SAEM (UAEMS) 1971 Annual Meeting Program

UN]VERSITY ASSOCIATION for ETIERGENCY MEDICAI SERVfCES

First Annual Meeting . t. - L97L May I4-I!, University of lt[ichlgan Ann Arbor, Michigan

TI{E FTRST AI{NUAI MEET]NG OF TJ{E UNTVERSITYASSOC]ATION FOR EMERGENCY MEDTCAI SERVTCES OPENING REMARKS

May l4 & Lr, L97L

CIIASIES I'. FREY, M.D.

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TASLE OF CONTE}'ITS

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PRXSIDENT]AIADDRESS Charles F. I1r" err University n f M i Ann Arbor,

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THE R$TOLUT]ON IN EMERGENCY NEDICAT,SERVICES CAISGORIZATION 0F HOSPITALS = THE IMPACT 0N YOU frvin E. Hendryson Chairman, Joint Corualssion on Bnergency Med.ical Services of the A.M.A. IJniversity of New Nexico Albuquerque, N. M.

....7

CATEGORIZATIONOF' HOSPITA]-,S4ERGENCYFACI],TTIES .

STII\O4ARY OF MORNINGWORI$HCFS Robert M. Zollinger, Jr. Case Western Reserve University Cleveland., Ohio

Report of Workshop #1 Ro-bert M. Zollinger,

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Report of Workshop # ThomasS. Morse Child.ren's Hospital ., ,25

Colilnbus, Ohio Report of Workshop #3 David. R. Boyd.

Northwestern University Chicago, Illinois

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Report of Workshop #,1+ Crrri I v J - ! L

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New York University N e wY o r k , N . Y .

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Report of Workshop #5 Harold. A. Pa.uI Rush Med.ical College C h i c a g o ,I l l i n o i s

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Report of Workshop#6 William Matory Howard.University Washington, D.C.

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Report of Workshop#T Louis G. Britt University of Iennessee I(nqxville,

Tennessee

39

Report of Workshop#8 Gerald. W. Shaftan State Unlversity New York, N. y.

43

Report o:ll Workshop #g Robert B. Rutherford.

University of Colorado Denver, Col-orad.o.

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TIN TRA]NING OF PHYSICIAIIS IN TITE E}4ERGENCY DEPASTI@IilI PA1\]EI,DISCUSS]ON Roland. FoIse Harborview Med.ical Center Seattle, Washington. . . .

TIIE NEED I'OR TRAINING PHYSIC]ANS IN EMMGENCYMEDICINE John Wiggenstein Lansing, Michigan. ..,...

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Ronald l(rome Detroit Receiving Hospital Detroit, M:iehigah.

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James W. A€na Cincinnati General Hospitat Cincinnatl, Ohio.

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t James Dineen Massachusetts General Hospital Harvard. Med.ical School Boston, Massachusetts.

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TIIE TRAININGOF PHYSICIANSIN TIIE E,I4ERGENCY 'iDEPAfiT}4ENT'' ' SUI\,[,IARY OF AFTERNOON WORKSII]PS l ' 'Alan Birtch Peter Bent Brigham Boston, Massachusetts. rDlaenta/ vv*r

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Report of Workshoh lfz George Johnson, Jr. Universlty of Nortn Carolina C h a p e lH i l l , N o r t h C a r o l i n a . . : . . : . . . . : I : Report of Workshop#3 John H. Carter Albany Med.ical Center Hospital A l b a n y , N e w' Y o r k . .l

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Report of Workshdp#4 Gustave Ad.ler Metropolitan

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Report of Workshop #5 Thomas J. ZtrkLe Loma Lind.a University Loma !ind.ar' California.

Report of Workshop #6 ' Christine E. Haycock New Jersey CoILege of Med.icine & Dentistry \Ter^rorL * \ T, e- r,^,J Jr eef gr esye. .Y . . .. ... .l ..

Report of Workshop#7 D. T. Freier University of Michigan Arrn Arbor, Mlchigan

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Report of Workshop #B Williarn R. Olsen TTnirror.c'i

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Page Report of Workshop /19 Ronald. L. I(rome Detroit Receiving Hospital Detroit, Michigan.

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Report of Workshop #t-O Peter C. Canizaro Southwestern Med.ical School iJarras, lexas

TI]E EMERGENCY UNIT - Improving

Financial

James T. Howell Peat, Marwick, Mitcheli

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I S YOURI]}4ERGENCY DEPARTMENT SO],VEM?

A STUDYIN COMMJN]TY I\MD]CALECONOMICS James R. MacKenzi-e McMaster University

HOlli CAt\ YOU MAKE YOL|REIvIERGENCY DEPARTMIXVT SOI.JVENT AIan R. Dimick University of Alabama

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CLOSINGREMARKS Michael .I. Mad.den University Hospltat Ann Arbor, Michigan

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On behalf of the University of ltlichigan and. its Med.ical Center, I welcome you to the Towsley Postgrad.uate Education Building.

It w'as a tittle over a yeal ago on March 5, L)fO in Birmingham, Alabama that many of us first met to find. out if we had. enough commonproblems to warrant formation of an associ-ation.

This question has now been answ'ered.. Everytime we get together we find. more problems in common. eight ind.ividuals in Alabama agreed. to One hu:rd.red. and thirty form an association which now at the time of our First Annual Meeting has over 352 d.ues paying members from universi-ties of the United. States and Canada. T believe this positive response re-affirms their need. for our Association which had not been met by any existing organization.

What has been accomplished. in the L4 months since the Birmingham meeting? First: We have constructed. a framework for our organization in the form of a constitution.

Second: We have given d.lmarnic impetus to this Association through d.ed.icated.energetic set of officers.

Third: We have ad.d.ressed.ourselves to keeping our membership informed. about activities in the field of emergency health services at our meetings and through our cornmittees for the purpose of helping our mernbers improve their own emergency d.epartments. We have made a good start on our informational program.

In the coming year the Quarterly Newsletter wiLI follow shortly on the heels of the prolific but iruegular stream of mail we now receive from Carrad.a. Fourth: The University Association for To give continuity to Emergency Med.icat Services is nou solvent. Fifth: the objectives of the Assobiation enunciated. in my opening remarks in Denver d.uring the Charter meeting we have d.eveloped four stand.ing eommittees to which we wiLI soon add. two more. The purpose of these comnlttees is to focus on the problems of' emergency d.epartment planning, and postgrad.uate physied.ucation of med.ical students, and. house staff, cj-ans, the training of emergency medical technicians and. regional plann i n s o f e m e r s e n e l rh e a 1t h s e r v i c e s .

These committees are also meeting d.uring this our first annual prograrn. AII stand.ing committee reports wiIL be sent to our membership through the Quarterly Newsletter. arr.rb

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Regard.ing the two new committees. Public pollcy is based on public'awareness and. concern and. is implemented. in our society through a Those of carrot and. stick system of economic reward.s and d-eprivations. us interested. in improving emergency med.ical services think we know wha,t need.s to be done but lack of awareness by the public and consequently a Iow priority of' fund.ing of'ten prevents implementation of necessary imnrovements- Therefore. T em nnnorrneins the formation of two new cornmittees, a resource committee which will keep you informed. regarding sources which will have an effect on emergency of fund.ing and. pend.ing legislatlon health services.

The second. committee will keep our members informed. regard.ing the costs of emergency med.ical care of the acutely iII and ,injured. prior to and. after hospital arrival. f

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I4y opening remarks at the Denver meeting were directed. at deflning goals for this Association.

These remarks are available in the proceed.ings of that meeting which you have received.. The proceed.ings were published. through the support of the Division of Emergency Health Services, Health Servj-ces arrd.Mental Health Ad.ministration, Public Health Service, Department of Health, Ed.ucation and Welfare, and. will also be published. as a package with the keynote ad.d.resses and workshop summaries in the JuIy Issue of the Journal of Trauma. The Association meeting wiII be head.Iined. on the cover and. constitute the first 20 pages of that issue. ruq@J, I want to examj-ne with you the nature of our Association and. the relationship of our association with other organtzations seeking to improve emergency health services. m^^

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and. strucThe nature of' our Association is d.emocratic in spirit Membership is open to all university emergency d.epartment d.irectors.

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There are no provisions for retention of an emeritus or old. guard. group which might tend. to diminish the effectiveness and enthusiasm of the newer younger contributors.

To further democratize our Associati-on, I recornmendthe executive meetings preceed.ing the anrlual meeting be opened. to any member luho would. Like to attend. provid.ing, of course, that he a B ' r ev e v ps Llbr

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Fistand.ing committees be open to any memberrulshing to participate. n e l l r r - i n s e l e e t i n s m e m b e r sf o r n o m i - n a t i o n a s o f f i c e r s t o s e r v e o u r a s s o ciation, Iet us naintain an equitable geographic d.istribution representative of our membershin. with other orgariizaticrrs, we again emphaIn our relationship size our d.esire to work in eooperation and. harmony to complement rather than compete with the work of other groups whose purpose it is to improve emersencv medica.I services in the United. States.

To this end. I recommend.that we establish liaison with those organizations with similar goals and. purposes. Fed.eration meetings such as are held. in the biologic sciences and. communication between executive officers are mechartisms through which such liaison could. be developed.. We have made overtures Care and. the Ameriregard.in! such proposals to the Society for Critical can College of Emergency Physicians.

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I want to thank aLL the offj-cers and members of this Association your hetp and. support over this past year.

I pred.ict ow oganization thr.nrro"h tho vqbrr

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T}IE REVO],UTIONIN EMERGENCY I\,{MICAI SERVICES CATEGORIZATIONOT' HOSPITAIS - TTM IMPACT ON YOU

Dr. Irvin

E. Hendryson

May 14, L97L

T]-IE REVOLUTIONIN EMERGENCY }{EDICAI SERVICES CATEGORIZATIONOI. HOSPTTAIS . TIIE I}.,PACT ON YOU

You honor me tod.ay by permitting me to address this first annual convention of the University Association for Emergency Med.ical gratitud.e. express my For that I Services.

I have been struggling with the word. Revolution in the assigned. having been identified" At first, title of this d.iscussion for some time. with the Establishment for a consid.erable number of years, the political overtones of its meaning relative to violence and. overthrow'of a system, Fwther redelivered. in a University atmosphere, caused" some concern. realized. that it also sugchagrin as flection changed. that concern to I gested. rotatj-onal motion about an a^:ci-s,which in some quarters may be id.entified. as ttspinning of wheels.rt The thought of such a possibility t.rno wa5

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d.irected. at the Emergency Med.ical most assured.Ly there is revolution placed. upon it.

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It is clear ind.eed"provocateurs.

that we are to me now and. I will state publicly If this be treason then make the most of it.

It is trnparalleled. in the rnagnitud.e of its purpose, its rejection of the past, and. its explosive change which is even now vibrant, mevolving. settled. and. still We are aII in fact at the epicenter of lt. the publication of Two of its bench marks may be identified.: the Neglected. Disease of Modern Society Accidental Death and. Disability, and. the revision of the Stand.ard.s of Accred.itation of the Joint CommisWithin the brief time spanned. by sj-on on Accred.itation of Hospitals. t967 to L97Lt a new concept in the d.elivery of priority these publications, med.ical services has emerged.. The Emergency Med.ical Services System has d.esign been recognized. and. the multiple inadequacies in its chain-Iink identified.. bench mark id.entified. the problem, as it d.id., the If the first These are excerpts from the second.brings regulation to its solution.

December, 1970 JCAH Stand.a,Id.sfor Hospital A.ccr,ed.itation in Emergency S,errri ncq.

STANDARDI A wett-d.efined. plan for emergency ca.re, based. on community needshall exist within every and. on the capability of the hospital, hospital.

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-r0STANDABDII The emergency service, when maintained., shall be well organized., properly directed" and integrated" with other d.epartments of the hospital.

Staffing shall be related. to the scope and. nature of the need.s anticipated. and the services of,fered.. ]NTERPRETATION The emergency service must be werl organized. and. compretery directed..

When warranted. by its activities arrd.its d.egree complexity, the emergency service should be organized. as a ,of d.epartment.

There should. be a Chief of ftnergency Service who is a member of the acti-ve med.ical staff . ft is to be hoped. that this stand.ard. for accred.itation transferred. to the university Med.icat school. faculty structure.

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The handmaid.en of Stand.ard I is Categorization for the d.iscrepancies in the capabiLities of Emergency Departments to d.elj-ver priorlty (ot, emergency) med.icat services are w'eLI known. Frey and. Huelke working at this lnstitution confirmed. it.

Moreover, the process itself is not so oininous as it once seemed.. Simpty stated. it becomes a method. for classification of the h o s p i t a l ' s e m e r g e n c ys e r v i c e c a p a b i l i t y .

Ostensibly, the basic purpose of categorization is to id.entify the read.iness and. capabitities of emergency d.epartments, hospitars, and. their staffs, to receive and. treat people with acute med.ical problems.

Ambularice person-nel, Iaw-enforcement officers and. others, havi-ng ad.vance knowled.ge of the d.esignated. categories of emergency d.epartments in an ateat will be able to select the institution to which emergent patlents should. be taken.

0f greater significance however is the fact that it offers a mechanism for institutional self-evaluation that inevitabty must offer the promise of capability improvement which, in the finar anarysis, wirr positively i-nfruence the d.elivery of emergency med.icar care.

The d-evelopment of programs to correct can only lead. in the same d.irection.

d.eficiency

and. weakness

Recognizing the ad.vantages of categorization of hospital- emergency services, physicians and. hospital administrators in many commurrities have categorized. their institutions, each using their own sets of

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Several criteria and schemes of implementation with varying objectives. ganizations have offered. professional e physicians, committees, and or standards wrd.er and. guid.elines, criteria, varying classifications efforts have d-emonThese be implemented.. might which categorization strated the need. for uniform categorization guid.elines, representing a general consensus of those working in this area. groups, includ.ing the Committee on Trauma Concerned. professional of the American College of Surgeons, the Committee on Injuries of the Conference on BnerAmerican Acad.emyof Orthopaed.ic Surgeons, the Airlie guidelines or that gency Med.ical Servj-ces, and. others, have conclud.ed. should. that might be released. nationally standard.s for categorization of the the auspices held. und.er conference come from a multid.isciplinary Commission on Emergency Med.ical Services of the Arneri-can Med.ical Association.

This Commission is composed.of representatives of those profesinterest sional societies arid governmental agencies having particular The Commisslon accepted. this and. voltxttary prograrns in this fietd.. cha.rse the Bcra.nd. the A-l4Apromptly provid.ed. fund.s, and of Trustees of the Conference was convened.on February 2T-2Bt L97L. The conference has been held., and. a working draft of its recommend.ations prepared.. Presently the d.ocument is undergoing its fourth revision and. only yesterd.ay was exposed. to further ed.itorial honing d r r r i 4nu 6g qqr

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There is nothing classifled. or secret about the d.ocument. It that a small ed.itorial of efficiency, was d.etermined., in the interest r,vork force should. bring it to final form and that goal has about been achieved..

T am privileged.

to sha,re with you a brief

previ-ew of its

contents.

As you know there wiII be four categories d.esignated. und.er A subtitle wilt broad.ly define the scope of the capability najor titles. of each category in the following fashion:

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CATEGORYI COMPREHI]NSTVE E}MRGMICYSERVICE SCOIE OF CAPASILIT]ES equipped., prepared., and. staffed. to The hospitat shalt be fully provid.e immed.iate, complete med.ical care for all emergencies includ.ing It shall have those requiring the most complex and. specialized. services. patient load.s a capacity adequate to accommod.atethe d.irect and. referred. support to of the region served. arid,be capable of provid.ing consultative professi-onal personneL of other hospitals in the same region.

CATEGORY II SERVICE MAJOREMERGENCY SCOPEOF CAPA3ILITIES The hospital shall be equipped., prepared, and. staffed. in all m e d 'ei a l a n d s r r r s i e e l s n e e i a l t i e s t o r e n d . e r r e s u s c i t a t i o n a n d l i f e - s u p p o r t care for all such to patients as need.ed.. It shall also supply d.efinitive foll ow-through patient requires who patients except for the occasionat Transfer may be necessary and. shall be care in very speciatized. units. hospitals. other agreement with und.er

CATEGORY IfI SERVICE GENERAI EMERGENCY SCOPEOF CAPABIIITIES The hospital shalt be equipped., prepared, and staffed. in most and. Iife-support med.ical and. surgical speci-alties to rend.er resuscitative by preservices Additional ilt or injured.. care of persons critically Transfer specialists. arranged. agreements should. be mad.ewith non-staff hospitals. with other agreement be und.er may be necessary and. shall

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CATEGORYW SERVICE STANDABDEMERGENCY SCOPEOF CAPAS]LITIES The hospital shall be equipped., prepared., and. ad.equately and. Iife-support med.ical serstaffed. to rend.er emergency resuscitative persons pend.ing injured. vices ill or to other transfer of criticalty hospitals.

Transfer when necessary shall be und.er agreement with other hospitals.

It shall also be capable of rend.ering ad.equate med.ical services for non-critical illnesses or injuries.

The specifics for each category will be found. i:nd.er subtitles relating to the ftnergency Department proppr and. the Hospital with its supporting services.

Commonto all

Continuing Personnel

of the categories will

Education Programs for AII

be requirements relating

Energency Department

Aud.it and. Review Regular Comprehensive Review Mass Casualty Preparations Emergency Treatment References Hospltal

and. Emergency Department Record.s

Poison Control The probLems inherent to the implementation of categorization were given special consid.eration by one workshop appointed for this task at the conference. and This group exannlned.the pros and. cons of categorization has broadest sense, in its their concLusion was that categorization, d.oes not necessarily in and of itself merit.

However, eategotization provid.ed.. can be quatlty of assistance in improvcare It improve the of ing the quality of care if an evaluation survey based. on the stand.ards to d.etermine quality and. continued. period.ically is cond.ucted. initially improvements.

The categorization system can best be implemented. if the d.everopment process comes from the ttgrass roots Level.tt A locar pla.nning comcil may serve as both a stimulus arrd.means for implementatj-on.

Such a counci-I or agency should. be representative of a variety of d.isciplines and. professional associations working in concert to implement the recommend.ed.categorization system. Maximurncooperati-on between this ptanning councir and. state and. area-wid.e heatth planning agencies should. be e n r - n r r r e c *r a od "*'

'innqn* *he In this somewhat d.evious fashion T h n r r e g n n r n p c h e d cutegortzation i m m e d i q f a i m n a o f r ^ r i l ' i ^f i,rill have on you.

The major course, be found. in some of the perplexing questions attend.ant to implementation.

Letts consid.er some of them: !!4rreqrQ

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There is a probrem in d.etermining an adequate suppry of hearth manpower. Determination must be mad"eof the need. for the physicians t assistant and. med.ical technicians such as returni-ng military corpsmen.

Provision must be mad.efor continuing education of all emergency servi-ce personnel.

Economic factors: The adequacy of existjng facilities and. equipment against desired stand.ard.s, the need. to alter the physical plan d.esign for expansion if emergency d.epartment is upgrad.ed", the economic irrrlt,ae mnaef, u

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There will be a problem in d.etermining the optimum number of each category lever for the rocal commwrity. Al-l areas d.o not need. every facility to be Category I a.nd.the proper ratj-o of services to meet the need.s of the commwtity must be arrived at by the Community Councit.

This may well mean that some hospitals wiII close their emergency d.epartments and others will upgrad.e their service level.

Problems may ari-se as to how to put ttteethrr into categorization.

The achievement of categorizatiott wiLI not be an easy task locally, regionally or nationally. uhich has not only the prime responsibility but also for the total med.ical care siven in need. to face the implications h-sted. below:

The med"ical for

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WiIL the professi-onal reputation and. status of a Category II, III, or fV, result in a change in nurnbers arrd. Levels of the med.ical staff?

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What impact wiII peer prograns?

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The'general feeling of the public nrrst be taken into consideration.

After aII, the hospital should. serve the community and its need.s. alter his view of the health could clrastically However, categorization patient community must und.erstand. and. and. the care d.elivery system.

The accept any new patterns whlch are established.. is the legal A major factor in categorization hospital, other allied. med.ical personnel the physician, The following factors must of necessity be consid.ered.: of liability

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Effect of liability Governors

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of other parties such as ambulance Effect of liability personnelr police d.epartment, fire d-epartment, volunteer rescue squad.s, and. the Patient

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the Board. of

for cateFor the future, the impact roill be more significant probably first step to be a most will gorization of emergency services a not unmixed. for the total Hospital, a sjmilar kind. of classification it witl pitfalls. accomplished., If traps and. fraught many with blessing with system concept of a Hospital to the regionalization Iead. Iogically a center and. its cluster of satellites.

It accuracy the colleagues. supported. by

in the present state of flux to portray wlth is d.ifficult and your impact it witl- have on you, this organization, Patently there will be new Health Care Delivery systems financing mechanisms whose form is presently tmknown.

with, At that time you will be remernbered.as the Revolutionaires you this on salute physicians f and. teachers, end.earment. As I trust, notable anniversary of the University Association for Emergency Med.ical a.nd.prosper--press onj Services--may you flourish

FACIIITIES CATEGORIZATIONOF HOSPITAI EN4ERGENCY Surnmary of Morning WorkshoPs

Robert M. Zollinger,

JY., M.D.

Case Western Reserve University School of Med-icine Cleveland., Ohio

CATEGORIZATIONOF HOSPITA-LEMERGM\CYFACIIITIES

meeting of the University d.uring the first O:: May th, tlfl of l4ichigan Association for trknergencyMed.icat Services at the University categorigroups d.iscuss the convened. to \^rere in fuin Arbor, ten workshop These sessions followed. a key zafr,ton of Hospita} Emergency Facilities. of a noting ad.dress by Dr. Irvin Hendryson which includ.ed. d.istribution ca.tegorization scheme as proposed. by The American College of tentative to the ACS Comrnittee on Trauma.

Surgeons Ad. Hoc Committee on categoyization and. the following comemotions These materi-als were received. with mixed. ments evolved.

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and. services in hospitals by serving d.ard.s would. upgrad.e the facilities as well as uniform standarcls which hospital physicians and administrators could. utilize. : s f i n a n e i a . ll r r r e s n o n s i b l e t r r r s t e e s a n d e l e c t e d . o f f i c i a l s The proposed. stand-ard.s Listed- both the manpower and. equipment required. in and many discussants emphasized.the need for speciemergency facilities, fic training and. conti-nuing ed.ucation of emergency personnel, especially A means of the physicj-ans who d.eal exclusivety with emergency practice. faciLities emergency performance the of and monitoring the capabilities or economic d-iffiwas proposed. as desirable d.espite obvious political should- be mechanism projected. a monitoring such that culties.

It was yet fotlow national categorizati.on guid.eregional in its administration J9l+.,

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that categori-zation of emergency al] anticipated virtualty by tocal rescue personnel by triage better could. result in facilities This system imnrorrins the initiat d.istribution of injured. patients. could. serve also as a basis for arranging further triage once stabillzing measures had been performed.. Actual examples of several or lifesaving citrr nr st.qte machanisms for triage of civi-Iian trauma were d.iscussed. and. most felt that real success would. be obtained. only when there was a.n effeetive svstem of communj-cationsbetween rescue and med.ical personnel in hosnif.als tha.t fi:nction in a coord.inated. regional manner. It was feared. that this was a utopian dream in the present system and would work lrf

rrvpyr

v

g*u

a n - l r r rw^t l urlhl e n n a ! !l I urllJ

fied. national

medi enl rlluqlvs!

health

n e r spnv rn4 rnu re l

yer

Several groups actively

hqrrc ln

and

hnsnii:a.'l

resources

existed.

in

a uni-

care system.

-l t- r. .m r !ir u J . i t r r . - -6 o -a- -.-o J c n c 1 r fr 4eue

d.ebated.r,rhether every hospital

^]+ M4 raJ r l - - F IgJ-Lr $

+t / rr l'4^u+

^-" arJ

institution

with

should. the

name

equipment arrd. must have emergency resuscitative hospitat in its titte available for be these should. and. therefore personnel for 1p-patient use eqt,-patient emergency patients who later could. be triaged. onward.. It was believed. that this goal could. be met in rural or conmunity hospitals.

However, this would. not be the case in the cities where multiple hospitals -t o-

-20-

have irregular geographic spacing, and variable commitments to carine

d.iverse means of financial for the ind.igent.

support,

Many workshops d.j-scussed.the issue of med.ical responsibility frur' nr

iuilc .hc

ilrrqlEerlL nd'ioan.F

.ir

.t-L^

nol-iant .L,d,u-Lctru rr.t r,rL.e city

afid. a strong

moral

commitment

was

expressed.

There was d.oubt that increa,sed. fund.ing for such a commitrnent was likely and the ad.d.itional problem of increased. use of emergency ward.s by non-emergency patients was exarnined.. some feared. that categorization would- provid.e aJL easy out for smaller or private institutions to crose their debt generating emergency d.epartments with the resultant j-ncrease in the load of non-emer8ency as weII as emergency patients on the nearest open institution.

Thus the relatively small nurnber of critically ill patients needing real ascend.ing triage may not be gleaned. from the general population seeking emergency care unless a carefully coord.inated. and. financial responsible, health care system exists for the local treatment of the non-emer8ency patients.

These people constitute the bulk of work in most emergency facilities and. there was tittle hope expressed. that "public ed-ucationtrwould. suceeed. in cha:rging this accelerating trend..

The general consensus was that categorization alone would. not improve health calre except in that it would. catl attention to the magnitud-e of the current problem. For categorization to be effective it uourq most rl-l(ely have to be part of an overall plan of regional hospital, med.icaL, and emergency personnel cooperation and. coord.ination.

This wou1d. be hard. to achieve even with the broad. financial and administrative resources of a nationar hearth system. However, the goal of an effective and. efficient regional hand.ling of emergency patients was affirmed. as a3 important one toward.s which University affiliated. hospitals should. strive. r ' ^ ' . ' l ^

* ^ ^ +

T i 1 - ^ a -

RIPORT 0F WORKSHOP #I MMICA.L SERVfCES CATEGORIZATIONOF EI'IERGI]NCY Robert M. Zollinger, Jr., Case Western Reserve University Med.icine, Cleveland., Ohio

School of

, first introd.uced. thernselves briefly Each of the participants with an outtrine of their own hospital emergency service setting or else repreto this conference. Most participants their special relationship cities. in d.owntoun systems Hospital sented. Larger, usually University rural representation.

There was very little but were aware of categorization OnIy a few of the participants eight of the I4 present feLt that their emergency rooms would. faLL in for achievj.:ag Category Category I. Some of the exaet details or criteria I status were then d.ebated.. However, the consensus was that the overall abitrity of the hospital and its supporting staff were the real d.eterminjng factors once reasonable staff and equipment were available in the actual emergency room'area.

The naming of these ind.ivid.ual categories generated. a d.iscussion as to how some hospitals would accept being placed. in nurnber three or four. &ccomwould. be, first This then raised the issue of how categorization would. be plished. and secondly enforeed.. Most felt that self-appraisal for each hospital to decid.e upon whj-ch category it wished. to sufficient toward.s. This implied. that a given area accept or upgrade its facilities would. have to parhad. regionalization such that alt hospital facilities felt that some form of regional authority ticipate a^nd.the participants composed. of tay menbers of the community as weII as those enmeshed.in the hospital business would. be a desirable system. However, the question of the actual performance and. more importantly, monitoring the facllities cases was felt to be such a emergency hand.ting of in of these faciliti-es complex thing that this workshop d.id not spend. any time exploring this issue except to say that it would. be a function of this regional committee.

The workshop then heard. d.iseussion concerning the categorization State Law and. their Department of Health after which had. begun by ILtinois action.

Apparently 22 of the pO hospitals in the general l97O leeislative rrfull ,servicett emergeney capabitity but Chicago a.Jreawere felt' to be of private hospitals the consequence of this was that several smaller or so as to increase the facilities began closing emergenelr and out-patient which in most cases were the overloaded, Ioad. on the nearby institutions public supported. or University centers.

This generated. a d.iseussion as to patients away from given facilities-not keep should. categorization how from Category I but rather how it should. the minor ilhess specifi-cally

-2L-

-22-

enable passing upwa.rd.sor triage onward of the major ones to Category I centers.

It was felt by some that University affiliated. hospitals would. pred.omi.nate in Category I a^nd.that by fully supporting this system, they would. essentially be preserving themselves and. their own good cases.

The other sid.e of the coin was that these same University centers must not turn away any patient for financial reasons and. this d.egenerated. into a d.iscussion of how to triage out lesser iII patients.

The experiences of BeIIvue were unfold.ed by Dr. Stahl, and. the use of night cljaics or community clinics w'ere d.iscussed as methods of acquiescing to the patient load. where as others d.escribed. the poor results from pricing out or increasing the length of wait so as to create inconvenience as a means of d.iscouraging patient entrace to the emergency system. AII participants felt that some regj-onal coord.ination therefore was necessary between not only emergency facilities but clinic and. hospital facitities; and. most d.oubted. that this could. be accomplished short of a powerful regionalization scheme, or more h-kely a national health system.

Dr. Ma:rtz d.iscussed. how the state of Ind"iana had entered. into categorization arid. how there were really few problems with the hospitals accepting it.

This apparently was accomplished. with a governors advisory committee on emergency med.ical servj-ces which essenti-ally was voluntary and. regional in its implementation.

He stated. how most hospitals basicgood. at self appraisal once the stand.ard.s were set forth ally were fairly and. how not everyone really vanted. to be Category I. Dr. Martz also mentioned that the ambulance services were categorized. in this system and this w'orked. fairly weII as it has to a d.egree in the regionalization of many large cities by the police who serve as a.rnbulancefacility in a city such as Boston, Cleveland. and. many others.

An extension of this was felt to be a mobile care r.mit as an attempt to bring a higher level of emergency service closer to the city patlents.

This in general was not successful in increasing the salvage of acute life threatenjng illness such as myocard.ial infarctions d.eath. However, these or card.io-respiratory care uni-ts were fairly important in rural areas where they are usually staffed. with voluntary personnel. fn the rural setting these arnbulance services know fairly well which hospitals have what facilities available arrd therefore a form of triage or categorization perhaps is more easily accomplished. than in the cities where there are competing institutions of variable fj-nancial abilities and. commitments.

The question of ed.ucation of the public in the appropriate use of the med.ical facilities, be it the emergency rooms or clinics, was d.i-scussed. in the Canad.ian provinces by the McMasters med.ical stud.ent. He felt that this was a very significant feature whereas the mqjority of participants felt that this was an impossible task in most cities.

-23-

fn summariztng the feelings of this workshop, most felt that categorization implied. regionalization and. that this was essentially a coming phenomena in which we should. actively participate.

Most were w'orried. about third. party interpretation or implementation of these systems and. about the method.s of monitoring the performance of emergency facilities.

By this most felt that nationalization of the health system I^Ias a genuine specter and. that accord.ingly some regional method- involving the lay people as weII as physicians and. hospital administrators should. be created. now to show that this form of cooperation and efficient utilization of resources could. be accomplished. by private and. public ind.ivid.uals rather than by the national government.

REPOBT 0F WORKSHOP #2 CATEGORIZATION

.

Thomas S. Morse, M.P., Chil{rents

Hospitat,

Colurnbus, Ohio

Categorization is probably inevitable, good PotentiallSr featureB :

blessing.

and 1s at best a mixed.

a)

May help to improve facilities in some hospitals by serving as ia uniform, sta,nd.ard. which layrnen such as hospital trustees or elected. officials can und.erstand..

b)

May be used. by local groups to improve the initia} d.istribution. of injured. patients brought in by rescue squad.s.

o )

May be used. as a basis for prearranged. secondary transportation once life-saving measures have been carried out.

d.)

l4ay serve in nonspeclfic ways to improve emergency med.ical care by calling attention to the magnitude of the problem.

Potentially

bad. features : and political

al

Subject to financial

b)

Basically affects only a small minority to emergency rooms.

abuse. of patients

going

May provid.e an excuse for some hospitals to refuse to offer their fair share of care, especially to ind.igent patients and. may pose unfair econom"lc hard.ships on those hospitals who are left hold.ing the bag. . l l

Undue attention may be d.evoted. to categorization rather than to the larger problems of organization and. trainirg paramed.ical personnel and. overall community or regj_onal h'1

---.i-^

!r4[rrJr6.

kesent

categories a)

are unsatisfactory:

They are too broad., i.e., some hospitals are prepared. to offer superb card.ia,c care but not neurosu.rgical care of similar quality.

-2r-

of

-ZO-

b)

They imply high and. low rank rather thar^l a$jiropriateness to Iocal need.. Nurnbersshould. be reversed., or better still, aboLished.

c)

Who the hell told. who to d.raw them up anryay? Participants d.o not feel represented. either in the d.ecision to draw up categories or in the actual work of d.rawing them up.

Even if a perfect scheme could. be d.evised. it would. not solve aII of the problems.

If the categories aJre properly word.ed., if the categorization ls performed. on a local or regional basis rather than by edict from on high, and. if the potential abuses a,re recognized. and. forstalled., categoriza,tion can make a positive contrlbution.

quibble

have the chance to do the job ourselves, rather We still until the government takes over and. d.oes it for us.

than

REPORTOF WORKSHOP #3 ASSOCIATIONOF LNWERSITY EMERGTJ{CY ROOMPHYSTC]ANSWORKSHOP ON REG]ONAIIZAT]ON OF EMERGM\]CY T'ACTLITTES David' R. Boyd., M.D., Northwestern uni.versity

Med.icar schoot

The Morning Session for d.iscussion of categoytzation of Bnergency Departments was chaired. by D. R. Boyd. and. started. essentiarry by statements of the experiences of the participants in regionalization 1n their oiln cornmunities. The fllinois program for the d.evelopment of a Statewid-e System of Trauma Facilities as d.iscussed. in its relationship to the implementation of such categorization is now possible in this state by virtue of the recent statute public Act This cate goriza75_IB)B. tion plan allows the communities to categorize themselves on a bas1c three-echelon system: an trAtr category which is comparable to the comprehensive emergency service system; rB, category which is comparabre to a major emergency med.ical service facirity and. ttcrrcategory which is comparable to standard. emergency med.i-cal service system.

This law allows for each areawid.e or conmunity to serect, by written agreement, the hospitar(s) interested. in performing emergency services, and has a tegar restriction that these hospitals must provld.e emergency services on a community or areawid.e basis.

This program is und.er the guid.ance of the Department of Public Heatth, Divisicn of ftnergency Med.ical Service Coirncil and. the community or Areawid.e trtrnergencyservice councir.

The San F?ancisco Categorization Schemewas d.j-scussed.,which has been developed. utitizing the previous Al{A Emergency Room Cate gorization scheme and. is impremented. and publicized. through the agency of the ftnergency Med.ical service Ad.visory committee to the Mayor of that city.

This program is weII pubticized. and. presumably the cornmunity knows what the available services are in any specific hospital, especialry in the ghetto and. Iower social economic areas.

There i-s no formal presentation of this categori-zation, i.e., in the yelrow pages or other d.ocument.

AIso, it was not d.etermined. as to what tegal restrictions the Energency Ad.visory committee may have to implement and. monitor this prograrn. rt is entirely voluntary and. teft to the general cooperation of the community.

There was no disagreement wlthin the group for the need. for categorization of emergency facilities and the rest of the morning was spent d.iscussing the essentials of an effective categorization scheme. tr'irst of all, it was d.ecid.ed.that one shoutd. d.iscuss emergency services and that categorization of ftnergency Departments only would. be a rimited' outlook in terms of categorization.

The total care potentiat of the hospitat, that is the emergency room, d.iagnostic facirities, intensive care units,

staff

physicians

and. pararned.ical personnel

should. be the

^Q

id afarm'in-ino foa*^u ---, ^^+^^u.crJc].lllrrrrflB rauuQ.r.-t_rl caregorization aJty scheme. The available personnel in the emergency care areas was the most important component of the several Listed. und.er Question ff2. ft was the feering of the group to set high stand.ard.s and to develop a.rr emergency room physicia.n who has to'ua1 resuscitation potential.

The varying experience of the participants with emergency physicians was d.iscussed. but it was felt that rnany of the eflergency room physicians were basi-caLIy medical or ped.iatri-c, non-sqrgically oriented.. These physicians may be hesitant to utilize the necessary

s tqt rrbgriueaer l D

q rurunuh r rDr o q D !na?u"unca! |' Lo{dr u

cr cD

nrrifino-in _L/uu'Jl-llb t-ll

tracheostomies and. many times lrait bV

q a_ p SuurfbgriuCaa! . l

n-^+ t\uu

3 v6 rrrnDcur !r uTa+l o u u r. t -

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for this

^d++;rn 6c:t/Ul-IL6

n:.-i+^ qufUe

end.O-tfaCheaL

tUbeS,

tytrre of care to be d.elivered. ^-ri+ OIJ-

n rI I O

o a

"t-^na^--tUaJ]ggnl,

+^^ trltc

^^^ellle-!'-

gency room physician was d.iscussed. and. the necessity of having a totally competent physician in the emergency care area was felt by all but this d"iscussion was curtaited. because of the afternoon prograrn was to ad.d.ress itself to this problem.

The terms of a categorlzation prografl and. one that witl work must evaluate the totar facirity, but id.entifiable items, e.g.. d.efibrillators, card.iac monitors and. other equipment that a categorizing bod.y courd. put their finger on must be sperled. out.

The substance of the equlpment was not as important as the quality of the personnel but these are definitely more readiLy assessed and r.rrfortunately l^iilt be the hallmarks

nf

nnrr

q vf vo n

..a e oov *a y i

zqf

i nn

e n- *h. ual l l e

-

.

The evaluation of a categorization program was d.iscussed- and. the self-evaluation of an emergency area was not to be the basis of such a system. Financial requirements and patient load. necessities of a hospital may influence the self-evaluation of the actual potential and. capabilities of arr institution.

It was thought that an outsid.e agency such as the Department of Public Heatth shoutd. have a monitoring function in the categorization process.

This would. make for a miform and. fair assessment of the care potential given an institution.

Categorization would certainly Limit the total care dellvery of an hospital.

Enforcement of this program by the same agency would be in the best interest of the community.

The first steps should" be through the municipal agencies by the diversion of criticatry iLL or injured. patients bypassing the limited. care facj-Iities.

This is already being d.one in some communitiesl Toronto has a city'w'id.e rule to take the patient to the nearest comprehensive care facility.

This is working quite weII. Although Toronto does not have a categorization scheme, the basic essentials of such a prograin is in fact in operation by an executive ord.er. The problem of ambulances taking patients to the institution of their choice for economi-c favors and kick-backs was d.iscussed.. This type of patient transfer must come und.er some kind. of regulation.

Here

-2a-

aâ‚Źain, an emergency servi-ces council or municipal aâ‚Źency can augment a sensible transportation scheme. Such a system should. be evaluated. by an outside agency, such as the Department of pubric Hearth.

Tn*ebasis for categorizaticn shoutd. be the total care potentiat and. emergency care potential of the institution, the most important aspect of it being the professional capabilities in this area and. specifically in the emergency room, the most qualified. person, either aJr emergency room physician or resid.ent-in-training shoutd. be utilized.. kograms that use interns and. other general practitioners, retiring plrysicians, or moontighting physicians should. be d.iscred.ited.. The categorization of hospitat facilities by the Department of Prrblic Health should. grad.e the total hospitat and. license the hospital to perform certain fi:nctions rather than specific personnel.

This would. make the hospital responsi-ble for pr6visj-on of such services and. would. give a hand.le to those enforcing aâ‚Źencies responsible for these regulations. the need. for the general upgrad.ing of the emergency area personnel, commwrications and. transportation systems would be possible with a categor:,zati on and. regionalization prograJn. There was consid.erable d.iscussion that the American CoLIege of Surgeon Categorization Scheme was cutting the things a little too fine, and it was the feeling of the group that there should. be only three basic care categories.

These shourd. be comprehensj-vecare facirity; general care facillty and a stand.ard. care facility.

An ad.d.itional category might be a walk-in 24-hour clinlc or infirmaries (ind.ustriat) tnat treat mostly noh-emer$ency patients.

This category should. be incorporated. into a,ny proposed. system to provid.e a basi-s of contror over these units.

A basic problem that was not resolved., and. was the apparent d-ichotomy between the care potential cabegortzation on one hand. d.one by the professional and. lay agencies, and. the ability to police these same categorization programs on the other hand.. As d.lscussed. earlier in the morning, categorization wou1d.not be worthwhile unless hospital capabilities, restrictions and guid.etines were enforceable.

The categorization system of ltlinois was again d.iscussed" and. the monitori-ng function is much easier in a rural area where the competing facilities are less numerous and. are alread.y self-categorized. as a matter of natural selection.

This process is rather d.ifficult in urban areas where the competition between facilities for a fixed. nurnber of available patients, along with the d.epend.enceon emergency room admissions for economic survival.

Here again, the d.iscussion of categorizing for the welfare of the emergent patient and. not the hospital was emphasized". It was the feeling of the group that recommend.ations of' categorization should. not be rhatered.-d.owntr and. thus make them mearri-ngless. It was emphasized. that all organization s and. persons involved. in these health servj-ce progralns must face the hard. cold. facts of finances and. availabj-ll.ty of ad.equate ca.re. Also, the care potentiar of any specific institution must

.tJ

-30-

fit into a commwrity-wid.e system, if r,re are not going to go brokb, and. d.o a great dj-sservice to the public, which looks to us for guid.ance in this complex problem.

It was agreed. that categorization itself witl not improve the quality of care but certainly categorization and. the consolid.ation of resources in a community witl in fact move us toward.s this d.irecti-on.

REPORTOF WORKSHOP #4

Cyril

Cameron, M.D., New york University

The first topic d.iscussed. was categorization The ma"in reasons for categorization were felt to be: I. 2.

3.

4.

identification of the capabilities promoti-on of efficiency regi_onally impetus to improvement publlc information

of Emergency Rooms.

of a hospital on a planned. basis

It was recognized. that these reasons would. not necessarily reflect favorably upon a particular hospital.

A poII of the mernbers showed.one in favor of categovLzat'ton and. fourteen agai-nst. The overall opinion was that categorization may work in cities, but would. be unhelpful in rural qTA'

A

The other major topic consj_d.ered.was the training of E.R. personnel, chiefly physicians.

Ihe presence of Jarnes Agna of Cincirurati in the group was most helpful in the lively d.i-scussion that followed..

Some of the points d.iscussed.were: l.

whether the E.R.P. (Emergency Room physician) should. have to treat a,mbulatory cases as well as true emergenci_es. (most members: t'yestt)

2.

whether courses in E.R. care shoutd. be given to med.ical stud.ents and house staff ("yust')

3.

evaluation

4.

whether the E.R.P. could. or should. be prepared. for munity role ("yest')

,.

the use of trained. paramed.ical persorurel ( t'essentialt')

6.

communj-cations and transportation or rural patients (I'essential")

7.

the necessity for the E.R. or Arnbulatory Care Department to seek equality with other Departments so that betterquality personnel may be attracted" to E.R. posts.

of the success of such courses ('rd.ifficult")

-?t -

systems for

a com-

peripheral

-22-

B . the ltdehumanizationtr associated. with E.R. c a r e ( a s e r i o u s problem for which no easy solution exists and to which a great d.eal more attention and stud.y need. t o b e directed.).

tha-frman I s Reconmend.atio.li:

D o c t o r D a r r e I Thorpe proved. an efficient arrd. capable secretary, and. is willing to act as chairman of a subsequent workshop.

nrBonrol wonrsnop #, REVOLrnrON IN EMERGENCY MIDICAI SERVICES, CATEGORfZAT]ON Harold. A. PauI, M.D., Rush Med.ical College

The workshop began with a porr of the 'rworkshoppers " on the question, "Do you think that categorization of emergency services is inevitable (or inexorabre)? rf so, why? what obstacles d.o you see?,, The group was unanimous in its opinion that categorizatj-on was d.esirable and inevitable.

A Canad.ian colleague (trtonaghanr euebec) spoke briefly of the effect of the "long report" of the Royar commission on Health which has had. a marked. effect on total categorization of all med.ical facilities in his province.

In his word.s the hospitals categorized. themselves, but the government regionalized..

Our participant from the usPHs (wottingham, washington, D.c. ) berieved. that categorization and regionalizatLon have alread.y been in progress and that we age now recognizing and. stud.ying the process so as to exped.ite it.

He named.lnstances in san Antonio, Texas, md southeastern Kentucky (Hazard.) as examples.

As obstacles to categorization and. regionalization many in the group foresaw the following factors--habits, plrysicia.n prestige, hospital financial worries, system vulnerability d.ue to sud.d.encurtailment of expend.itures for med.ical\y ind.igent by the State, in other areas economic competition (or the fear of it) between d.octors and. hospitals.

On further reasons for imptementation of regionalization Conte of san F?ancisco cited. a recent situation there in which there w,as rra crisj-s of I.C.U. empty bed.s.t' This was cited. as an example of expensive and rxrnecessary dupticatlon prod.uced"by inad.equate regional prarurlng.

Zirkle thought that administrators in many hospitats would. welcome regionalization.

Implementation might be d.ifficult, and. legislation might be need-ed.. Arso, the d"everopment of proper triage and. training peopre to d.o a good. job in triage would. be a special challenge.

Winkler ot'Ann Arbor ind.icated. that great impetus had. been gained. in his area by the organization of an emergency med.ical councj_r for the commlrnity, by the provision of acad.emic appointments for staff members of his hospital which is an affiliate at the university, and. by the institution of. a government subsid.ized HEAR system of rad.io comrmmi-cation between police arnbulance canj-ers a:rd participating hospitals.

He felt that the problem of categorization and regJ-onalization can be solved. without merging hospitals into one system. WoIf, University of Kentucky in Lexington, noted. that hospitats should. be categorlzed first a:rd. that emergency room categorization wourd follow.

Att felt that a wilringness of a facirily ro allow actj-ve medical aud"it of its emergency room activity for quality an4 efficiency was ar. essentiar character in rating or categorizing the facility.

-33-

-34-

To the question a

surorising

maioritrr

rrnted

t'Should.every hospital lln6

lr

An

o l n n r r a n fr r v

have an emergency room?tl

'm r rirnr vn rr i l r fr, u J

c *r o. d +ro* "- .i =hd^", o

thcir

vier,point welr (Monagha"nand. Allen).

The minority position pointed. out that every hospital should. be able to provid.e resuscitation and. tifesustaining measures for its local community and. for its in-patients.

Further, the danger of even more unequal d.istribution of load. with subsequent hazard. to patients mighl result from irnplementation of a position which allowed. certain hospitals to escape from some o ligation for erierp'cnrilr

qarrr-i

aoc

On the other hand., the majority argued.: (f) funergen cy room facilities could. be expensive duplications, especially in cLusters of hospitals near each other, (Z) " carefully planned. network with good. cornmunication would. be more rational, *d (3) uetter nationar heatth cost coveraâ‚Źe regard-ed. by many as imminent would. red.uce the economic hazard. or eliminate it.

AII felt that their o",'n facilities rated. in Category f (highcst), although careful examination of any system known or und.erstud.y prod.uced. thoughtful qualification by severar participants when they thought of such regulations as rapid availability of bLood. or incorporation of radio communication.

In summary, this workshop was characterized. by rmiversal participation a.nd.enthusiasm. It felt that categorization and. regionatizatton carefully planned. would be a good. thing and should. be worked. towa.r'cl.

Although several expressed. the opinion that regulation or legislation would. be necessary to assist in implementation, there also appeared. to be a consid.erable consensus tha,t many d.etails could. be worked. out within each system and that this would be prefereable to super-imposition of any categorization that was rigid d.ownto minutiae.

nnponror wonrssop #5 REVOLUTION]N EMERGH\]CY MEDICAI SERVICES: CATEGORIZATION Thomas E. Piemme, George Washington University

Med.ical Center, Wash.rD.C.

Workshop ff5 add.ressed.itself to four questions.

Available to us were the previously circulated. five-class categorization that resulted. from the Airlie House Conference. Although there witl be substantial revisions, the Workshop d.id. not have these avaitable for d.iscussion.

Although comments refer to the earlier d.raft, they wourd. be as appricabre to any subsequent d.raft that maintains the same rigid. criteria in the higher categories.

A summary of the d.iscussion relevant to each question fol.Iows: Can or should any hospital |

^ T

meet the crit_eria

d.elineated. in categories

t t ' /

A recent survey in the State of Georgia revealed. that no hospital within the Commonwealthwas able to meet the criteria d.elineated. guid.elines; category within I or II or the that only two hospitals within the State were able to meet the criteria of category fII. No hospital with which the Workshop particlpants were affiliated. was capable of meeting the requirements for category I or If. From our knowledge of other institutions in the United. States, it is fair to say that no hospital in the United. States is presently prepared. to meet the criteria of categor:y I. The specific inhibiting requj-rements were first the d.emand. that blood. be available on site typed. arrd cross rnatched.within l-l minutes. most hospltals would be the requirement for the preInhibiting sence of a burn unit within the emergency center.

There is much issue as to whether it is appropriate to mand.ate the presence of a fully equipped. operating room within the emergency unit.

Nor is the requirement that the fuII range of speci-alty services be present within the hospital twentyfour hours a day necessarily a prud.ent one.

Rigid. national categorization flies in the face of comprehensive hea.'lth nlanninsThe nresence of more than one or at most tw'o burn units within most large cities is patently outsid.e the realm of good. jud.gment. Rather, effective d.issemination of knowled.ge to the public and. to transportation agencies vould. result in better utilization of facilities where highly specialized. firnctions might be concentrated..

On the other hand, the absence of a burn unit in cities where there is good. pri-or health plaming should. not d.eny the other major institutions the opportunity for appropriate categorization at a high Level for its other furrctions. too rigid-, and make In surnmarfy,the stand.ard.s are entirely

'J)-

-Jo-

the assumption that its own wheel. shourd. universlty

each hospital

hospitars

d.esiring status classification

invent

be requi'ed. to meet minrmum stand.ard.s?

There was a unani-mous agreement of the workshop that this ques_ tion should be a.nswered-affirmatively.

The principal reason for this wa,s that unlversities are increasingry becon-lng the d.ominant centers for ed.ucationar prograrns of alr types, that they provid.e an i*epracable community resollrce, and that they serve as mod.els for other hospitats within their sphere of infruence.

These mi-nimumsta'd.ard"s having been id.entified', they shourd. perhaps serve as a basis for red.efinition of category f.

Should cate

izatiort

aud.it be established. on a r

a I b a s e?

onal,

or on a nation-

rt was the strong feeling of the Workshop that aud.it should. be provid.ed. regionarry, a.nd that the B agency of the comprehensive health pranning act should. provid-e that aud.it, or at reast bear the responsibirity for categorizing locar hospitars.

This is entirery in the interests of good. pla.nning. rt is unnecessary that a city of )orooo be served by five category r emergency rooms; it is equarly inappropriate that a city of SOOTOOO be served. by no hospltals whose services would. entitle them to high quality categorization.

Further, pranning agencies may increasingry wish to restrict hospitals from evolving very costty highty specialized. units avaitable elsewhere within the region. tror example, no more than one hospital within a reglon need. have the capacity to .do renar trarrsplantation or open heart surgery.

Nor need. there be more than one burn unit if the unit is sufficiently comprehensive and. of capacity to serve a large metropolitan area. There is a substantial risk that categorization in one of the higher levels may become a status symbol and an objective of a board. of trustees, an objective that may be inappropriate and. not in the interest of area wid.e ptanning.

Are tLe criteria T

TT

as stipulated"

--l TTT raJtcr L-rt nospitals

all_ that

should. be required. of cat

?

The answer to this was clearry no in that the capacity to deIiver emergency health services d.oes not guarantee that the hospital yill rend.er th,em to all patients without regard. to the economic status of the consumer or in some areas to his race. fn ord.er that this be j_nsured., we urge the inclusion of the stipulation that all hospitats within categories It rr, and. rrr must receive, treat, and. see to appropriate folrow-up care of all patients vho present themselves without regard. to resource or evid-ence of the abirity of the patient or third. party to pay for services rona-i

rrorl

-37-

psychiatric tributio.ns

Littre or nothing in the guid.elines is said. of soci_al and. services or of the quarity of nursing a.nd paramed.icar conto patient care in emergency rooms.

fn summary, the facets of health care ad.d.ressed.in the d.raft d.ocuments available to the workshop are at the same time excessivery rigid. in areas where they should. be, and. tack stand.ard.s where some should. exi-st.

EEPORT0F WoRKSHOP #7

Louis G. Britt,

IJniversity

of

Tenncccoa

rFanno , --....-ssee

The initial d.iscussion in the workshop was d.irected. at the suggested. Iist of questions: Question I It was generally agreed. the basic reasons for categorization were to set acceptable star:.d.ard.sand to genera,Ily improve aII &nergency Rooms in the country. ft was atso fert that this might herp cut d.ornmon wasteful d.uplication of effort and facilities.

Question II The group fert that it w'as impossibre to separate the basis for categorization as listed.j however, personnel and. facilities in the Emergency Department were thought to be far and away the most important aspects.

The relatlonship between these two factors was more i-mportant then any single factor.

Question Iff The standards should. be national in scope and. for political reasons, regi-onal ad.visory and. evaluation committees would. be most appropriate.

In ad.d.ition, there are many reglonal problems which are totatly d.ifferent from those in other parts of the eountry, so that although basiq national stand.ard.s could be set, variations would. be necessary on a regional basis. q,uestl_on IV Arr agreed. that this was basicalty a problem of ed.ucation in that the patients should. be taken to the proper facirity on the front end. thus avoid.ing the problem of limiting the abititles to treat. rf regional Emergency Departments were available, then initiat resuscitative care shourd. be availabre in any Emergency Department, with the patient then referred on to a more complete center.

Question V The group was quite d.efinite that every hospital should. not have an Emergency Department, if the legal and. the accred.itation stand.ard.s coul-d be adequately hand.Ied.

-39-

-4U-

Question Vf There l^ias an r.;nqualified I'yest'to this question with the und.ersta:rd.ing that regional centers were mand.atory. Ad.d.itionally, the rurar and urban problems in many ways, although interrocking, wilr have to be consid.ered. separately.

SpecificaLLy, it would. seem appropriate that mariy urban and. suburban hospitals could. easily interlock facilities whereas, those in smaller towns would. have to be associated. with one or two specific centers in a large urban population.

Question VfI Ad.equate record. keeping a:rd. aud.iting, of course, was consid.eredmand.atory by all participants in ord.er that the problems in d-elivery of emergency care cart be und.erstood and qua^ntitated.

Ed.ucational programs both in the hospital having Emergency Departments and. ad.d.itionally in raoi

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aarlare

would.

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Question VIIf The participants, of course, were familiar with the scheme set out by the Ad. Hoc Commi-ttee on Trauma of the ACS but they felt that they were unrealistic.

Question IX There was general agreement that no hospitat could. really place itself in Category f as d.efined. by the Ad Hoc Committee. That many would. have d.ifficulty qualifying for II but that it is much more important to categorize the level III and. IV facilities.

The d.iscussion continued-, one of the major points being, that where trauma centers have been set-up specifically in Chicago, that some of these smaller suburban hospitals had immed.iately cLosed. their Bnergency Roor,s a:rd. had. "d.umped.r'a large number of patients on the more compLete facilities.

Unfortunately, these patients were not necessarily emergencies or traurna so that it was felt that the categorization and. ren'i anof i pn+'i^h El-onaL]-zaufon

^r'ten orlen

c o u l d . bpe coul-q e

self -defeati sel^

nrr - esneei al lrr in

f , h e -.trge l,r

urban centers.

Because of these problems, regionalization was thought to be important ln terms of d"ivid.ing the problems into the urban areas often associated. with medical schools arid. Large ind.igent populations and. categorizing rural areas where the problems are consid.erably d.ifferent then

thev

are

in

the

'l

arse

rrrhpn

centers.

About half the group were strong for categorization but had. some strong d.oubts that it would. work efficiently. point that major One was made, however, was that this w'as aJr isolated. area of stand.ard.ization

-4r-

and inprovement in care; and that categorization should. be coupled. along w i t h the coordifration of an overart change in the delivery of hearth servi-ces to make it really meaningful.

Further d.lscussion ind.icated. to mar.y people that the stand.ard.s as outlined. by the Ad Hoc Committee on Trauma were basically impossible and referred. much too often to hospital facilities rather than to Bnergency Card.iopulmonary Resuscitation and. supportive personnel and. facilities. kobably the most important aspect of categorization are the category rv hospitals, rather than the category r hospitals.

Thrs creation of stand.ard.s, care, equipment and. personnel.should. be much more important in terms of ad.equate emergency management of the targest nurnber of rF n v rr .

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bypass, renal dialysis, etc., are important only in a small numbers of patients as opposed. to the rather large volume of peopre injured. on the highways and. outsid"e of instant contact with category r facirities.

Therefore, it was felt that the Category III and fV facilities should. be concentrated. on, to encourage hospitals to at least reach these standard.s rather than close their emergency facilities, thus actually d.ecreasi-ng the amount of emergency care avaj-Lable rather than improving it.

The essence of most of the d.iscussj-on was that orgNtization and categorization were important if they were incorporated. into an overall Tegional system of deliverying emergency a.nd.other health services.

REPORTOF WORKSHOP #B

Gerald. W. Shaftan, M.D., State University,

New York

of frnergency General agreement on any topic on categorization Med.ical Services was not obtained. although all members of the d.iscussion in group d.id. confirm the need. for interlocking of ftnergency Facilities Hospitals in close proximity in ord.er to provid.e high level emergency care to a cornmr-lnityin all d.isciplines.

In a broad way it was the conof frnergency Departments was a sensus of the group that categorization TTecessa.rv a a rn q d

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for

srnerinr pe.!/vr

mediea.l

emergent

CaJe.

was premature and. would.

It uas felt by maJryr however, that categorization be practical only as part of a regional hospita} categorization plan restsince so ntuch of the basis for &nergency Department classification It was noted., in ed on the backup facilities available in-hospital. nroo-inn

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be

consid.ered

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gency Department cLassification, for no matter how adequate the staffing, a restricin the frnergency Department itself, equipment, md faciLities policy should automatictive (possibly for economi-creasons) admi-uting Emergency Department to the lowest category. aIIy red.uce that hospital's estabLished stand.ard.s would It vras suggested. that nationally place a floor for minimum accred.itation of a hospitat and. cause community pressure for upgrad.ing the avaiLable facilities.

It was the consensus of the group, that based. upon these national stand.ard.s, specific categorization assignment should. be carried out at the local level--once again as part of a regional med.lcal plan.

It was hoped. that categottzat'ion would be a means to ind.uce hospital board.s and" trustees to increase the quality of the'ir FinersenerrT)enertments and this was consid.ered.the primary value Second.arily, 1t was felt that with ad.equate classiof such classification. fieaf,ion- in association r,lith a regional hospital plan and a well-coord.inated. communication system--that is one that permits arnbulance to phya mechanism nould. evolve s'i c'i an or nhvs:ici an tn nhrrsi e-'ia.n consultation patients accord.ing to the need. of for proper and. equitable d.istribution of the patients for Emergency Department a:rd"hospital facillties--1n informed. triage. other word"s intelligent 4uvf

vr

frrJ

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for Emergency Departments as suggestedThe categorization hrr tho arl Tfna committee of the Committee on Trauma was consj-d.ered.far uJ urru lrvv vv nu better than that proposed. by Dr. Henderson. While aLL hospitals in an area of hospital d.ensity need. not have an Bnergency Department as such and. might or should" post signs ind.icating that they d.id. not care for using the name e m e r s e n c v n a t ' i e n t s - . it u a s f e l t t h a t a L I i n s t i t u t i o n s "hospital" in their title personnel to operate should. have equipment, with vlrvr

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-43-

-44-

this equipment, for the resuscitati-on awaiting referral transfer.

of both in and out-patients

while

Discussion arso centered. on a changing emphasis in Emergency Department orientation, away from the perhaps more spectacular but less commontraumatic problem toward.s the routine med.ical d.ifficulties that are consid.ered. emergencj-es by the patients presenting themselves to these facilities. koblems of categortzation aLso were d.i-scussed.includ.ing resj-stance to categorization because of the inevitable ensuing pressure and.monetary consj-d.erations, resistance to transfer of patients to other facilities for much the saine reasons and. the d.ifficulties in enforcement of categorizations of tsnergency Departments because of local hospital pride.

While no concLusions were reached. on the solutions to these problems it seemed.to us that with National Med.icat Care, many of these d.ifficultles would solve themselves.

In summary, our Group believed. that categorization of Emergency Departments should. be d.etermined. at a local level on stand.ard.s d.eveloped. nationally, utilizing these categories as part of a regional med.ical plan, and. that until such hospital regionalization was effected. there was little ratj-onale for their categorization other than to stimulate the upgrad.ing of existing Bnergency Departments.

REPORT0F WORKSHOP #g CATEGORIZATION OF HOSP]TAIEMERGFJICY }4MICAI SERVICES Robert B. Rutherford., M.D,, University of Colorad.o

tion

The group unanimously approved. the basic of El4S.

concept of categoriza-

The proposed criteria for classification were thought to be fairly realistic except possibly for Category I, but it was felt that the separation between categories should. be more d.istinct, particutarLy between Categories I and. II, If and. III whereas the gap between III and. IV was d.isproportionateLy great It was felt that volunta.:ry regional ad.option of recornmend"ed. nationar guid.erines r,ritr take consid.erabre time, particurarly in the United. States, as opposed. to Canad.a, which has stronger national controls and is already more ad.vanced in regard. to regional planning for emergency medical services.

However, because of the great d.ifferences from one region to another in the United. States, the group felt that these guid.eIines probably would. have to be mod.ified. and. ad.opted.to fit ind.ivid.ual need.s.

It was anticipated that categorization would. be d.etermined. on the basis of a self-eva,Iuation questionnaire fotlowed. up by a site visit.

The question of just who would. d.raw up the questj-oru:aire and. make the site visit has not been recommend.ed.. Carried. further, the need. for some recognized. authority in settling matters pertaining to categorization to categorize hospitals initiatly and. period.ically reassess their status, to assure conformi-ty with the stand.ard. ad.opted.need.ed to be faced.. That is, there was concern that without some reasonabLy strong authorlty or tlbitetr to categori-zation, it might fair to have much lasting impact. rn this regard., it was suggested that it was unrealistic to expect the Joint Commi-ssion on Accred"itation to provid.e any reverage in this regard..

Generally, i-t was agreed that since categorization would. probably have to be a regional matter, its implementation would. Iikety fall to some regional med.icar planning aâ‚Źency, such as a community ad.visory council on emergency med"ical services.

That is, the first step toward.s categorization would have to be to either convi-nce the existing regional pranning group to take thi-s on, or, in other regions, require the formation of such a group, d.e novo. Thus, categorization wourd. serve as a stimulus for regional planning of EMS, but in many regions, categorization could. not be accomplished. until a solid. for.u:d.ation for regional med.ical nl annino

h a r l f i r gufu,

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established. uouqwrrDtrsq

and qtq

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}/*vJaU_LIJ_Lry,

-45-

ma.lty years away. In ad.d.ition, following the actual categor1zation, there would. be consid.erably more time consumed.before its implementation 1n the form of an organized reglonal or conunllnity plan governing the transportation of the acutely iII and injured. by ambulance and. other rescue workers to the appropriate hospital.

In regard. to other factors which might be taken into consid.eration in determining categorization, in ad.d.ition to ED space, equipment, personnel and. its backup facilitles, it was suggested. that it wourd. be d-esi-rable to have some means of measuring performance.

The form that this should. take was not elaborated., except for the suggestion of a utilization review of the emergency services, includ.ing all d.eaths and. complications arising from emergency d.epartment admissions.

It was felt that the factors currently d.etermining t,he hospiral to which acutely ill or injureri. patients are taken in each community, were usually poorly defined. and as often as not, based. on informal local grourrd. rules which were further modified. by a number of subtle factors which had. nothing to do with elther the patientrs cond.ition or the ability of the receiving hospital to provid.e prompt and. ad.equate management of that cond-ition.

It was suggested that many of these extraneous factors rvould. have to be recognized and. d.ealt with, before categorization could. be successfully implemented. rt was generarly fert that, if nothing else, categorization would. Iead. to an upgrad.ing of the emergency med.ical services of a significartt number of the hospitals being categorized-, to the next highest level, while others would- probably want to t'd.rop out of the emergency room businpq o tl a nl-i rol rr rrsDD s*urrsl.J. Ilrrwever, it was felt that in implementing a regional p1an based on hospital categorizaLion it would. be important to also obtain specific commitments from the various hospitals in the communicy or region, regarding their role in the management of the 'hon-emergency" patient.

That is, if j-ncreasing numbers of emergency patients wourd. be referred. to the higher category hospitals, it would. be unrealistic for them to also be expected" to hand.Le increasing numbers of non-emergency patients.

As possible sotution would. be for certain of those hospitals that were not expected. to provid.e care to the acuteJ-y iIJ- and. injured. at the higher levels to maintain open clinics for the }ess seriously ill or non-emergency patients.

There were no strong sentiments regard.ing a preference for four or five categories, but several felt that the names of the categories should be more obvious in their implications regard.ing the ability of the institution to provid.e emergency med"ical care.

The current names were criticized as not provid.ing any obvious d.istinction between the four categories.

For example, possibly as an attempt not to offend. any institution, the Lowest category was currently id.entified. as a stand.ard.. rather tha,n a limited enerB'ene\rserr-inc

-47-

It was felt by some that it might be just as vell if the public r,'rerenot involved. in categorization.

That is, categori-es could. be assigned. plan and. a regional based. on this d.rar,'rnup, and. all the appropriate ambulance and. rescue workers given specific d.irections accord.inglnr with little need. to involve the general public.

With the general public out of the picture, hospitals might be less threatened. by their assigned category. in rural 0n the other hand., it was countered. that, particularly to the hospitals was frequently not by arnbuatreas where transportation Lance, it would. be important for the general public to know exactly rrhat the d.ifferent categories implied..

It was generally agreed. that while nurnbers probably should. not be used., that the names of the various categories should. be more explicit.

It was also felt important by some, that whatever regional plan was implemented. in regard. to categorizartion, that the abitity of patients to pa,Vr as implied. in the new Stand.ard.s of Accred.itation of the Joint Commission, should. in no way d.etermine patient d.istribution.

FinaILy, it uas felt that it would. eventually be important to have some system of evaluating just how weIL categorization was working.

This evaluation plan should. be d.esigned. prior to the implementation of categorizatlon later. and. not as an afterthought any It was felt that the emphasis should. be on not restricting hospital from improving its emergency servj.ces or limiting its participation in the d.elivery of emergency med.ical services, but it was important that each hospital perform effectively at the level of categorization they chose to attain.

Most of the remaind.er of the d.iscussion centered. about the probIems of implementation which were thought to be the place where categorization would. either succeed. or be aband.oned..

DEPASTMENT THE TRAINING OF PHYS]CIANS IN TIfi EMERGENCY PANELDISCUSSION t:OO P.M.

Dr. Roland Folse,

Chairmart

T}M TMINfNG

OF PHYSTC]ANS]N TiM EMERGENCY DEPASTI\MNT

we are goj-ng to change the format just a rittre, but stirl the same content. kobably the most important area that we can d.evote ourselves to as physicians in university centers has to d.o with the training of other physicians.

The need.s are extremely great at this time and. we are d.everoping around. the country a rarge number of emergency centers that require physicians to man them on a 24-hour basis.

The numbers that we need, how we are going to train them, and. what tytrles of physicians-all of these are lmportant questions that we are going to try to at Least raise tod.ay. we have a group of experts who each in their own way aJe working ln this area who will try to give us in perspective the problems related. to each area and. then we will have some genqral d.iscussion after these brief presentations and. then we wiIL be able to carry much of' this question and. d.iscusslon period. into the workshops.

Our flrst speaker is Dr. John Wiggenstein, who is the Chairman of the Board for the American colrege of Enrergency physicians.

He has been very active on the natj-onar scene and. has talked. to many, .many physicians who are working in this area and. he vilt tark to us about the needs in this cormtry for the training of this type of physician.

-q1 -

MEDICINE TIIE NEED I'OR TRAINING PHYSICIANS IN EMERGH\]CY Dr. John Wiggenstein Lansing, l4lchigatt

you have all heard. and read. much about the ttcrisis in emergency ca3e.tt It is said. that our emergency d.epartments across the nation are not only mismartaged.and. poorly staffed., but, to hear some teII it, most in many areas much Unfortr:nately, and. acad.emic d.isasters. are financial to this dilemma Numerous factors contributing of what they say is true. are: heard commonly have been suggested.. some of those more f-)

the increased. use of the emergency d.epartment by the general public for non-emergent reason

2)

the publicts

3)

the rising sancra

incid.ence of traffic

accid.ents and. trawna in

I

the mobility

4)

increased med.ical awareness

of o*r patient

population

tod.ay, etc.,

etc.

I think we can aII read.iJ-y agree that these are legitirnate factors conbut what is absolutely to our emergency d.epartment problem. tributing facamazing to me is the fact that seld.om is one of the most significant physicians that tors implicated., that is, the d-eplorable lack of training The average physician is d-efinitely receive tod.ay in emergency care. short chalged. by his med.ical ed.ucators in this respect and therefore in a.n emergency d.epartment setting. calnot practice effectlveLy Let us examine his acad.emic background.. Where d-id. he receive this rrainins?

T h e c h a n c e s a J e s l i m t h a t h e r e c e i v e d . m u c h e m e r g e n c yd . e tr'ew schools ind.eed. includ.e emerpartment training in med.ical school.

During interns'encv med'icine as a4 ind"ivid.ual entity in their curricula. d-uty department pult emergenci forced. to ship this luckless fellow may be j-n a satisfactory but because of poor supervision this seld.omresults Learning experi-ence. The picture is much the same d.uring his resid.ency. and member of the med.ical staff of as a private practitioner And. finally e hosnitat h e m e r rf i n d h i m s e l f a g a i n f o r c e d . t o p u I I h i s s h a r e o f e m e r in ord.er to maintain his staff privileges. gency d.epartment responsibillty a

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service Gentlemen, I need. not suggest to you that involuntary to you suggesting I am is not conducive to high quality emergency care. that at no time in the average physicianrs ca,reer does he receive ad.equate marlaâ‚Źementof patients in the emergency d.epartin the efficient training properly ment and at no time in his career has he received. sufficient

-r3-

- > 4-

supervlsed. experience in this d.epartment. And. I also suggest to you that unless appropriate ed.ucational progra.lns become more read.ily available, this so-called. t'crisi-s i-n emergency carerr is only beginning. we d-es_ perately need. programs in emergency med.icine at alr levels of th: med.ical educationar }ad.d.er, in every med.ical schoor curriculum, md as a require_ ment j-n every general rotating internship.

We need. resid.enci_es in emergency med'icj-ne to provid-e med.j-car school grad.uates with sufficient knowledge to support a career in this specialty.

We need. short concentrated. coLllses in emergency med.icine to prepatre those experienced. physicians who wish to refresh and. upd.ate their knowled.ge in emergency care.

Also for the benefit of part-time emergency physicians such as the pontiac plan physicia:r, an ongoing in-service training prograrn wourd. seem to be most appropriate.

How marry physicians atre we talking about? rn the state of Mlchigan we have more than Boo ptrysicians employed., either furl or parttime, on a regurar basis in our staters emergency d.epartments. Although an annuar survey has yet to be cond.ucted., it can be conservatively esNimated"that lorooo physicians in this country are d.evoting a significant portion of their ca"reer to emergency med.icine.

This virtual army of physicians, increasing in ni.rmberd.airy, need.s training bad.ry.

In conclusi-on, I would. Iike to emphasize the fact that we need. to train not only physicia's interested. in emergency care, but arso arL physicians in the community regard.less of speciarty, at least they should" be trained. in the basic erements of emergency care--such as cardiopurmonalry resusci-tation and. the latest ad.vances in the treatment of shock.

Attendance at period.ic courses of this nature should. be mad.ea reouirement for medical license renewal. r have attempted. i-n a very brief period. of time to emphasize the desperate need- that exists tod.ay for training physicians in emergency care. r sincerely hope that each of you wirr return to your respective uni-versities futly recognizing these need.s with renewed. enthusiasm for instituting the necessary progra.lns in emergency med.icine.

Detroit

Dr. Ronald. Krome Receiving Hospital,

Detroit

I think for the benefit of my professor and. chairman I ought to say that my opinions are not necessarily his or that of the med.ical school.. tell you And. he is not held" responsible for anything I say and. he uill that he is not responslble for anything I ever say.

Dr. Wiggenstein has alread.y allud.ed to the fact that inexperienced. house staff attend.lng or voluntary staff on a rotational basis or part-time physicians, are all utilized. presently to cover the emergency d.epartment. This sort of med.ical staff arrangement makes continuity aJld canrt care impossible and d.ifficult, if not impossible.

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an attempt on the part of the hospitals to resolve a problem created. by being a basic economic law of supply and a shortage of physicians--this d.emand.. The only problem is that the medical schools who are the suppliers of physicj-ans are not keeping up uith the d.emand.sthat the community is making. Nursing care, teaching ald. the patient aII suffer from +U IrI ^J D. i d ' 1! @^U^A r - U^ r- F r6 - j Im c IIIS !I

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vuDrJ, 'rsqrwq! ochools have exhiblted. an attitud.e of what my fellow BaItimorian m:ight caLI benign neglect toward. the emergency department.

Really, the med.ical schools have never d.eveloped. any sort of holistic approach to training in the emergency d.epartment, for the stud.ent, for and frightthe intern or for the resid.ent and. what is even more startling ening is that med.ical schools do not seem to realize that they have a responsibility physicians and that to return to the community vell-trained. well-trained. phynow the community is d.emand.ingexperienced., full-time, siciaris in the emergency d"epartments. ^r.^T,-

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In material previously d.istributed. to aIL of you, the American of College Emergency Physicians has focused its attention on the training at as well as the d.efinition of the emergency physician.

Tentatively, of an emergency phyleast, they have formulated. the following d.efinition contact, emergent, urgent sician as a physician wtro (n) provid.es first and. immed.iate halth services to all patients of aLI aâ‚Źes; (B) evaluates q em iha nofi an f I -.*ergent, urgent and immed.iate health need.s and provid.es ..such services that are immed.iately ind.icated. and. then refers the patient care when 1nto the appropriate other physician for further d.efinitive (C) He also insures that the patient wiII have available to d.icated.. him appropriate follow-up care in or out of the hospital as ma41be required..

This attempt at a d.efiniti-on d.oes meet, we think, academic stand.ard.s for a specialty d.efinition.

We also think that the acad.emic d.efinition of research must be broad.ened.to ilclud.e reseaJ.ch oriented. tc method.s of health care d.elivery and. similar community and. service related. problems.

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of med.ical school.s really should. be to identify Qne obligation aJeas in the health care system that need. improvement and. then the method.s of lmproving that system. There is no denying the fact that emergency med.icine extracts from aII the existing in-d.epth specialties and there is also no d.enying the fact that no specialty truly stands completely, autonomously alone.

The material which you have received. from the American College of Emergency ?hysici-ans has outlined. the basic essentials of the resid.ency and. emergency medicine which will consist of 35 months of training in the various in-depth specialties with the primary focus being in the of treatment of acute med.ical probemergency care and the recognition in hospital ad.ministration and med.ical Law. Iems with ad.d.itional training We think that the d.evelopment of such highly trained. med.lcal person-nel and to d.eliver good. med.ical care in an efficient will irnprove oi-rr ability meaningful manner and. to d.evelop ed.ucational prograrns which wiII also be meaningful for all the allied. health professionals and to be able to teach and meaningful stud"ents, all stud.ents, in an easier and. more efficient way. No specialty really need fear that the physicians trained. in emergency medicine intend. to go onto the ward.s, into the operating rooms, into the d.elivery suites, into the offices and abscond.with their patients and. we d.on't feel there is any necessity to train and. their specialties, the emergency physician in so much d.epth. facts of life are that competent, wellThe very realistic trained. plrysicians who d.evote their time and energi-es to emergency med.inurnbers to meet the current d.emand.s cj-ne are not presently in sufficient surgery and orthoped.ics includ.ed, is prepared. to and no other specialty, fi I I +.his necd nor can this d.emand. be met by moonlighting house staff . lrvv*,

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and med.ical This time we who represent the teaching hospitals to, or rather profession need. schools and. our that our realize schools professionals to deliver are, obligated. to, provid.e highly trained. rnedical environment and. set without anybody specialized. care in a restricted. feeling the need. to go on a.n ego trip or without anybod.y becomi.ng paLanoid..

Thank you.

Chairman:

That is what you call bringing it right on down bit it?

Nov we are going to continue on and. talk a little fically about the programs that are underway, or at least services Dr. James Agna, who is d.irector of the outpatient General Hospital, will continue in this vein with some of' annaq

- 57-

front, isn't more speciin preparation. for Cincinnati their experi-

Dr. James W. Agna Director, Outpatient Services Cincirurati General Hospital, Cincinnati,

Ohio

At the risk of sounding evangelical or at the risk of boring some of the members of the d.iscussion group in which I participated. this morning, I will recount to you some of the reasons why we felt that ue should. d.evelop a,n emergency physician program at the Cincirrnati General Hospital.

The long-ra^nge goal of this program is to d.evelop a prototype emergency health care team, a team uhich will render optinum med.ical care in an emergency unit setting.

The program's major emphasis is d.irected. the emergency new breed. of primary physician, d.evelopment a toward. of physician, who will be the leader of this nev health team. (l) To train the The aims of this prograrn are as foltows: physician to become expert in the d.elivery of med.ical care to a broad spectrum of med.ical problems encountered. in an emergency u:nit t (2) fo necessaJry for the physician to attain d"evelop ad.ministrative quatlties Iead.ership in this field. of end.eavorl (3) To stress the physicianrs Resid.ents, role as a teacher in all aspects of emergency med.ical care. interns, med.ical stud.ents, nurses and. other allied. health personnel wiII (4) To encourage research come und.er this aspect of his responsibility; research, d.irectly related to the ima. clinical in two categories: provement of care to the patients with specific emergency med.ical problems. b. research as related. to the total concept of the emergency to continuity of care. health team and. its relationship It is evid.ent that the status of emergency rooms has changed.

No longer are the activities d.ramatically over the past twenty-five years. of' an emergency unit limited. to rather cj-rcumscribed. emergency med.ical problems.

In some ways the emergency unit niight be better id.entified by the unwieldy term as the d.epartment of unpredictable medj-cine, especially after ):OO P.M. and" on weekend.s. In maJry areas of the communityl. rrot impossible in the evenings and early only in ghettoes, it is virtually morning hours to obtain the services of a physiciart for cond.itions which The acthe patients themselves would. acknowledge are not emergencies. of a microcosm represents tivities of the emergency unit in some respects the entire community's health problems. The spectrum of what is consid.ered" an emergency ranges from an abrasi-on to a life endangering injury.

In ad.d.ition to d.ealing with these problems, the emergency unit also funcIn a sense, tions as a primary care source for routine med.ical problems. the emerthrough cond.ucted. a form of neighborhood. health center is also gency unit.

Rend.ering this type maintenance care and episod.i-c care for for an emergency r:nit but minor illnesses may not be a d.esirable activity

-r9-

-50it is evid.ent that most emergency r.urits offer this service.

Many people find' the only access to the health care system is through a hospital emergency unit because of being transients in the community, new arrivals, or people without fina.r:clal means who have not aligned. themselves with the private sector of med.ical care.

It seems unlikely that med.ical care d.elivery will be reorganized. in the near future in a mar:ner which wourd. significantLy ameliorate emergency rooms with respect to involvement in this broad. range of health care servj-ces.

The judgments required. of the personnel who work i-n emergency units are of consj-d.erable gravity and complexity because interspersed. anong the more mundane med.ical problems are gravery irl peopre in need. of the basic armamentarium of a uell-equipped. emergency unit.

Therefore, health personnel in such a unit, especially in a lead.ership role such as a physiclari, must have a sensitivity to the community need.s along with better than average skilrs for managing serious med.icar problems. unfortunately ma:ry emergency units are und.erstaffed. and. the staffs asslgned. are often und.ertrained.. Because of the need. for more ad.equately trained. emergency ixrlt physicians, a two-year resid.ency program has been d.everoped at the University of Cincinnati lr{ed.ical Center.

This resid.ency has been approved. by the Resid.ency Review Committee for General l\^actlce of the Al4A Cor-rncil on Med.j-cal Ed.ucation and. by the Ameri-can Aca.d.emy of Family Practice.

The number of resid"ency positions approved. is six per year and. the length of the prograrn is two years.

A total of t2 resi_dents can be in the prograln at one tjme.

There is one resid.ent in training but there will be six resid.ents in this prograrn on Juty t, L9TL. This trainee in emergency med.ical care will supervise transportation and communication systems, participate in emergency unit d.esign, and interrelate with personner incruding nurses, attend"ants, ord.erlies, crerks, rad.io operators and. ambulance dri-vers.

WhiLe d.eveloping his specific professional skiIIs, the trainee i-s expected. to observe or participate in the other steps in the process of d"elivering emergency med.ical care.

He is expected. to par_ ticipate in in-service training program for atl the members of the emergency unit staff.

These prograJns, as well as the knowled.ge gained. while servi-ng as emergency unit physicia-n, wi'l.l allow the resid.ent to d.evelop his own i-d.eas concerning the relationships of an optimum emergency unit team. The rerationship of this r.rnit to comprehensive health care is emphasized. The program is interd.epartmental. when the resid.ent is assi-gned to a particular service, the d"aily supervision of the resid.ent is the responsi-bility of the d.irector of that servj.ce and. his staff.

The resid.ency rotation offers the trainee the optimum exposure to a wid.e spectrum of medical problems which are encountered. in an emergency unit.

A significant portion of the resid.ent t s time is spent in training outsid.e the emergency unit but oriented. toward. problems encountered. in an emergency unit.

this

It is expected" that a certain nurnber of physici-ans completing program will assume responsibilities rur tnr i i n. for uoumr ?u rT o a6ns?r\rru J u u&Ie IfI

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commwtity hospitals.

Other trainees may embark on a catreer in the acad.emic aspeqts of emergency physician training. that It seems justified. establishlng departments of emergency care would. be an appropriate fi.nction of an acad.emic health center.

These d.epartments could. then be the focal point for ed.ucation of physicians who intend. to make emergency care a primary career and. for short-term training for second. ca.reer physicians with special educational need.s. FinaIIy, the role of the emergency unit physician in an acad.emic health centerin which resid.ents and. interns have training rotations through an emergency unit is somewhat d.ifferent from an emergency unit pLrysician d.elivering primary care in a community hospital.

These physicians would. continue to participate in care but would obviously have a d.ifferent role type teaching and. administrative than the emergency physician in a non-teaching hospital.

Chairman:

Dr. James Dineen will be our final panel member to make a presentation, He is 1n the Department of Continuing Ed.ucation in Harvard. and wirl give us some of his experj-ence in postgraduate training of physicians in the area of emergency medicine.

I

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Dr. James Dineen Massachusetts GeneraL Hospital Department of Continuing Ed.ucation, Harvard. Med.ical School

Instructor,

I think the stage has been set very r,vell by John, Ronald. a.nd The message that comes to me from what f have heard. is that for

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What I would like to d.escribe is our experience at Massachusetts General Hospital.

With a very short course we have had. experience attempting to teach some of these physicia;rs some of the ABCs of emergency med.icine and my reason is purely to stimulate others of you who are in similar academic settings who might be ablc to do the same to develop similar courses.

Let me start with a brief' descrlption of the course. It is two weeks. We take six stud.ents at a time and our goal is very limited..

It car: be expressed in two vrays. One is that we really try to zero in on is attempting to teach these people to at Least be able to hand.Ie anything for lO minutes, always with the d.irect assumption that there is help corrring axound. the corner.

The second. way we could express our goal would- be to lake the physicians as they come to us and. get them to take tw'o steps forward. uhether they are on the five-yard. Iine or the fiftyyard. line.

If you Look at the students who come and. f look at the }ast thlrty--the average age is )0, two-third.s have a general practice backsrorrnd . nne-s'ixr-.h have

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The actual course structure in mechanics is that during two hours in Lectures.

You could weeks we spend. approximately twenty-five n r e d ' i r . f .m : n r r n f l h e s r h i e c t s t h a t w e c o v e r b e c a u s e t h e o r i g i n a t o r s o f t h e course have an internal med.icine bent.

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IrOOO-bed.rmiversity hospital setting of roughly 2rO patients a d.ay, art competent house staff.

At the same time that we abundance of fairly preceptor whose prime job is to have the stud.ents down there we have a search out appropriate case material that is in the hou.se at that time and. to get it turned over to these student physicia:rs.

When they come ule give them temporary licenses in the State of Massachusetts. They get a temporary appointment to the staff of MassaIdeaIIy, chusetts General Hospital so they are covered- medical IegaIIy. preceptor. patients get help the with the of sick to manage the they The preceptor's big goal is to look for patients whom the d.ayrs lectures experience--both for the can be applied. to.

That is a very lnteresting certai-nly preceptor and for the stud.ents. had. the experi-ence of I have giving very clear lectures on coma and. walking d.ownwith the stud.ents and. sweating like hell trying to figure out what uas going on with this sitting there smiling comatose patient.

They all Look very intelligent j-n class and. nod.d.ing their head. as you talk about card.iology or something or you keep shoving EKGs in front of their noses--you really get a feel of where we stand. whatever area in the In terms o:[ mastering technique we utilize get to try to exthe stud.ents to try best. seems to be the We hospital They all have to go to press what techniques they real}y feel weak in.

If they feel they need. to know blood the OR and" Iearn how to intubate. gases and. heart failure sick we take them to the respiratory care unit. lo get It is obvious that you rnobilize the resources of your institution going things couple have a of master these techniques.

We them to iazzy procedures on in terms of the computer world., with at least tuo emergency progran in the as problems.

One is the cardiopulmonary resuscitation plays with it for a couple of computer and. the student sits d.own and. hours and the computer respond.s the way he treats them. A Lot of them d.ie, some d.o weII. We have a coma problem that is progranmed. in the computer.

What are the results of this course? WeII, Letrs take a few comments. First, Dr. R. R. Hannas, Jr., Vice Chairman of the Americart

-6rcolrege of Bnergency Physicians, frequently refers to the emergency physiciar:.s as tigers.

I agree entirely.

These docs are formally scheduled. to finish at p:00 at.night, but frequentty they are there untir L2 or I a.m. They really get turned. on. And. simultaneously these instructors get turned. on. They are so pleased. to be teaching people who are out there d.oing it in contrast to the third. year med.ical stud.ents who are going to be psychiatrists or public health officials and. really couldn't care about coma at all.

We give them a test when they leave too, and we get a 40 percent improvement in score. We d.on't think thatts terribly great, but we realj-ze we stirl have to d.iscount that by po percent when you come to the actuar apprication d.own 1n the emergency ward.

But we d.o feel we turn these stud.ents on and. get the ball rolling. group that got us involved. in this is fortunately The initial in a hospital that is ten miles away in Lynn. r was a resid.ent when they came throwh in l-p68 and. now r have the occasion to go out there once every mont[ or two.

There is no d.oubt that the level at which they are j-s functioning at now terribly exciting.

They sit d.own and. you just tark at a lever of real modern acute pathophyslorogy, exactry Like you would. talk to the house staff.

These gWS ar.e aII GPs who close their offices in the fifties, and they refer to themselves as the old retread.s. Well, for old retread.s with just a little bit of nud.ging they have come an awfully long way.

QUESTIONAND ANSWERPERIOD

I want to ask Dr. Dineen what the training of these old retread.s has done to the interns and. resid.ents in the emergency room?

DR. DINEEN: Thanks for remind.ing me. There is a very clear two-way street going on down j:r the emergency rootll. I wot^Id say the number one a,rea that these old.er rrretreads" have done something is how to teach our d.ocopners, but it goes way beyond tors how to be polite to patients--for +l^ -+

DR. AGNA: Dr. Dineen, did-ntt you say you had a result of one of your stud.ents uho d.ecided. af'ter tw'o r^reeksthat he shouldnrt be working in art emeroannlr

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There is nolhins uorse than to run a two-r,reek course and. realize that some t' may go off wearing a T-shirt that says "I graduated. of your trgra.d.uates franr

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DR. TOMPEIlAm, George Washington University,

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I rrvoutd.tike to open up Pandora's box here for a second. nxcept for Jim Dineen there was a consonance about the other three discusif T might, ild see what sions about which f would. Iike to quarrel a bit, the responses there aJ.e to this.

First of all, I am concerned that what we are really talking On the other hand., it about here i-s primary care for emergency problems.

We have not got this is the patient who d.efines the emergency problem.

Largely occupied wj-th minor choice and. as we know our emergency rooms are ilJnesses and. the worried. weLI and. not necessarily those patients who may have that which we would. d.eemto be a true emergency. And. if we go emergeney physicj-ansr PoPulate our emergency exclusively a,bout training for many of whom there should. of patients, nwnber rooms, attract a la.rger be a more comprehensive approach to health d.elivery, then we are really highlypound.ing tacks with sled"ge ha.mmers. ft is a very high-trained., clutter wlth to continue wiLL specialized. person.

The emergency rooms the worried. weLIs.

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What we really ought to d.o is to build. a system, I think, where perhaps or even part-time in ue can free that physician who is full-time the emergency room, to d.o that for which he is actually there.

I think we have another problem if we go about creating resid.encies in emergency care exclusively.

We still have the problem of getting these patients, some of whom come to us repeated.ly and appropriately, into a health maintenance organization, if I can use that phrase.

Then that makes some sense. I wond.er if we shouldnft be, rather than training resi-d.ents exclusively in emergency med.icine, become involved. in the training prograrns now evolving to train resid.ents in primary ca.re, community hea.lth

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Then we can d.evelop total ambulatory systems. We have an emergency room that feed.s on ambulatory service.

We can provide service that d.efines geographic areas and solve much Larger problems than creating exclusively a resid.ency in emergency med.ical care which I think I would. be opposed. to.

DR. I(ROME: f think we have a very complicated. problem In a word., I agree. in this program out of the context with the comard. I d.onrt participate m r r n i turJr m ci l l s qoJ d u f ir r E

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But for the present There are a Lot of ways to go about this. time and. for the foreseeabLe future this is the focal point which may be a.n ind.ictment on our health care system. It has broken dovnr and this is the only place that d.elivers at the moment, in terms of a certain type of need. of people, and. the worried. weLI are aIL over the place and- maybe we have oversold ourselves ever;place, but it hasnrt been a irnique experience in the emergency care area.

CHAIR}4AN: John, how about in a smaller community? How about this d.isbetween the worried. weII and those that are acutely emergent? tinction What role do you see there for the primary physician?

DR. JOIII\ WIGGENSTEIN: WeII, I agree with the doctor when he says the emergency room, We see so marl1rnonof course, is not really r,rhat its nanre ind.icates. if you would. confine your acemergent cases. Out of rea"l practicality, tivities to life-end.angering problems the emergency d.epartment would. probgroup. So this is just being pracably not be able to support a ful}-tlme pay the bills. tical.

Now I agree with everything The non-emergencies

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that was said., that this is not the best system. I think we need. to work on our health derivery system. The kind. of physician he was tarking about as far as a pri-mary physician you think of when you are thinking of health maintenance organi-zations--this is another type ind.ivid.ual.

And. perhaps this emergency physician and. primary physiciaJr car1 be one and. the sa.lne,but I don't really see it that way. I think that there is a place for a person to be trained. strictly in the emergencies that would. present themselves to a busy emergency d.epartment. furd. think I there is a place for training the primary physician for health maintenance orsanlzations.

C}IAIR}4AN: Part of the hangup in the past has been the d.efinition of the so-called" traumatologist, the feltow who takes care of the major emergency facllity versus now the vast numbers of physicians who are taking care of community medicine in an emergency d.epartment. Now we have to face this d.ilemma by training probably both of these or more than one category.

Here is a question.

ART LEADER,McMaster University: r was wond.ering why does it have to be a physician and if, perhaps the panetist coutd. d.iscuss the qualities that they want in an ind.ividual who is staffing an emergency facility.

I arn thinking particularly about the corpsmen or perhaps the nurse practitioner as an alternative to the very expensive training of the physlcian.

DR. ]GOME: r would. like to respond to that, and. would. rike to respond. to this at the same time.

I agree with what you said. and. with what my colreagues said. in the panel, but what r think you are talJcing about is utopia.

Continuity and c&Tâ‚Ź--wâ‚Ź d.on!t want our patients fragmentized..

We want everybod.y to take care of the patient from the tjme he enters the hearth care system to the time he reaves. f would. like that too.

I think that is a good. way to have medical care.

I am not sure we could. get that in a realistic amount of time a.nd.r d.on't see the emergency physician as being trained. to the exclusion of that which John mentioned. taking care of the community med.icar need.s, if you witr, in the emergency d.epartment. I see a very real role for the nurse practitioner, if you wiII, any of the allied. health professionals, the new allied. health professionals, or whatever we want to caII them--to see the patient initially perhaps and. to d.o certain things, but I am not sure though that they could. d.o all the things that we would. want them to d.o until the d.octor arri-ves.

I think we could- use our registered. nurses more efficiently, for example, a.nd.our physicians, by d.eveloping other allied. health professionals, but

I am not sure it

could. be d.one to the exclusi-on of the utitization

of

nhrrsi r-i qnc

DR. IGRL MANEGOI,D,San Leandro,

California

I am not a member of the University Association of Emergency Directors. f am JJ years ord. and. have d.one emergency ned.icine foy 5 years--2 years part-time and- 4 years furr-time. r sort of seem rike a platrt, because I am a member of the AECCP, f am a mernber of Ron l{rome's committee on education of the A-ECP,I took Jim Dineenrs course in L)6), zurd it is excerlent, and. r know three people who are going to be part of course.

Agna's I would just like to make a very blunt plea. ft is time for y:u gentlemen to get off your ass and. on your feet and. take care of 6O miltion people that are coming to emergency d.epartments. In no way d.id. f ever anticipate getting into this fietd..

We now are getting commrmications from med.ical students, from interns and resid.ents, who r^rant to join us fulr-time.

There aJe no stand.ards. There j-s no training. r had. to t r a v e l 3 r 0 O Om i l e s a c r o s s t h e c o u n t r y t o t a k e J i m D i n e e n t s c o u r s e , w h i c h was the onry course avairable of its kind. rf you gentlemen who are d-irectors of university d.epartments d.on't d.o it, who is?

CHAIRMAN: Thatrs a good response. Letrs just take a show of harrd.s. How many emcrgency d.epartments have some type of ongoing postgrad.uate course now that cart train some physicians who want to come and. spend. some time.

Raiseyour hand. How many? WelI, there are four or five available which meafl.sthat the potential for doing this is great. r would. say that every emergency department courd. do this, but the big problem we are rearly facing is how much taboratory space does an emergency d.epartment offer paramedics, medicaL stud.ents, nurses a:rd.postgraduate phyfor training sicians?

How maJtypeople can get into a room to see a flail chest?

T;<JLlLtt

L^" IrUW

qI U

JOU

take and. bring

s nulr v sr r e D

tuhrnr ta u

n e r i . i u J vru. rr r* lr a r !il

in successfully

nrnl.rl em? },4vv!v!r.

llnr^r monrr

nonn-l

o

rJ a . n

yOU

to 1o that?

DR. DTNEEN: year and. a half we took only four stud.ents at a time The first and. only allowed trlo of them at any given time working d.own in rhe â&#x201A;Źrrrâ&#x201A;Źrgency room working as an extra load.

Our physical plar:t is quite stressed in terms of space although it has improved. in the last few months. f think you put a finger on rearism.

There need. to be a rot of centers doing this.

We train only six at a time.

We run the course three times a year because lre rely on volunteer labor and you can wear out the welcome mat if you come knocking on the door too often.

-73-

C}IAIR}'IAN: f have a similar course that runs about one stud.ent at a time about every six weeks and. then starting over.

I would. be interested. if we talk about the med.ical students because they are also a part of this same problem.

They clog the wheels as much as anybod.y. .whether we are part utilizing the community hospital. as of our med.ical stud.ent emergency training course they go out to the type of a hospital that is set up as John is talking about and. they find. it a far better experience, gratifying to them, tha,n to get into my own emergency d.epartment. So that is another avenue.

COMMENT FROMT}M FLOOR: I came here because of the fact that I was hoping that you as an association would. guid.e us in the establishment of the d.epartmentat structure and faculty recognition that we can seIL not only to our exâ&#x201A;Źcutive committees but also to the university.

I would. Iike to ask mernbers panel of the and I will ask it again in the workshop this afternoon.

It is quite d.ifficult to establish all of this.

I see you have some problems here. in the establishment.

It is difficult The stand.ard.swill have to be set.

I hope this assoeiation, and. it is the only one I can think of, I am hoping it will give us guidance in how such an emergency d.epartment can be set up and what the academic qualifications should. be had. so that it can be worked. into the curri-culum of the med.ical stud.ent.

CHAIRII{AN: Tell

us some of your problems in setting

that up.

DR. DINEEN: You donrt want to hear them aLIl We have srrpport from aII of the d.epartments for this, and. it is need.ful.

At the present time I am reaLly not certain which is the best way to go in terms of either estabIishing a d.epartment of emergency care or a d.epartment of outpatient services.

I feel at the present time I have some options and we are working toward. a d.epartmental status of some type.

It might be too narrow a field. to establish an emergency u:rit d.epartment in terms of thlnking of comprehensive care services.

DR. IGOME: We have d.epartmental status

cnhnnl

'tarrar

-za#.

T I f rh v e

tuaa vcr !k . w ew L

h a v eu Irqv

at a hospital

tuaw lku rel n

nresent'l

yruDurru+y

level, v ' i sJ p

in rrl

but not at the tuhl l ue

ltnesotiarlv6vula-

tionrtscore.

That is to have the d.epartment of community med.icine at Wayne make a division of community med.icine und.er whom we would. f\"rnction

aD

urlE

^u fr

- ^sr ' v^ 'snr l o !

D

denartment

of

d * -aI 'nwn* r i m a n l c - - f

f.qmilw

nra.ef,ice

he

denqrf.monf.

a.ncl nerhans \

4

r

*

}

/

v

r

nf

even

q

v

v

$

amaroannlr

a senerpi,e v

l

q

f

v

r

m . . .a- *d- i

a n IpI C , - _i L

dennrtment

fu. lhl ca

of

arnbulatory care.

We have talked. to the chairman of the d.epartment of conrmunity med.icine and. he seems very receptive to this idea.

We are pregetting sently trying to d.evise bhe mechanism of it through.

Getting it through at a hospital level was not too d.ifficult at aLI. CHAIRMAN: I think r r c v ' r r cu *qp f sr Ji l r r

hv uev vrr ,r fne l n g

one caution entangled

many of us have to entertain in

l-ha

nv^]^'1an

^F

i ' . e g i n n - ir l bn g

is that we can fa.m'i lw !(aurlJ/

OfaCtiCe

r

prograrns in our own university.

Many of these are going through d.ifficulties and. growing pains and. I hope this will not interfere to get emergency training our ability und.erway because if we wait some of the fam:ily practice problems to be solved., it is going to Iate.

DR. CIAISTINE E. HAYCOCK,Ner,rJersey College of Medicine,

some with for be too

Newark,

I wond.er if there are not two t;pes of emergency physicians that we have to train.

One, who is in a large hospital center and. who may be in a departmental speclalty and the second man who is in the community seeing everyone because certainly in my emergency d.epartment med.ical people are seen by med.ical people and surgical problems are seen by surgeons and. there is not an overlap except in the triage area. When you have the triage specialist trlaging through the d.epartmental area, and certainly the fellow who is seeing the surgical patient doesnrt requi-re aLI the knonled.ge of EKGs and vice versa, and. yet the man who is in the small community hospital in our saJnearea where I worked. for three years, then I had. to know everything because I was the only one there.

There is a d.ifference.

DR. ]GOME: However, the We have that kind. of setup at Receiving Hospital. area of triage, if you will, is so Large that we think that economically to use our surgical staff they should. not necessarily see every 'rsurgicalrr problem that comes in.

That we like our emergency physician to see hj-m initially and perhaps he d.oesnrt belong in the emergency d.epartment at aII. Now, if this is a simple triage then the man with the hernia who has some d.iscomfort would. be seen by the surgical resid.ent that night if i-t nere a simple kind. of triage.

If it is an emergency physician who can evaluate whether or not it is incarcerated- or not incarcerated., etc. , aro

patient

lhan

narhon<

he

ncn

d.epartments--get

faad

nim

OUt

tO

the

CLjniCaI

a1.eas--to

him out of the emergency d.epartment.

the

OUt-

- 75-

DR. }IAYCOCK: what r arn getting at is the nurse triage--the triage is one of three areas--minor, med.ical or surgical--and. not one that is referred. out but is seen by a physiciaf,i or intern or someone much higher than that, or perhaps your practicing physician.

C}IAISMAN: I think this d.oes emphasize that there are d.ifferences 1n the size of the hospital as to what our training need.s are, which is probably the story of med.ical training in general.

DR. HAROLDA

PAUL, Chicago, Presbyterian

St. Luke Hospital

In the problem that is going to be with us of interfacing emergency physicians with community physicians, or primary physicians, o:r whatever you call him, wourd.n't it be ad.visable to try to get in alt of those progra.lns some of this kind- of training so that when you d.o have it, if you ever d.o, ad.equate numbers of primary physicians, there is ad.equate knowled.ge that is nor^rbeing proposed. by the kind.s of progra.rns that you suggest so that this program in the final result may not, unless we d.onft sorve the other problem, turn up a neu speciarty which everyone admics will not be id.eal.

PANELIST: (lr.

Dineen)

We have a jr-:nior intern elective in the emergency unit started. this past year for senior stud.ents. rt is very popular. we have not only a general emergency unit experience but also the med.ical d.epartment has one for specificatly medical emergencies. They are quite possibte and. many of the stud.ents participate, obviously not going into a prima.ry emergency unit career.

CHAIRIvIAN: This really should. be basi-c for all med.ical stud.ents a:rd. I as part of their early curriculum and. as a part of their probably -l r|hi c ater el enf.i rra J-.imo too, is our most popular elective j_n med.icaf .i6 ^+-! +r,+ ^ +u: ^ .-. on A^ r^,., +rJo ^ qo school.

This is something we nuirll rlQW, l-IlslJt-ruIe yeal In1s t-n our own med.ical school. think

ITTTD,

DR. DONAr,DM. THOMAS,university Louisville,

of Louisville

schoor of Med.icine,

Ky.:

I would like to know if any progress is being mad.ewith the powers that be towards establishing criteria in resid.ency review committees. we are trying to start one at our place and. r have got guys who

-75-

want to enter it, erren get

but untit

n sf,i nend. for

we get someonehere to approve it

f canrt

it.

C}IAIRMAN: The American College of Emergency Physicians have estabLished. what in our opinion are guid.elines for the establishment of emergency physician resid.ency. fn ad.d.ition to that we have submitted. these guid.eLines to the American Medical Association appropriate committee. f think it is the council on education, uith the request that a resid.ency review committee in emergency med.icine be established.. in This is stil} committee. It has been about two months since we submitted. this.

This is the first step.

The establishment of a resid.ency review committee prograrns d.o not have to faLI in emergency med.icine so that the particular und.er the heading of some other particular specialty, as it uas in Dr. Aonn I c

creo

PAIVELIST :

- in

(lr.

oenprnl

nrncti

no

Rgna)

I have had. several Letters in the past few months from the AlvlA grumpy type letters CounciL on Med.ical Ed.ucation--rather remj-nd.ing me that I was a pitot project and"that I was categorized as a general practice resid.ency. I think this is an ind.ication of the inquiries they are receiving about establishing the progra.ln.

CIIAIR]I4AN: It is obvious that this is quite popular, but you know this is the frosting on the cake because we have 51000 physicians who are calling themselves emergency physicians who are Lookj-ng for training of d.ifferent nature now and I think we need to add.ress ourselves very much to these physicians.

This is something that can be d.one j-n our hospitals presently and can even be d.one at a commuriity hospital level.

DR. STUAIT M. POTICHA, Northwestern

University,

Chicago, ILt.

One of the panelists suggested a three-year residency prografl for training this type of physician. f wond.er if everyone on the panel feels that that is the right amorxrt of tjme or isn't it a bit long?

Could. we get an opinion as to the amount of time that you think is ad.equate to train emergency room physicians ?

DR. W]GGENSTEIN: I think that Dr. I{rome mad.e that statement and he based., I think, the recommend.ation on a stud.y that he d.id. f wonder if you could. talk about that, Ron as far as how long the actual course should. be.

-77-

DR. IGOME: If We went to a three-year resld.eney without an internship. group years. that two The would. be there W'asan internship then there was with me in Florida where we di-scussed.this, actually we mad.ea list of what we thought everybody should. know to d.o this and.make in our own lhe only way mind.s an approximation of how long it would. take to d.o it. to, scope a,mount I thlnk, a a broad get to includ.e in and. all of that to llttle less than 16 months C}IAIRII{AN: There are obviously going to be d.ifferent problems in d.ifferent hospitals as to how this should. be set up. I am going to call this panel d.iscussion to a close becausewe wiII be able to contjnue this in the workshop sessions. f want to thank the panelists for their participation.

SUIV$4A3IES SUNN.4A.RY OF T}M TEN WORKSHOP on TMINING

DEPARTMENT OF PHYS]CIANS IN THE EMTNGENCY

AIan Birtch, M.D. Peter Bent Brigham, Boston, Massachusetts

SU}O4ARY

To summarize the concert of opinions expressed. in any one of the ten uorkshops, where lO to 20 people uith d-ivergent backgrounds and. . jueDe s yn rr e u- di rurqdr u

+ ^ , t ;q a D u U D UU

a vr r ec ; ^ . i - ^ ^ fhl q <JUlrrsq

tvr4a .wi +n r.-ir r rno g

n - ,f

+t JLl ^l e

n h . , d . i n . i o r a . i h l_ll f,..Jb_LUld.tl,s

Ilmero.ennrr

Department, is difficult.

To attempt to present an accurate consensus of these ten d.iverse summaries is both hazardous and in ma:ry ways red.und.ant.

However, several commonthread-s of positive concern ran through the fabri-c of the ten workshop d.eliberatj-ons and it witt be these po:i.nts that I shall attempt to underline.

The increasing need for improved acute health care d.eli-very i-:n the Emergency Services of both the University and Community hospitals was a ynyn+a r c net r r v q

fu. un

e rl -I r . e

T^ L-i-^ _LU UIJ_ttB

-L^'"+ d,UOUU

meaninofll

s rhr nv rr f . o

u!

rnd

lnno

rorm

l_mpfove-

ment in this area requires the recruitment of qualified. d.octo:,.s, training them adequatell/, and changing the image of the Bnergency Service into that of a respected. and. progressive d.ivision of the hospital.

The solution o u rf

Ji n II t e u cr re sst)

u,

da, ft .J a a rn

to the initial

e e qer r l rr Jr

sp tu: ep6ev

n v -f

requirement Lies in the stimutation

tre'inincr

in

ihe

naadc

qnd

n r ^_' p e f

CaJe

of the emergency situation.

Presently availabLe courses in ad.vanced" first-aid. (really primers in elementary emergency care) offered. in Med.ical Schools are met with a.n enthusiastic response by the first year med.ical classes. enthusiasm carried This should. be forward by lnclusion of emergency medicj-ne as part of the t'Corerrcurriculum or as ueII planned e}ecI irrpc

dtrrino

jnnr anant.n

l-hoe:r'l\r

t.y

h - ' r- eu sb uul a lr a r

lrarTc

JUq4

af

ar nq / d / ov Jr @

m e d i r . !pal!

c f e c tu"r i vv eu gluv

s vr r. rhv nv rnt D

l

e q

nd

ShOUld.

p'nment of a a Ds Ds + 6it l t r r u J l

be

Stud.entS

fUffnef

in

the

c l i n i c a l y e a r s t o t h e E m e r g e n c yS e r v i c e s ( e . S . ) .

Their experience in the E.S. as weLI as that of the yourg resid.ent staff should. be supervised. and. coordinated by a fulL-tlme ftnergency Service Dj-rector artd.his staff.

It is not surprising that interest in the Emergency Room is not sustained a.t tuhrgr u

nfesent-

since

vo' e. ,r4eu

a+^ s li q s lAl U^ D r Le D ,

Jv vowu rn6s! r. e r

oi iren fu' h ir Dc rr 9 e rl sa 6o ae ui .soqd, r l ou rr "ee b!vLrr +^,._L+ i.^fronrrpntlrr ht Jr Jr Ud,Lr6ltU fIIIaUgtlCIIUTJ

iI n ft tt hr lal L

-r o o r r . l e r

and supervised. rargely

on a tttrouble shootingrrbasis

genCV

rw. t' IhU^b-c^

Suerf V ivCr veu u

interest)

DrirT a o s uf u u^ rv u

nairy1e717 rAqnnncihi r uDj/vrrprwrrl!I'I!rvu J

n l r oa nl Jr r

l i t . ,U y

i iU + f" u+u' iu^I -( -J I f ) , ti fn, cl D h n < n . i f - . r1-, 1l -

by a part-time / . ann/ ql \

pnOaSoScIj-lDr It y.

+^ uL,

dU +n S a If lf. ,

Emerpf

J-mafy

Lies in other areas.

Ma:ry participants felt that the establishment of d.epartmental status for the Emergency Services, with a fult-time Director who had. the abllity a-nd the authority to enlarge the teaching responsibiLity of the hospital staff inthe Emergency Roomwould. invest this area with previously Iacking respectabitity and contribute much to the immed.iate a;1d.Long range solution of this probrem. rn ad.d"ition to improving teaching in our present system at the med.ical stud.ent and. resid.ency levels, d.epartmenta1 status would. facilitatethe training of a potential new subspecialist, the Emergency Physicia^n.

-or-

-Bz-

General agreement was expressed (B of p workshops) tfrat a need. existed. for Bnergency Plrysicians and. that llniversity hospitals shoutd.

I'unani-mj-ty accept responsibility for trai-ning in this area.

No of opinion emerged.as to how to best train these individ.uats but several pertinent points w'ere mad.e. This new subspecialist must attain both training and. respectability in the setting of a university Residency program. rt might, therefore, be ad.visabre to require one or two years of training in a general estabrished. d.isciprine (Med.icine, surgery, or Farniry praetice, etc. ) to aLl-ow the man to have a broad.ened.clinical background. followed. by a period. (r yeal or tess) of intensified. training in the emergency aspects of care.

This type of prograrn seems more workable than to attempt to integrate the Bnergency Resid.ent, starting as a neophite, for 2 to J years into the acute aspects of many established. services where he admittedly would. have much to learn but littte to contribute and. would. Iikety be regarded. as a trfifth wheel. " The short intensified. program would. have the ad.ditional ad.vantage of allowing physicians, who d.esire to leave established. practices to obtaln training, to become Bnergency physicians.

REPORTOF WORKSHOP #I

Alan G. Birtch,

M. D.,

Peter Bent Brigham Hospital,

Boston, Massachusetts

There was general agreement that a need. existed. for an adequately trained. Emergency Service Physician.

This need. stems from the combination of increasing Emergency Service patient load. of both emergency and. nonurgent type coupledL r^rith the unwillingness or inability of the Community Hospital to staff thelr Emergency Services to meet this need. and. the increasing resistance, in the University setting, to hand.Ie this mushrooming patient load. by lengthening House Staffts Emergency Service rotaticns further.

Therefore, by default, it would. seem better to have a mal with recognized training i-n emergency care fiII this void. than contj-nue our nresenf t,r vuvue

ynqquLlfL. or rrrn

n rf u

notnhr^rarF lreuurlwLrrn

uauaunl p l O l l l J - S e

COVef

age.

There was no unanimity of opinion as to how the training of the Emergency Service Physician would. be best und.ertaken in the context of otrr present d.epartmental structure.

Most agreed. that where a Department of tr'amily Practice existed., that it would. be the most approprj-ate area for this progran to originate. rn the settlng of the Department of Family Practice, it was hoped. that the proper attitud.e of concern for the patient would. be engend.ered which might encourage the Emergency Service Physician to organize folLow-up caffe, especiarry for the non-urgent n-ti ^-.* !@uasrtub.

^

It was agreed. that the Emergency Service physician (p.S.p. ) should. have responsibility for the initial evaluation and. care of the patient with consultation immed.iately avaitable to assume total care responsibilities when admission or involved. out-patient proced.ures were ind.icated. (examples of later: casting of fractures, tend.on lacerations, etc. ).

The abilities, i-nterest, and.expertise of the ind.ivid.uar E.s.p. might allow exceptions to this later point but the results obtained. must always be judged. against the stand.ard. of care available by other members of the staff. fn the Community Hospital setting, the total responsibility for emergency service care would. likely fall to this man. It was hoped. that in the University Hospital setting, his activities could. be coordinated. in both servj-ce and teaching with that of both the General and.

E.s.P. Resid.ent staff . Three yea.rs after medicar schoor was probably needed. to give training in sufficient d.epth to arlow the physician to handle the initial care of emergencies in all d.isciplines.

Three of the 12 mernberspresent felt that their institution wourd be willing, at the present time, to initiate a program of Emergency Physician Training once fuII guid.eLines were established..

-oJ-

ot,

Discussion of the present status of ed.ucational outlay in our Emergeney Ward.s revealed. that only 2 of our services fraa a futt-time d'irector who spent his working d.ay teaching and. supervising care within the Emergency ward., while one had. a part-time visit carrying on this function.

In the remaind.er of units the teaching by hospital staff was on a consultant basis with most of the expertise being passed. from Senior to Junior House Staff and. in turn to the med.ical stud.ents.

Although this ratter system may work fairly well, it was unanimousty agreed. that it was not id.ear. fn the acad.emic setting, therefore, an E.s.p. of high cariber would or courd. fufilr a major teaching role, if properry utirized..

nrponr or wonrsnop #e TRA]NnIG OF T}IE EMERGXNCY ROOMPHYSICIAN George Johnson, Jr.,

M.D., llniversity

of North Carolina

The training of the emergency room physician was d.iscussed.by looking at three overlapping areas: the medical stud.ent, the house officer, and. the emergency room physician.

The Med.ical Stud.ent: a)

Although instruction in emergency med.ical servj-ces per se need. not be a part of the core curricurum, viabre and exciting electives are necessary.

b)

kinciples of card.iopulmonary resuscitation all stud.ents.

must be taught

The House Officer: o'l aJ

i/lnnmrrn-i l--r t-,^, vururLrr.ruy ilospi-tars have a rot to offer the house officer in the emergency room si-nce they are generarry better supervised. than unirrersity hospitals.

b)

University hospitals tend.ing coverage.

c)

Emergency room physicians and. patient relations.

d)

University hospitals must stilt ciples of trauma and illness.

e)

Emergency room aud.it important

have a d.ifficult

time in getting

are good. in teaching

at-

techniques

teach basic biological

prin-

concept.

Emergency Room pliysicians : a) b)

In general,

a good. concept--are

here to stay.

Two-week crash training donnrr n-, j,. ogrann.

programs stop-gap measure--need.

Not sure about need. for

three yea,rs, but no one has stud.ied..

ncqi

c)

-86-

d.)

would. seem a person with in-d.epth training in emergency room services wourd. eventuatly reprace ind.ivid.uar speciarists in the emergency room. This is true even in ed.ucationar centers and wou.rd.be und.er Division of community Medicine.

nnponror wonrsnop #3 THE TRAfI{]NG OF PHYSICIANS IN THE EI\4ERGENCY DEPARTMENT John H. carter,

M.D., Albany Med.icar center Hospitar,

Arbany, New york

The members of this d.iscussion group agreed. that emergency room physicians should. be able to recognize arl emergent med.ical, surgicar and. psychologicar cond.itions, and. initiate appropriate initial therapy, par_ ti cularly c ard.ioputmonary resusci_tation .

Although as a group we felt there shoutd. be specialized. training progratns and. courses for physicians before being employed. in am emergency room, it was not felt that a new Board. or a new speciarty group should. be set up. rt was felt that existing organizations such as perhaps the Acaderly of General Practice could. ad.equatety hand.Le training and. certification for physicians managing emergency d.epartments in most hospitals. fn Large teaching hospitals or large urban hospitatsit was felt that there was a need. for a d.irector of emergency services with ad.equate certification in one of the major speciarties in med.icine, surgery--but more important with enough administrative and. professional authority to ru:' a coorclinated. and. authorized. program of emergency services and. trainrrt6

.

Alr in the group fert that training in emergency room caJ.e should' be emphasized. at all stages of med.ical ed.ucation--stud.ent, intern, resident and post-grad.uate staff physician level. fn university and. teaching hospitars it was felt that art speciarty groups should. be involved' in the training of stud.ents, house staff and. the grad.uate physician in emergency med.ical servi_ces.

Qn

REPORT 0F WORKSHOP #\

Gustave Adler,

M.D., Metropolitan

Hospital

Centre, New york

The d.iscussion covered several aspects of emergency med.ical care, but concerned itsel-fprimarily with physicia:i staffing.

Basic to this d.iscussion, was that general sol-utions for emergency d.epartments were d.ifficult to present because the need.s were d.ifferent from community to community and. from hospitar to hospital. some participants fert that emergency departments should. have a Walk-In-Ctinic ro provid.e better care for both groups of pabients--the emergency patient and" the non-emergency patient.

Physician staffing was discussed.. It was noted" that few physicians choose emergency medicine as a career.

Therefore, it was thought that medical stud.ents should. have more exposure to the emergency d.epartment through elective time in this area.

Training prografls for physicians should. be estabrished. some participa:rts fett that famity physicians could. firr this need, while others fert strongry that this is a special field. requiring speciar training and skill, md that the emergency d.epartment physician needs to feel a higher status level than he has previously realized.. rt was arso strongly felt that the med.icar schoor shourd. play a big role in furfirring commnnity need.s in this regard..

It was further noted. that physician staffing is expensive and. that hospitars must be wilring to pay good. sararies if they want good. physicians and thus, good emergency d.epartments. These physicians must not only be good physicians but also good. coord.inato::s and rnust assume supervisory respons ibiliti es .

-Ro-

REPORT0F WORKSHOP #'

Thomas J. Zi-rkLe, M.D., Loma Linda University,

Loma Lind.a, California

Inter-reLationship of present Emergency Service lrith the Family Practice or Community Medicine resid.encies avaiLabLe at various centers and how this r^rould.conflict or complement the training of emergency room medical personnel.

Only one member of our group had. an emergency room resid.ency at thp

nreeanf.

i.-inp

In several places the emergency room is a d.ivislon of the family nrarl'

i ao

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an

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was

no relation between the emergency service and. the family practice unit.

The suggestion was mad.ethat baccalaureate d.egree persons be trained. for emergency med.ical use. This was suggested. in light of the Large number of persons \^rhohave been exposed.to Nhis type of care in the military service.

By and. Large the group felt that this would. be an unvise plan.

The next major d.iscussion was the use of med.ical stud.ents in the emergency room and. how this related- to emergency teaching.

The use of med.ical students in the emergency room varied. wid.ety from one area to another.

Some larger city hospitals have regular student rotations; how' ' p\rAT ro-A ohn-?ahf Lhore i*!c lto -n ai f har 16cc6h +ha a+rl.lan* norl *q l ure'q either partieipaapyar'rru lessen the stud.ent tion in the emergency room, based largely on medical-Iegal tiability problems.

The final portion of the workshop d.ealth with the plans of the various med.ical centers represented. for emergency room resi-d.encies. 0f the twelve med.ical centers represented. one has ar:. emergency room resid.ency now functioning.

None of the other workshop members favored a"n emergency room resid.ency. TVo members suggested. that short courses in a Continuing Medical Ed.ucation setting, such as is carried. out in Boston, would. be nr.ncntnh

l e

tn

ihe'i r

r r n ' i r r e r sDir tvrJr

.

In summary it was the feeling of the workshop that there is no great curuent need. for a full separate specialty in emergency room med.icine and the universities represented" had. no specific plans for moving in this d.irection.

-ot -

REPORT0F WORKSHOP #6 T}IE TBATNING OI' PHYSICIANS IN THE EMERGENCY DE?A.RTMENT C h r i s f . iv np r'u

!t r.

.l {rq" rur / c o c k , M . D . ,

N.J.

CoIIege of Med.icine & Dentistry,

Newark

I.

should. physieiar:s be trained. prior to working in the Energency Room?

The consensus I/ias that they should. be, and that progralns should. be developed as soon as possible to d.o this.

2.

The Workshop felt that tlie Emergency Room should. have d.epartment status with a full-time d.irector uho spent part of his time with ad.ministration a.nd.the rest of his time teaching.

Und.er him should. be trained Emergency Room physicians supervi-sing and. trainlng resid.ents and. interns.

About half of our group were surgeons and half internists.

The group strongty opposed having the Emergency Room as part ttAmbutatory of an caretr Department.

They felt this woutd. tend. to downgrade the critical care aspects of the Emergency Room and. make it more of a 24-hour thalk inn clinic.

A query of the present status of each of the workshop mernbers revealed. a wid.e I'hod.gepod.gett of authority a,nd.d.uties.

3.

Motivation of stud.ents toi,iard.s becoming Rnergency Room physicians was d.iscussed.. Here it was felt that the cornmunity need.s, securityr good. financial rewards, regurar hours, etc. would. entice a good. nrmber of stud.ents into the field. if such tralning were offered..

Stimulation of the students is being carried. out at those schools where the Emergency Room Department is part of the curriculum or is offered. as an elective.

It is a very popular one at the University of' Nebraska.

The question of manpower shortage to staff as they should. be was brought out.

Another problem is the d.isparity the community group emergency room salary, It was felt that the attraction was more important than salary.

all

these positions

between faculty salaries which is much higher. to an excitlrig

vs.

new specialty

The group cond.emned. the current practice of placing the Least experienced. man (ttie intern) in this most d.ifficult area.

It is strongly felt that the M.D. in charge should. be no less than a second.year resid.ent, and' interns should be there only und.er supervision by a well-trained. man.

-93-

REPORToF woRKSHop#7 TIM TRAINING OF PHYSICIANS TN T}M E.MERGENCY DEPABTMEIVI D. T. Frei-er, M. D., University

of Michigan Med.ical Center, Arur Arbor, Mich.

The subject was divid.ed into three parts for d.iscussion: (I) Med.ical stud.ent emergency ed.ucation t (2) traini-ng of interns and resid.ents (alr specialties); und (3) postgrad.uate emergency ed.ucation, includ.ing residency for tremergencyphysicians.'r No one disagreed. with the need. for beginning the orientation of emergency med.icine in the freshman year.

Three schools represented., offer tr'irst Aid. courses.

OnIy one has a formal first two year curriculum set up for the subject of trauma and. acute injury.

Most effort in this fietd. began vith the ltfilfD program and. has continued.. AIL schools have a Loosely formed prograJn of minimal emergency room exposure d.uring the clinical yeaJs consisting of nights spent in the emergency room and. tutoriars.

Some clerkships are offered. for some practical experience.

Most of the activities are quite popurar.

The teaching in the crinicat years is rarely done by staff faculty.

Little is offered. in the way of manikln CPRpractice.

The training of all interns and. specializing resid.ents was emphasized.. The required. knowled.ge and. skill-s includ.ed. formal CpR trainingr arrhythmia recognition, arl d.rainaâ&#x201A;Źe proced.ures (pleural, pericardial, blad.d.er, etc.), hemorrhage control, utilization of all intravenous routes, and. knowled.ge about overdosage and. poisoning. !.ormar programs must be formed. to includ.e aII of these skitts.

Haphazard. acquisition is unsatisfactory.

If the intern is exclud.ed. from the emergency room, uhat specialties wiII Learn these skiIIs except surgery? The question of who has to teach brought a strong consensus of opinion that Emergency Departments must be formed. with hospitat and. acad.emc status so these formal prograrns can be carried out.

The d.epartment head. should. have this responsibility.

One half of the hospitals represented., have interns as the primary physieian in the emergency room with resid.ent backup. Most agreed. the resident is very competent, but a strong feering was expressed. that permanent staff, 24 hours a d.ay, was the id.eal for experience, maturity, end

f.cqnh'i

no

The need for postgraduate training is obvious.

Numerous progralns exist for technicians and. med.ical help personnel but few if any for the specific purpose of review of emergency med.icine for physicians.

Many other specialty prograns are given but few concern themselves with that critical first hour of care.

This need. will not be met untit Emergency Departments are established. and. recognized. acad.emically.

It vas agreed.

-95-

-96that

emergency resid.encies must be estabtished. and. guid.elines of the ACERP were agreed- on as acceptable guid.eh-nes. The subcommittee on grad.uate ed.ucation of our own organization has been charged. with the d.uty of consid'ering this problem and we await d.iscussion on their recommend.ations. rn summarxl most of the 7 posed. questions were answered.. Arr physiclans must be trained in emergency med.icine, not necessarily before working in the emergency room, but certainry before they act as primary physicia.ns.

The skirrs were carefully outlined. as suggested. by the committees of ACS, NRC, etc.

There is a strong need. for Emergency Department physicians and. especialry a need. for his recognition as a speciarist.

His part as a ttcommunity med.icinetr specialist d.epend.son his location and the size of the hospitat.

AtI subspecialties must take part in the teach_ ing und.er a coordinated. program. The training should. be carried. out at alr revels from freshman stud.ents on up. The emergency physician resid.encies shourd. be limited. to those d.epartments seei.ng at reast 3orooo emergencies annually as suggested. by ACERP. Nurses can be trained. to augment the physician wherever possible without consid.eration of replacing him.

ruponr or worucsuop #B THE TRAINING OF PHYSICIANS IN TIA M,IERGENCY DEPABTMENT Wi'.Iiam R. OIsen, llniversity

of l[ichigar,

There was genelal agreement that physicians is a manifesbation of a change health care services.

Therefore, planning projection of what the health care system to flt into the existing system.

Arrr Arbor, Michigal

the need. for Emergency Room in the system of d-elivery of should. be d"irected. toward. the wiII be rather than a.n attempt

The Emergency Room physlcians should. be prepared to rend"er d.efinitive cane for one visit probrems (u.g., contusions), initiar care for minor problems reguiring forrow up care (".g., place sutures but not remove them), resuscitative care only for acute serious problems (unti-f +i,r^ ^,'1*-i r-+i -^ ^L pnyslcian une a,cunrt,tl-ng or suJgeon arrives), zu:d triage servj-ce only for non-acute probLems requiring prolonged follou-up (mifd. congestive heart peptic ulcer disease, etc.). failure, This implies that each system offering Emergency Room type care should also be able to provid.e follow up caJe conveniently.

There l^Jasa majority but not unanimous opinion that the Emergency Roomphysician eventually should be a specialist in his own right, not a general practicioner who has Limited. his field. of end.eavor.

Consid.ering the urgency of the need. and. the logistical problems involved., the training of Emergency Rocm physicians should. be viewed. in two phases. a)

Phase I - The need for Emergency Room physicians now: This can: be achieved" best by a combination of d.id.actic and nra.ctieal

ynvnvs f .vsbr !a d r e | l . e

t.rai nino

n_ f_

nr ectinino 5_

nh' r-_yst_ct_ans

now involved. in Emergency Room r^rork or planning to d_oso.

These sessions should. be two to four weeks in d.uration at busy Emergency Rooms in teaching hospitals.

Most workshop participants agreed. that it would. be easier to teach an internist or a general practicioner the surgicaL skills involved. in an Emergency Room practice than to teach a surgeon medical skiIIs. h

l

Phase II - The eventual need.: Best met by starting now to form formal residency programs, preferably of two yeaxs d.uration.

-97-

REPAPT vrlr

rllr

nI' vr

TTTnPKSHflP #Q yrvrrr\prtv4 7l /

Ronald. L. Krome, M. D., Detroit

Receiving Hospital,

Detroit,

Michigan

Physicians

A general d.iscussion concerning the use of full-time Emergency was held.

Although there Tdasno unanimity of opinion, many

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corununity hospitals and,for those that have little d.iscussants d.id. feel that even in the larger Sotne be some benefit to having Emergency Physicians in and. meaningfully train their house staff. ( "Does intern have to do aII the suturing"?)

m r u !.6ir o r uh f . h v vp

it rnI t

fu.rhl r e

SmaIIef

or not house staff. hospitals there m:ight ord.er to more efficiently a surgical resid.ent or

The consensus of the Workshop r,ras that the med.ical schorl.s are obligated. to provid.e the trainlng for the Emergency Physician, but the method and d.uration of such training was in some question.

Most concern trresidentsrrwhile was about the use of these they rotate on the other specialties.

Several d.iscussants were concerned. that they would. be used in lieu of surgical resid.ents, etc.

The positlon of the ACEPwould appear, h"rt"""rJ" be that these resld.ents were to be used. to|tsupplementrr existing house staff.

Bnergency Physicians need. not know how to perform surgery, etc., but to properly d.iagnose and. initiate treatment.

The d.iscussion then turned. to the training of students and. house staff in the Emergency Department, and the Logistical difficulties in using this Department as a teaching arena.

The d.iscussants agreed. that the use by many d.ifferent d.isciplines of this area mad.efor great confusion and. d.ifficutty.

The overcrowd.ing by patients further compound.sthe problem.

It has become obvious that the Director of the Emergency Department wiII have to establish the priorities who can of ed.ucation (j4-, come into the hnergency Department to be taught and. to teach?).

The Workshop agreed. that there has not been enough focus on the content of training for medical stud.ents, etc.

We discussed. the varying method.s of teaching med.ical stud.ents.

-99-

nnponror,wonrsnop #:_g T}IE TRAINTNG OF PHYSICIANS IN T}M EMERGtrNCY DEPARTMENT Peter c. canizaro,

M.D., southwestern Med.ical schoor, Da}ras, Texas

The members of the workshop agreed. with the need. for training physicians who have a speciar interest in emergency med.icine, but there was a general consensus of opinion against a two or three year resid.ency training progra-In. The progra.m as outlined. by the Arnericarr correge or.

Emergency physicians is consid.ered. too na,rrow a speciarty in regard. to training a'd. would. be a'arogous to training a pre-operative or a postoperative surgeon. An alternative approach would. be a six or twelve month training prograln taken after the completion of a starrd.ard"resid.ency in any of a number of speciatties.

The choi_ce of resld.ency programs might includ-e generar surgery, generar practice, famlry med.icine or internar med'icine' Emphasis then wourd. be upon training an alr-around. physician first, folrowed. by a short period. of ad.d.itionar training as an emergency physician.

Another d.rawback to the furl resid"ency progra.rn i-n emergency med'icine is the fact that a significalt percentage of ind.ivid.uals who complete this prograln may, in fact, become d.isiltusioned. in the future ar:d wish to engage in some other type of med.ical practice. of immed.iate importance is the need. to d.evelop a traini_ng program for physicia.ns who have been in private practice for a number of years and now wish to specialize in emergency med.icine. It is I.eLt that the same six to tuelve month program could. be offered. to these ind.ivid.uals.

As an alternative, a properry d.esigned. three month prograrn would. probabty suffice. rdeatry, the programs wourd. be d.esigned" and. implemented. by the emergency room d.irector in a setting where d.epartmental status had. been achieved-. However, it is recognized. that cond.itions in ind.iviclual hospitars wirr vary consid.erably and. require d.ifferent sorutions.

The remainder of the time was spent d.iscussing the need. for better training of interns, resid.ents and stud.ents in the emergency d"epartment' rt was fert that much courd. be accomplished. now without ad.d.itional expense or ad.d.itional staff.

The use of variou.Sp"" of aud.iovisual equipment was d.iscussed., although it was recognized. that these were simply methods of increasing the efficiency of the time spent in teaching' Although long-term planning for comtrrehensive training prograrns utilizing the best available teaching techniques is d.esi-rabre, the need. for improving the present progra.ms by temporary changes is obvious.

At the end- of the period. it was apparent that the paner d.iscussion and- the workshop had. accomprished. at reast one goal-_arl of the members fert they had. received. consid.erabre sti_mulus to improve the quality of training in their emergency d.epartments.

-l0l-

T}M EMERGENCY UNIT Improving Financial

Management

James T. HoweII Principal P e a l - M a r w ' i c k -M i t c h e l l & C o .

THE EMERGENCY TNIT

Through the emergency jnit of a large hospital the major issues facing American med.icine tod.ay.

flow many of

Primary med.i_calcare Second.ar.ymed.ical care Tertiary

med.ical care

The respective personnel

rores of the garnut of hearth professionar

Who d.ecid.eswhat is

an emergency? The patient

or the physician?

The pubLic image of med.icar care, d.octors, and. hospitars Payrnent for

non-hospital

Med.ical legal

med.ical care

problems

Can the medical team concept really

work?

Are med.ical costs too high?

But this evening you have asked. that our attention be focused. upon the financial solveney of the emergency rxrit.

I am very pleased. to be asked. to talk on this subject.

Having the meeting in Ann Arbor is a special d.ivid.ent for me since Michigan is home to me and my family.

Then, I arn very d.elighted. to d.iscuss emergency unit issues with this d.istinc'.-i ^L'^'] EuJDrrEU

6l

U(,L}J.

To d.iscuss emergeney units, med.ical caJe, and financing it wiII be importa::t to our communication if I d.efine some terms.

I characterize an emergency unit as follows: For the d.iagnosis and. treatment gencles.

of trauma and surgical

For the d.iagnosis and. treatment ped.iatrics and. psychiatry.

of med.ical emergenci-es includ.ing

The pubric, however, utirizes the emergency unit med.ical clinic.

In some instances thevisits because the patients are frightened. and that

-r05 -

emer-

for a general are emergencies d.efinition

-IUO-

suj-ts me. In other j-nstan.ces the patients arive at the emergency unit because of convenience, accessibility and availability.

To get a bit closer to the d.iscussion of the finances of an emergency unit, I am making a series of assumptions most of which f feel nrrj{-a Yurus

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The emergency unit T,{eare both thinking med.ical center.

The

emersencu

r r n . . iI

j c

r+ avok rl r J l r r n r . r n a 6 f a n d .

but it d-epend.supon its relationship to d.eliver med.ical care.

There are no uritten objectives services uhich the hospital out.

about is part

C O n t f O vL! !l veed

with

its

hu Jr r

of a

n q

hnsni rrvDlr

tues !.,l

.

medical staff

concerning the programs and. and. physicians intend. to carry

Because of the nature of this association, f am assuming that the quality of' care is excellent and. r.rnder your control and. that patients are satisfied..

I am assuming also that the med.ical staff of the emergency unit, again because of the nature of your association, is fof the most pa;.t in the full-time med.ical manaâ&#x201A;Źement of patients in the emergency u-nit. tr'inally, I am assuming that both the med.ical staff and the ad.ministration of the hospital have raised. the problem of financial solvency of the emergency function.

I place the ad.ministrator jn this position because the facilities, equipment, md overhead are his responsibility.

Both the med.ical staff and ad.ministration share the responsibility for the medical prograJns arrd. servlces for the community.

The charge which we have before us, then, is to improve the financial status of the emergency unit.

Further, thesolution should consid.er the satisfactions of both the medicaL staff and. hospital administration, as weII as continue the patient satisfaction.

Based upon our definition of the emergency prograins and services and. the assumptions which we cited, our approach wiII be to set out all the costs for d.eLivering care and all the revenues for having given it.

While we have someone gathering these data, there ale many other things we should. krrow.

A statement of objectives, med.ical prograins and services which can be agreed. upon by the ad.mjnistration and. med.ical staff .

-r07what are the mixes of patients, that is: trauma, med.icar and. surgical emergencies and. generar med.icar ca,re. (tn ttris t am rooking for the physicianrs d.eflnition of emergency med.ical care. ) where d.o the patients cians ?

rive

and. d.o they have responsible

physi-

What med.ical resources exi-st in the areas where the patients Iive? (physiciaris, hospitals, emergency units, neighborhood. crinics and. otherprivate and. pubric prograrns) which patients pay for their services and. which ones d.o not ? (wtrat is the payment mechanism, or is payment out of nneker?\ what are the mechanics of pricing, charging, bilting Iecting?

(How effective are these systems?)

and col_

what are the vorumes of serviees by type of med.icar care probrem? (wtrat times of the d.ay and night d.o these patients arrive?) what are the staffing patterns by professionar category including the number, compensation and. the shift which each person works ? what is the rore of each person on the emergency care team from the moment the patient arrives ?

How dld. the patient get to the emergency unit? (self-rererred., refemed. b another physician, a public agency?) rs the emergency unit

a part

of teaching

prograrns r

(wnicn ones ?)

From the data correctj-on we shourd. expect an anarysis of expense and. lncome of the emergency unit relating one to the other.

In the analysis we should expect to lsorate the camse(s) of rxrfavorabre cost-revenue d'ifferences.

Generally we can expect these to fatl j.nto external a.nd.internal problems.

Potential

external

problems :

The patient group may not be served. by other med.icar resources in the geographic area.

The patient group may not have third. party coveraâ&#x201A;Źe or the type of coverage necessaffy for the manner in which they are using the emergency servj_ces.

?

1 no

The patient group may be a ghetto popuration who canrt afford. med.ical care and. there is no neighborhood. crinic yet established.

It .

would' be very significant if the analysis of the patient load. revealed. an emphasis on general med.ical care of & Rofi- erhâ&#x201A;Źrgency nature.

An emergency r-mit is a very expensive way to deliver general med.ical care.

So often icar rf '

Potential

for some reason one emergency unit w'as receiving or being referred. a heavy proportion of non-paying patients, a so'ution should. be sought.

Internal ff

there j-s no agreement arnong institutions in a geographarea which usuarly resurts in high costs for arr.

problems :

no objectives concerning the programs and. servj-ces which wiII be offered., we can anticipate proliferation of services without guid.arrce. We can expect that we may d.upticate services of othermed.ical resources.

These elements of planning failure may become quite expensive with little chance of recovery of cost.

By the same token aâ&#x201A;Źreement should. be reached- about what emergency progra.tns and. services are not going to be operated.. In both instances med.ical and. adr y 1 i p i c 1 - . r r 1 - . i r r a n n - ri n i . s g

If '

should.

be

established.

and. enforced..

no penetrating administrative and. med.ical cost analysis system has been estabrished., then we can hard.ry expect eharges and.fees to reflect cost.

After

knowlng accuratery the costs of seeing a patient in the emergency unit, we must then stud.y the proced.ures by which charges and. fees are set and caruied. out includ.ing financiar screening, bitring, charging, colr-ecting cash and. charges.

rn the absence of a stud.y of the dairy of problems may emerge. rs the staffing pattern rlrell as the peak load?

patient

road., a series

matched. to the low road. period. as

Are the proper personnel on d.uty at the coruect patient Load. period.s ? ft courd. be very expensive to have highly quarifid. people on duty at loi^r load. period.s.

-r no-

major teaching program may increase costs in the emergency unit particularly because of the d.uplication of supervisory staff members.

The more the emergency unit is used. for a general med.ical clinic, it can be anticipated. that costs will mount and. it wiII be d.ifficult to charge the fees necessary to cover cost.

It

is for this reason that triage becomes important 1n the d.aily operatj-on of the emergency turit.

Those patients who can be seen in the outpatient department should. be d.irected. there with arr appointment as soon as possible.

If

the emergency unit were staffed. and. operated. as a true emergency unit, it would. be less d.ifficult to recover costs since most third. party plans do cover these medical problems and in ad.dition, maJry of them d.o become hospitalized. which further assures third party coverage.

It

is more important that the business representative in the emergency unit becomes a scholar of aII tirird. party systems on both the hospitat and. the physicia.n sid.e. FuII ad.vantage must be taken of aII allowances provid.ed. in these systems.

In the deflnitlons and. assumptions that were mad.eearlier the emergency unit was designated. as belonging to the hospital.

This is important to the d.iscusslons of the role of clinical laboratories and. X-ray equipment in the emergency unit.

CLearIy the cost of operating the emergency uni-t will go up if both are provid.ed and. staffed" in the unit.

If the hospital, per se, provid.ed. one rtstat" laboratory and. one X-ray service, it wourd. be Iess costly than also provid.ing d.uplicates in the emergency r-rnit. Naturally this requires that such services are read.ily accessible for emergency patients.

The cost analysis about which we have been talking has related. to aII med.ical visits in the emergency unit.

The analysis could. be carried. further to show the costs of specific cases such as fractures or coronaries or strokes, but probably the mcst important cost d.istinctions are between the emergencies and. the general medical visits.

Generally the costs of the emergencies are covered by the third. party plans and. the general visits are not.

Qt rmmovrr vwrs[|4_y

In this paper, the question of improving the financing of emergency units has been discussed.. several points have been mad.e.

- tto-

clear statement of objectives of the prograin arrd services which will and. won't be operated. is required. for both the hospital and medical staff.

The med.ical resources of the geographic fied. and. coord.inated..

A penetrating hv ov

area shoutd. be

cost study matching expenses and. income should.

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Staffing of all professional levels should. be carefully to the patient hourly load. Ievels.

Increased. partlcipation personneL.

matched.

should. be sought from paraprofessj_onal

Major problems can be anticipated. in the emergency visits ara

rlanarel

med.iCal

in

fl"enonol'lrr

natUfo

+he

felated.

rihich COSI

for these visits is higkr in regard. to the other emergency visits and. seld.om are general visi"bs covered by third. party systems in the degree as true emergency visits.

It

would be wise to triage the general visits with paraprofessional people and arrange for these patients to be seen and. cared. for in a much less expensive facility such as a general QPD clinic.

This would. also d.ecrease the personnel in the emergency unit, thus, d.ecreasing cost.

In increasing income, a knowledgeable ad.ministrative employee should be placed in the emergency tmit to ca.rry out d.etailed. financiaL screening, pricing, applications of appropriate charges and. fees, billing and collection procedures.

The emergency unit specialist should. seek the best sched.ule which uses hj-s expertise on the true major emergency probIems. It is most Likely that third. party systems wiII cover his services.

Again, he should. make the best use possible of paraprofessional personnel.

In d.oing this, the object is to make greatest use of the physicia,nrs time and. creating a volume service.

The fee policy af

within

n c r f n rr vmr 4- ir n4 rrrrb

f.hc

the emergency unit

Finally, the emergency rmit is not pital's reimbursement formula, centives

for

is to cover the cost

c p y r r iv nrev u .

looking

to

cost

completely thus

boi-lnd. by the hosprovid.ing ad.d.itional in-

red.uction.

]S YOUREMERGENCY DEPA3TMENTSOLVENT? A ST{.IDYIN COMMUIV]TY I\MDICA], ECONOI\trCS

Janes R. M a c K e n z i e , M . D .

Is your Xmergency Department solvent ? The question is especially pertinent at the present time when the total costs of patient care in the Emergency Department can be recovered. by both the hospital and the physician through third. party payrnents. However, the costs can only be recovered. if the hospital and. the physiciar: are able to id.entify the appropriate costs and bitl the ind.ividual or the agency involved..

This talk will d.escribe: the method.s used. by my hospital to id.entify the costs of Emergency Department care; and. those used. by the Ontario Hospital Services Commission, (the government run prepaid. health i:rsurance agency), to reimburse the costs to the hospita! the totat cost to the community of seeking convenience care in a hospital emergency d.epartment versus seeking it in a d.octorrs office; atld the influence total health care costs have had. on the d.evelopment of emergency medical care facilities within the community.

Our hospital onl.y id.entifies the direct costs for Emergency Department patient care, i.e., the cost for salaries, med.ical and. administrative supplles and. repairs for equipment. costs which inThe indirect clud.e capltal depreciation for equipment and space; and for heat, Light, telephone, md cleaning, are not cost accounted. against the Emergency Department budget, but rather against the hospitat capitar bud.get or service d.epartment invol-ved.. The sum totals of the hospital costs are then presented. without specific frnergency Department id.entification to the payment.

Ontario Hospital Services Commission for Thus, the actual costs for Emergency Department care in our hospital were not read.ily available for analysis until they uere separated. from the capital fr.:nd., and. the accounts of the service d"epartments involved..

following

In L97O the total manner:

costs were $390,872 ana were d.erived. in the

f )

Direct

costs

2)

Ind.irect costs.

3)

Total costs

..

3321162 )o,4yn

..39O,8r2

Since the number of patients admitted. to the Emergency Department in I!/O was J)1206, the average hospitar cost per emergency d.epartment visit in llfO was $10.00 Casualty offi-cers and. physicians staff our Emergency Deparrmenr on a rotational basis for L5 hours per d.ay, while other physicians, such as general practitioners and- specialists, also see their own patients in the Emergency Department.

In ad.d.ition, interns and. resid.ents staff our

-'t I ?-

I

d{ 't .l

)

-rr4-

I

.1

fr 1 i

Emergency Department 24 hours per d.ay. The staff officers charge a fee for service for nnJ:ieni a;

physicians

andinterns donot. rt was ;r;;:t:;: ffi:::l.i3'i::liHrii: Lurrevus\.r.

and. casualty

;;:t*ill:"

o^-n,-------\rr.rr-Lugthe year rplo for Emergency Department plrysiciansr services.

I therefore, aud.ited. the charts of patients seen in the ftnersencv Department d.uring a two week perio,L in tr'ebruary, and. assigned. a ciraqge against each chart for physician services in accord.ance with the lplO fee sched.ule of the Ontario Med.ical Association.

If aII of the services and proced.ures had. been charged. for d.uring the period. und.er investigation, the average physician charge per Emergency Department visit would. have been B./). ![is average fee crosery aâ&#x201A;Źrees with physician charges in other North American Emergency Departments.

The Lowest fee would. have Ueen $5.00 for a limited. examination of the involved. system, and. would. have applied- to most of the non-urgent or minor emergency patients treated. in our Emergency Department.

This category of patient constitutes at least 60/, ot our yearly Ernergency Department visits.

The highest charge would have been $r8o.OO for the resuscitatlon, d.iagnosis and. initiar treatment of a multiply injured. patient. the On other hand., this type of pa_ tient and. others who need. card.io-pulmonary resuscitatlon, constitute less than J/s of our Emergency Department population. nnl-lanfad

Ar"r.in,

fnterns and. resid.ents t salaries must also be ad.d.ed. to the cost physician of care. our Emergency Department averaged 2.5 interns at $516oo per year, and 2.! residents at $Br\oo p"" l.uur for a total of

$3z,5oo

Finarly, the average patient gets one laboratory test per visit, whlch costs $6.0o. Thus, the average cost for patient care in our Emergency Department can now be cornputed.: L.

2.

Hospital

costs for

a.

Direct

b.

Ind.irect eosts.

services rend.ered.

costs

332,j62

58,2gO

Physicians charges per patient a.

Servj_cephysicians. . . .

$g.f>

b.

I n t e r n s a n d .r e s i d e n t s .

$O.gO

3.

Laboratory costs per visit

4.

Total average cost per EmergencyDepartmentvisit

$5.00 VG.65

r

,l ; :i . l

,l

) l I

i

), ,

-t t 5-

Does this mean that the cost for treating the non-urgent or minor emer_ gency in our Emergency Department is certainly not. $26.65 per visit? r have arready pointed. out that physician charges vary from $:.oo for 6o/o of this type of our Emergency Department popuration, to $r8o.oo tor 5% of them' simirarty, the costs for raboratory services vary between o for 25%t and $:-3o.oo for L/o of the Eniergency Department visits. rt must arso be assumed that the Emergency Department d.irect and. ind.irect costs which average $:-r-$:-a per patient per hour wourd. be ress for the patient being treated for I! minutes ($s.oo) ttran the one being treated. in the Emer_ gency Department for 2 hours ($eL.oo).

Therefore, it might be assumed. that the cost for treating the non-urgent or minor emergency in our Emersencv Department wourd not be $26.6j, but $8.!o (prus r;bor;t;;y charges). rf the cost of interns and. resid.ents were d.ed.ucted. from this cost, the average charge for the non_urgent patient would. Ue $B.OO. In comparison, the average cost to visit one of our most respected. generar practitioners in his office is arso $B.oo. (muoratory charges have been reft out of this comparison on the assumption that the cost wourd. be the sa.mewhether the patient visited. theEmergency Department or the d.octor,s office).

The preced.ing cost anarysis of our Emergency Department which may not be absorutely correct, was nevertheress a revelation to me. rt is now possible to specurate that there may be an economic reason r.or nonurgent and minor emergency patients to frock to our Emergency Department in ever-i'ncreasing numbers. rf so, this reason may be a more powerfur stimurus to increased. Emergency Department utirization by this group, than those usualry referred. to, such as rack of physicians, transient popula_ tion, etc' For instance, it is certainly more economical for the working portion of the popuration to seek ca.re in our frnergency Departmenr at their convenience, than it is to seek it in a d.octorrs office at the convenience of the d.octor. Let me elaborate. rn Hamirton the average worker changes shifts at J or L o,crock in the afternoonr e.g., during the time most d.octors have their office hours' If they wish to see a d.octor, they must take two to four hours off work at one end of the shift or the other.

This amounts to a loss of J fo Lo/' of the total work weekr md represents a financial Loss to the worker or his compairy. The loss amounts bo perhour in the average $5.00 Hamirton industry, or $r5.oo for J hours he i-s off work.

Thus, the totar cost of health care to the person who misses work or to the cornmunity is n o t $ B . O Ob u t r a t h e r $ 8 . 0 0 p r u s $ t _ 5 . 0 0o r a t o t a t o f $ 2 3 . 0 0 . f f o n t h e other hand., he d.oes not mlss work, the totar cost to the community for medical care is onry $B.oo. No wond.er the patients with rurny noses a'e flocking to the d.oors of our Emergency Department.

The d'octor and the hospital ad.miaistrator have aid.ed. and" abetted. this trend., for strictly selfish reasons. The hospital which has an Emer_ gency Department nlrst provid'e expensi-ve space and. equipment an4 in-hospital back-up facitities, staff them with highry skitred. and therefore, expensive

-U_5-

personnel 24 hours per d.ay. This provid.es excellent, but expensive care for the few people that need. it each d.ay. One way to cut the unit cost of emergency care is to look after the non-emergeney patient d.uring the majority of the time when Life-threatening of major emergencJ-esare not present in the Emergency Department.

The non-urgent patient then becomes to the Emergency Department what the Loss leader is to the supermarket, i.e., to the overhead. and" thus cutting the unit a method. of contributing cost care of the true emergency. The willingness of the hospital to accept the non-urgent patient has been a grand. solution for the d.octor, mechanism to provid.e for his patient because he now has an alternative care d.uring the unattractive hours of the night and. the weekend.. even though it is based upon sound. economic Is this solution, principles the best one available to the average m4jor hospital Bnergency Department or to the community as a whole? I think not.

Gradually, patient past years, load the non-urgent has surpassed. over the several As a result, the capacity of many Bnergency Departments to cope with it. trained. in true emergency care d.octors who are ill an increasing number of and an equal number of u-nskilled. nurses are being mobilized. to care for all of the patients in the Emergency Department. This solution is economically sound. to the hospital because their limited. training will cope with BO Lo 90% of the load.. It may, on the other hand., be a d.isastrous solution for the person who need.s expert care.

Converselyr mmy of the and therefore having to pay for perEmergency Departments are training, sonnel - who are pvr$r9!,

exnerts

in

a.l'l asneets

of

emerB'encv eerc -

Whi ]e

this

is

med.ically sound it d.efeats the economical ad.vantage of caring for the non(75% of the Emergency Department costs are related" to urgent patient. salaries and. wages. ) to this d.ilemma? I would. like to What are the alternatives present only one tonight, although there are many others that are worthwhile.

The most obvious one is to concentrate the true emergencies of the irnmed^iate and. regional communities, med.ical or surgical, into one re^^.i,..i-d

vglVJII6

rI I.U^D^ }-/-I .Ui A+! ^ 1

w w rhr .r iu e r rh

ri os

geared 6uarvq

fr unl n

lur rr r uau

a e rm t l earr6ov a ! vnJ e 1 ;

ve4au1. a e -

T r rh r ue

p S' t a f f

availabel to d.eal with the emergency would. be trained. and. facilities card.iopulmonary resuscitation and. d"efinid.iagnosis of disease or injury, tive initial care and. d.isposal of the emergency patient while the high emergencies would. allow a more d.ensity of major and life-threatening patterns and. facilities. economical utilization The minor of stafflng emergencies and. non-urgent cases would. be cared. for in convenience clinics, where the med.ical and paramed.ical staff were not as highly skilled. and. therefore less costly than those in the true ftnergency Department.

First, it I believe that the solution would. accomplish two objectives. would. cut the total cost of med-ical care to the community for both the true emergency patient and. the non-urgent patient.

Second.ly, it would. d.ivid.e the patients in such a way that the medical teams would d.evelop skills related. to the patients' need.s. This has obvious ad.vantages for resid.ency and. continuing med.ical and paramed.ical ed.ucation.

I-l

-LL7-

rn summary, a method. for cost analysing emergency d.epartments in Grtario has been presented.. Attention was d.irected. to the fact that the utilization of the Emergency Department for non-urgent care may be economically sound. for both the hospital and. the community, but possibly med.ically unsound. for the patient uith major or life-threatening injuries.

An alternative aJrrangement for the care of the emergency and. non-urgent patient has been posed. which is both med.ically and economically sound for the community. tr'inally, I would like to pose the question again to you, ttis your Emergency Department sorvent?" or should. r have started. with the questi-on, rri.s your community emergency med.ical service solvent, and. if it i-s, d.oes the solvent state imply safe treatment for your true emergency nnf.'ianfc?lt

f w v 4v r 4vp

a

HOWCAN YOU MAI{E YOURE}trRGENCYDtrPASTI/ENTSOLVENT

AIan R. Dlmick, M.D. TIniversi tv

of

Al abama

DEPABTMHITSOIVEIVI HOI,ICAI\TYOUMAICEYOIIREMERGENCY

DR. DIMICK: Here are Apparently we are rxrique for a University Hospital. year L959-7Ofor our University the financiat figures for the fiscal Hospital: Universlty of Ataba.maHospitals and.Clinics Detail of Bnergency Department Costs Fiscal Y"ur Amount D i r e c t Expenses per Financial Statement: Salaries Fringe Benefits Supplies Drugs rrla 1 anh nn r v !v}rrrv..v

a

Repairs General Expense Less:

$298r.t4 L9852 't

1()qo?

'L///J

2h<h< -VJVJ

2679 aanl.

1>v+ NAA

M

Cred.it to EmergencyDept. for Hospitalrs Supplies Inventory Ad.justment

( t5r4

Adjusted. Direct Expenses Add:

Emergency Dept's. pro rata share of overhead. from General Service Depts.

Build.ing Depreciation Equipment DePreciation Administrati-on, and. General Reception, Mail artd. Elevators Print Shop Rrrchasing, Receiving and. SuPPIY Communications Linen Service HousekeePing Plant 0perations, Maintenance Security PharmacY Oxygen TheraPY Med.ical Record.s House Staff

g\697\7

$458073

LOO29

aB3B:3896 190 9948 L985 27228 27\ao 394L9 !o13 r4064 2375 32\5 LL66B7

292L32

- l a - )

Totat EmergeneyDept. Costs-Fy L969/TO

$z:53r.3

Total EmergencyDept. RevenueW L969/70

QUESTION: How much of the revenue d.o you collect?

UNWERSTTYHoSPTTA.L: ASSISTATITADMTNISTRATOR, Mrss oLAIRE UI\DERWOOD, ApproximateLy

BA/o of the revenue eventualJy.

QTIESTION:

.{re you on an accrual accouhting system?

MISS UI\DXRWOOD: No. DR. D]M]CK: The basic

charge is

$:-2.00 for

patients

seen in our Emergency

T)anqriment

MISS U]\DERWOOD: One point I think you ought to know is this d.oes not incl-ud.e Revenues generated. from each hospital are Iaboratory and x-ra,X charges. and we cost ourselves by laboratory and criteria based. on the d.ifferent As far as average (per d.iem) costs a^re concerned- the exx-ray costs. pense of these services, as weII as the revenue, go to the Laboratory and. to come up with That is why it is so difficult Rad.iology Departments. the sarne figures from hospitral to hospital in cost accounting.

QUESTION: Isn't

this

actually

fund.ed-by the Energency Department?

MISS UNDERWOOD: and central supplied. as No. In add.ition, we have solutions d.rugs.

Laboratory and x-Toff costs andand. we also charge for our well, charges are in other dePartments.

-12"-

DR. IIAYCOCK:

were x-ray

I heard- Dr. Mond.s say that some of his best revenue generators and. raboratory. rt helps get their head. above water.

DR. DTMTCK: But that n n r " t vm an .ger1

fw.

revenue goes into

the Ra.d.iology and. Laboratory

De-

#v u .c

DR. HAYCOCK: But that should. be cred.ited. to the ftnergency Department.

What about the charges for your patients seen in the ftnergency Department and. admitted. to the hospitat?

DR. D]IIICK:

hospital

Arl charges in the Energency Department a^re grouped. with charges.

the

M]SS UNDERWOOD: You get into d.ifferent method.s of payment. BLue cross pays totar charges for Emergency Department care and. we receive money from the county for the indigent Load. on a per d.iem basis.

CLOSINGREMARKS

Michael J. Madd.en Assistant Director ITnirrersi trr

Hosni tal

Ann fultt

lfinl-rir urrr$aJl wtr

Avhna f!r'uur.

,

Given the very ad.equate presentation presented. by Dr. Howell and. Dr. MacKenzie, I will keep r4y remarks very short and just try to emphasize some of the points made by these gentlement.

As you are probably aware from your visit to our emergency service today, the accessibility to our emergency ur:it is not exactly true in our case, since our emergency room j-s on the 4th level of the Outpatient Build.ing.

When we start tatking about the cost in the emergency room we have to think also about comparability of costs.

T worked. with the University Hospital Executive Council special committee on ambulatory costs for the Last six months a.nd.this group has had. a great d.eal of d.ifficulty in costj-ng arnbulatory services because each of the institutions uses a d.ifferent format and. different criteria for the costing of their servicesl thus, their costs are not compa,:rable. We need" not apologize for this faet,, but must make great efforts to try to get costs that are acceptable for each of the institutions operating ambulatory care services.

A point raised. by Dr. Howell shoul"d.be emphasized. and. that is that revenue versus costs are important.

More important is that income versus cost. fncome being d.ifferent from revenue in that revenue is the cha.rses

made in

f.ha

emoroonnrr ov'rvJ

-^Om

a.nd. that

inCOme iS

the

CaSh feCeiVed.

from those transactions.

This can be a greatly d.ifferent figure, given problems which are commonto many emergency services. the collection Dr. MacKenzie mad.ean assumption in his presentation that if you give good services to a patient in the emergency service that you rlould. receive payment for those services rend.ered.. This may be true in the Canadian health systern and I arn sure is, but in the U.S. health system, the one who is more likely to pay is the traumatic emergency, who is covered. under BIue Cross-Blue Shield. or other insurances.

The non-eftergent walk-in patient d.oes not often have insurance coveraâ&#x201A;Źe.

So just to have an economically sowrd. system rests not only on our ability the charges rend.ered., but on our abitity to collect cash for those charges.

We havE noted in many of the speeches that there has been a breakd.own in the d.elivery system. Here in Arue Arbor there has been the development of the F?ee Peoples Clinic of Ann Arbor, Incorporated., which is d.esigned to service both street people and. stud.ents in the Ann Arbor, Miehisnr, A:rIA.- Resid.ents and. staff men lrom the Tlniversitv of Mich'iB'a.n provide the physician staffing for this clinic at no-pay and. patients receive free care at this clinic.

We have an arrangement where patients are referred. to our arnbulatory setting or our emergency service for care after being seen at the Free Peoples Clinic, but if this happens, the patient himself is billed. for the services received" at the U. of M. One thing ihcf

tha.r

ara

nqrf

should. be said. regarding nf

o

-lurc^T;nStitUtiOn

the emergency services-and. that

a lr qar br vg4 e r s

institUtiOn

-r2Bhas to d.evelop policies whlch relate to what type of patients a.re seen and' served. and what the changes are, who staffs the Energeney Roomand. other considerations.

With this consideration there should be a policy regard. ng whether or not the emergencyservice has to be sorvent. rf it has to be sorvent we can do things to reetify that. rf it can be camied. at a ross because of a^njnstitutionar poricy, that is arso possible.

-120.-

DR. FROMSAI\]FRANCISCO: This interferes We have large numbers of walk-in patients. patients. is true, but we need. to care for This with the acutely ill hospital. ofthe the walk-in patients in the emergency facilities It j-s our responsibility for the level of the quality of care they get and. the follow-up.

Although we have supported. a report from Johns Hopkins when analyzed. they found that 87 percent of examining this situation, these patients received. no care.

And. a certain nurnber of patients received bad. care.

CIIAIR]vIAI{: I certainly

aâ&#x201A;Źree with you.

DR. II{ACIGI{ZIE: When you I donrt think it is a question of for or against. get the follow-up care i-n marrJrcases where they have looked. at such things It as the routi-ne hemoglobin, you d.on't get any better level of care. provid.e all levels of is not right that the emergency d.epartment should.

CHAIRII'iAN: One question f would. like to ask Dr. HoweII. we put interns and. resid.entsr salaries in?

What column d.o

DR. HOIiELL: We feel that this is a d.irect expense that should. be allocated. j:rto the salaries of the interns and. resid.ents for a1l care irrespective of whether the hospital pays for the interns and resid.ents salaries or The services are rendered. by the whether the med.ical school d.oes it. for they resid.ents the time are in the emellgency room. interns and DR. WILLIA]VISONOF CLEVEI,AIID: bothers me.

The patient who comes in who is not sick--that put costs has us in this rise i-n med.ical is the breakd.ovn.

There The position.

I would. suggest that the best thing we could. d.o is to set up night clinics and. staff them with house officers.

DR. PLATT OF DENVER: We find. that non-emergency patients in the emergency room keeps from us caring for the real emergency patients.

We dontt like triaging

1 ^ n -J"

them out.

We caII it screening the people out. terns use is the I'screening clinic.rl

The term that

our in-

DR. HO}i-ELI,: Obviously to triage them out is not the answer. There has got they comeback to be somewhere for them to go. You d.o triage and. still fvnv

rrn rr vu.

J

Tf

+!

rrnrr

.y v4

|69]1

at

ffOm

it

a pure cost point of viewr you treat

yollr Olill nOn-emer$encf the patient in Iesser facilities or you create hours thing main of the d.ay. Another ctinic that operates through the cllnic. them out with open appointments in an outpatient I see is triaging

DR. WAGNER OF P}tr],ADELPIIIA: which I want to ask a question about our Philad.elphia situation '\uorried wellsft Mainly about 5o to /O percent are I think is difficult. and our true emergency patients are a.bout one third..

DR. PEIMME: Perrnsylvania is

a special

and terrible

problem.

DR. HOWXLL: Obviously, I thlnk what you are saying is this is one of the costs that has got to be in the picture of rend.ering the care of this type in an emergency unit and face the issues of'what the costs really are matched. up aâ&#x201A;Źainst your revenues.

We have been facing this in the med.ical world. where the public program d.id not pay the cost and. it isnrt new to us, however d.eplorable it is.

Our continuing argument with the goverrunental agencies saying you are not paying costs atrd. then they turn arowrd. and. say show us your costs therefore we are not in a, very good posltion to argue.

DR. PEilO4E: every med.ical Although Pennsylvania pays only $4.00 per visit, school is subsid.ized by the state.

In Washington we have the reverse of that.

DR. WAGNER: The State of Pennsylvania pays FrlOO for the ed.ucation of each med.ical stud.ent.

It depend.s on where you want to spend that money.

Most schools will get that rei-mbursed.

-t?t -

DR. PATN SCUDDEROF'NtrWYORK: The New York BLue cross is plcking care blII. CIIAIB}{AN: This is the first

state to d.o so.

DR. MYCOCK: Is this

a matter of' semantics?

up the entire

emergency