ED management : the monthly update on emergency department management
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A new study suggests that proven strategies for eliminating boarding and crowding in the ED are being left on the table in many hospitals because leadership has not stepped forward to eliminate pockets of resistance. Further, there is new evidence that changes in practice intensity in the ED are contributing to crowding even though some of these changes were designed to do the opposite. ⋯ Experts say such strategies are difficult to implement because they are hospital-level rather than ED-level problems. A new emphasis on physician satisfaction surveys is driving ED practice intensity along with changes in billing practices and technological innovations.
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Alarmed by adverse events involving opioid drugs, the Joint Commission has issued a Sentinel Alert urging hospitals to take steps to improve safety in the prescribing of these powerful drugs. In addition, the Food and Drug Administration (FDA) has launched an initiative that will soon require the manufacturers of long-acting and extended-release opioids to offer education and training to physicians and others who prescribe these pharmaceuticals. ⋯ The FDA reports that nearly 16,000 Americans died from overdoses involving opioids in 2009, and in 2011, there were nearly 23 million prescriptions written for extended-release and long-acting opioids. Some new guidelines on opioid prescribing in the ED urge providers to avoid prescribing extended-release or long-acting opioids altogether, and to consider measures that will limit opportunities for drug diversion.
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While EDs are accustomed to preparing for mass-casualty events, the EDs responsible for caring for the victims of the mass shooting at an Aurora, CO, movie theater on July 20, 2012, say the emotional impact of dealing with such a senseless, horrific event remains challenging. Still, the ED directors from the two hospitals who cared for the most patients that night credit established disaster-response procedures and regular practice drills with helping them to successfully manage the crisis. Within a 30-minute time period, the University of Colorado's Anschutz Medical Campus in Aurora, CO, received 23 critically ill or injured patients, one of which was deceased upon arrival. ⋯ The Medical Center of Aurora received 18 patients, 13 of which where suffering from gun shot wounds; all survived. Hospital administrators say ED providers and staff have responded in different ways to the tragedy, but the emotional impact has been difficult for some. Resources, ranging from spiritual support and grief counselors to psychiatric help, have been made available to help ED personnel access the kind of help they need.
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Even though the U. S. Supreme Court has upheld the bulk of President Obama's signature health care legislation, the Accountable Care Act (ACA), the prospects for full implementation of the law remain uncertain as political opponents still vow to strike down portions of the law at the earliest opportunity. ⋯ Some experts predict that EDs will see a flood of new patients when the Medicaid expansion provisions go into effect in 2014, but this trend may be tempered by the fact that newly insured patients will be able to seek care in other settings. The health reform transition is expected to be most difficult in states with large uninsured populations, and experts agree that a shortage of primary care physicians will drive ED volume in many communities. Hospitals and health care business interests are putting pressure on states to opt in to the ACA's Medicaid expansion provisions because it will make federal dollars available to cover 100% of the cost to cover newly insured Medicaid patients for three years, and 90% of the cost after that.
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The Joint Commission has revised its standards regarding ED patient flow and patient boarding so that hospital leaders must establish measures, set goals, and take responsibility for resolving throughput challenges. Some experts applaud the change, noting that problems with ED crowding often require system-level solutions. ⋯ Hospitals and EDs need to look at how they will address behavioral health patients who are waiting for transfer to another facility. Safety needs to be the key consideration.