Emergency Care and the Public's Health
The development of new diagnostic, therapeutic, and information technologies
A growing need to prepare and respond to emerging public health threats
The expansion of the role of allied health professionals to address the workforce crisis
Novel expectations for care coordination
The fundamental economics of emergency care under new payment models, and
The key relationship with American law.
Emergency Care and the Public's Health explores the complex role of emergency care in the context of these changes and as an increasingly vital component of health care systems both within and outside the US.
From an expert emergency medicine team, this new title is a reference for emergency care and critical care providers, allied health professionals and hospital administrators. It is also for relevant for public policy and healthcare policy professionals.
Jesse Pines, MD, MBA, MSCE, Director, Office for Clinical Practice Innovation, Professor of Emergency Medicine and Health Policy, The George Washington University, Washington, US
Jameel Abualenain, MD, MPH, Assistant Professor, Department of Emergency Medicine, The George Washington University, Washington, US; King Abdulaziz University, Jeddah, Saudi Arabia
James Scott, MD, Professor of Emergency Medicine and Health Policy, School of Medicine and Health Science, The George Washington University, Washington, US
Robert Shesser, MD, MPH, Professor and Chair, Department of Emergency Medicine, The George Washington University, Washington, US
Emergency Care and the Public's Health
The emergency care system in the United States
Jesse M. Pines1 and Jameel Abualenain1,2
1 Emergency Medicine and Health Policy, The George Washington University, USA
2 King Abdulaziz University, Saudi Arabia
Over the past 4–5 decades, care in hospital-based emergency departments (EDs) has undergone a fundamental transformation. Emergency care of the 1960s and 1970s in the United States was delivered in the "emergency room" or "ER": literally, a small location or room within the hospital where a limited number of after-hours emergencies were seen. Then, the rest of the hospital was basically closed. ERs of the past had no legislative requirement to see patients who could not pay, and providers who worked there were not formally trained in emergency care.
Fast forward to 2013 and the large EDs of today are very different: sprawling departments with 50–100 separate patient rooms, immediate access to advanced technology, highly trained staff, and a federal mandate that all patients require medical screening examinations regardless of their ability to pay. The twenty-first century ED serves as the staging area for the critically ill and injured, an always-open location that provides high-quality acute unscheduled care, and has a critical role in the nation's safety net. While the ERs of the past arguably played a small part in the public's health, the ED of today plays a critical one, and the role seems to expand year after year. EDs are increasingly the "front door" of the hospital, currently the source of approximately half of inpatient admissions to US hospitals.1 EDs are the critical pivot point where patients from all walks of life have life-threatening diseases excluded or receive prompt treatment.
Today's US EDs have tremendous diagnostic therapeutic tools, resources (such as computed tomography (CT), ultrasound, and laboratory testing), and expertise at their disposal to deliver high-quality care. Yet, EDs simultaneously suffer from the wider systemic problems in the US health care system.
ED care is highly fragmented. Often, ED providers have little knowledge of patients' medical history beyond what patients can recount, or what information resides in their local hospital records. It is not uncommon that patients' primary care providers (PCPs) never receive the clinical information of an ED encounter.
The past decade has seen dramatic increases in the use of diagnostic technology in the ED, namely CT scans and laboratory testing. A recent study found that the number of CTs grew 330% from 3.2% in 1996 to 13.9% in 2007.2 While the CT has been transformational in the practice of emergency care, dramatic increases also mean there may be overuse. This is a particular issue in trauma patients, and in some trauma centers the CT seems to have replaced a careful physical examination.
ED crowding is a major problem that exists in more than 9 out of 10 US hospitals. ED care delivered during these more crowded periods has been associated with several negative clinical outcomes including poorer patient satisfaction, higher rates of complications and mortality, and lower quality of care.3 Several solutions exist that can improve crowding, and in some cases eliminate it, yet these interventions are underused.4
Electronic health records (EHRs) – which are now being woven into the fabric of US hospitals – solve many problems such as doctors' poor handwriting. Yet, at the same time, many EHRs are often difficult to use and can dramatically hinder ED performance during their implementation. Some create systematic errors, and most systems are not interoperable: information kept in one system cannot be shared with other systems easily.5
The objective of Emergency Care and The Public's Heal