination of emergency department (ED) patients for any reason. The Office of the
Inspector General (OIG) of the Department of Health and Human Services enforces the statute.
The objective of this study is to determine the scope, cost, frequency and most common allegations
leading to monetary settlement against hospitals and physicians for patient dumping.
Methods: Review of OIG investigation archives in May 2015, including cases settled from
2002-2015 (https://oig.hhs.gov/fraud/enforcement/cmp/patient_dumping.asp).
Results: There were 192 settlements (14 per year average for 4000+ hospitals in the USA).
Fines against hospitals and physicians totaled $6,357,000 (averages $33,435 and $25,625
respectively); 184/192 (95.8%, $6,152,000) settlements were against hospitals and eight against
physicians ($205,000). Most common settlements were for failing to screen 144/192 (75%) and
stabilize 82/192 (42.7%) for emergency medical conditions (EMC). There were 22 (11.5%) cases
eScholarship provides open access, scholarly publishing
services to the University of California and delivers a dynamic
research platform to scholars worldwide.
of inappropriate transfer and 22 (11.5%) more where the hospital failed to transfer. Hospitals failed
to accept an appropriate transfer in 25 (13.0%) cases. Patients were turned away from hospitals
for insurance/financial status in 30 (15.6%) cases. There were 13 (6.8%) violations for patients in
active labor. In 12 (6.3%) cases, the on-call physician refused to see the patient, and in 28 (14.6%)
cases the patient was inappropriately discharged. Although loss of Medicare/Medicaid funding is
an additional possible penalty, there were no disclosures of exclusion of hospitals from federal
funding. There were 6,035 CMS investigations during this time period, with 2,436 found to have
merit as EMTALA violations (40.4%). However, only 192/6,035 (3.2%) actually resulted in OIG
settlements. The proportion of CMS-certified EMTALA violations that resulted in OIG settlements
was 7.9% (192/2,436).
Conclusion: Of 192 hospital and physician settlements with the OIG from 2002-15, most were
for failing to provide screening (75%) and stabilization (42%) to patients with EMCs. The reason
for patient “dumping” was due to insurance or financial status in 15.6% of settlements. The vast
majority of penalties were to hospitals (95% of cases and 97% of payments). Forty percent of
investigations found EMTALA violations, but only 3% of investigations triggered fines.

Read More
Societal Impact on Emergency Care

The Changing Use of Intravenous Opioids in an Emergency Department

Volume 16, Issue 7, December 2015.
Mark E. Sutter, MD, et al.

Introduction: Government agencies are increasingly emphasizing opioid safety in hospitals. In
2012, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) started a
sentinel event program, the “Safe Use of Opioids in Hospitals.” We sought to determine if opioid use
patterns in our emergency department (ED) changed from 2011, before the program began, to 2013,
after start of the program.
Methods: This was a retrospective study of all adult ED patients who received an intravenous opioid
and had a serum creatinine measured. We recorded opioids used, dose prescribed, and serum
creatinine. As an index of the safety of opioids, uses of naloxone after administration of an opioid
was recorded.
Results: Morphine is still the most commonly used opioid by doses given, but its percentage of
opioids used decreased from 68.9% in 2011 to 52.8% in 2013. During the same period, use of
hydromorphone increased from 27.5% to 42.9%, while the use of fentanyl changed little (3.6% to
4.3%). Naloxone administration was rare after an opioid had been given. Opioids were not dosed in
an equipotent manner.
Conclusion: The use of hydromorphone in our ED increased by 56% (absolute increase of 15.4%),
while the use of morphine decreased by 30.5% (absolute decrease 16.1%) of total opioid use from
2011 to 2013. The JCAHO program likely was at least indirectly responsible for this change in
relative dosing of the opioids. Based on frequency of naloxone administered after administration of
an opioid, the use of opioids was safe.

Read More
Societal Impact on Emergency Care

Opioid Considerations for Emergency Practice

Volume 16, Issue 7, December 2015.
Thomas Terndrup, MD

On a backdrop of increasingly distressing opioid misuse
in our communities, and safety concerns expressed by The
Joint Commission and others, emergency physicians are
further increasing their utilization of these important agents
in our patients. Are we selecting the best opioid for our
patients? Are we providing the relief they need? And are we
doing this safely? We all hope these questions can effectively
be answered yes, now and into our futures.

Read More
Societal Impact on Emergency Care

Transformative Leadership: Emergency Physicians Lead AOA and AMA

Volume 16, Issue 5, December 2015.
Kory S. London, MD, et al.

Introduction: Feedback on patient satisfaction (PS) as a means to monitor and improve
performance in patient communication is lacking in residency training. A physician’s promotion,
compensation and job satisfaction may be impacted by his individual PS scores, once he is in
practice. Many communication and satisfaction surveys exist but none focus on the emergency
department setting for educational purposes. The goal of this project was to create an emergency
medicine-based educational PS survey with strong evidence for content validity.
Methods: We used the Delphi Method (DM) to obtain expert opinion via an iterative process of
surveying. Questions were mined from four PS surveys as well as from group suggestion. The DM
analysis determined the structure, content and appropriate use of the tool. The group used four-point
Likert-type scales and Lynn’s criteria for content validity to determine relevant questions from the
stated goals.
Results: Twelve recruited experts participated in a series of seven surveys to achieve consensus. A
10-question, single-page survey with an additional page of qualitative questions and demographic
questions was selected. Thirty one questions were judged to be relevant from an original 48-question list.
Of these, the final 10 questions were chosen. Response rates for individual survey items was 99.5%.
Conclusion: The DM produced a consensus survey with content validity evidence. Future work will
be needed to obtain evidence for response process, internal structure and construct validity.

Read More
Societal Impact on Emergency Care

Special Delivery

Volume 15, Issue 6, September 2014
Lori Ludeman, MD

Two months into my intern year I experienced something that I thought only happened on television. It was 3 a.m. on a relatively uneventful night shift. Being one of the newest residents working that evening I expected to get the less desirable cases, and this one felt no different. A new patient showed up on the grease board: a 22-year-old female with a chief complaint of constipation.

Read More

Availability of Insurance Linkage Programs in U.S. Emergency Departments

Volume 15, Issue 4, July 2014
Mia Kanak, MPH et al.

As millions of uninsured citizens who use emergency department (ED) services are now eligible for health insurance under the Affordable Care Act, the ED is ideally situated to facilitate linkage to insurance. Forty percent of U.S. EDs report having an insurance linkage program. This is the first national study to examine the characteristics of EDs that offer or do not offer these programs.

Read More

Outlaw Motorcycle Gangs: Aspects of the One-Percenter Culture for Emergency Department Personnel to Consider

Volume 15, Issue 4, July 2014
Anand N. Bosmia, BA et al.

Outlaw motorcycle gangs (OMGs) are an iconic element of the criminal landscape in the United States, the country of their origin. Members of OMGs may present to the emergency department (ED) as a result of motor vehicle accidents or interpersonal violence. When one member of an OMG is injured, other members and associates are likely to arrive in the ED to support the injured member.

Read More
Societal Impact on Emergency Care

Depression, Suicidal Ideation, and Suicidal Attempt Presenting to the Emergency Department: Differences Between These Cohorts

Volume 15, Issue 2, March 2014
Bharath Chakravarthy, MD, MPH et al.

The World Health Organization estimates that one million people die by suicide every year. Few studies have looked at factors associated with disposition in patients with chief complaints of depression, suicidal ideation (SI) and suicidal attempts (SA) who present to the emergency department (ED). Our objective was to assess individual determinants associated with ED disposition of patients in depressed patients presenting to the ED.

Read More

Guidelines for Field Triage of Injured Patients: In conjunction with the Morbidity and Mortality Weekly Report published by the Center for Disease Control and Prevention

The Centers for Disease Control and Prevention (CDC) has published significant data and trends related to the national public health burden associated with trauma and injury. In the United States (U.S.), injury is the leading cause of death for persons aged 1–44 years. In 2008, approximately 30 million injuries resulted in an emergency department (ED) evaluation; 5.4 million (18%) of these patients were transported by Emergency Medical Services (EMS). EMS providers determine the severity of injury and begin initial management at the scene.

Read More

Contact Information

WestJEM/ Department of Emergency Medicine
UC Irvine Health

333 The City Blvd. West, Rt 128-01
Suite 640
Orange, CA 92868, USA
Phone: 1-714-456-6389
Email: editor@westjem.org

Our Philosophy

Emergency Medicine is a specialty which closely reflects societal challenges and consequences of public policy decisions. The emergency department specifically deals with social injustice, health and economic disparities, violence, substance abuse, and disaster preparedness and response. This journal focuses on how emergency care affects the health of the community and population, and conversely, how these societal challenges affect the composition of the patient population who seek care in the emergency department. The development of better systems to provide emergency care, including technology solutions, is critical to enhancing population health.