UN]VERSITY ASSOCIATION

for

ETIERGENCY MEDICAI SERVfCES

First Annual Meeting. t . - -May I4-I!, L97L

University of lt[ichlganAnn Arbor, Michigan

TI{E FTRST AI{NUAI MEET]NG OF TJ{E

UNTVERSITY ASSOC]ATION FOR EMERGENCY MEDTCAI SERVTCES

OPENING REMARKS

May l4 & Lr, L97L

CIIASIES I'. FREY, M.D.

t r ' rnm the T)enar tmc-* ^ f c ' vn- - - , ( SeCt iOn Of Genera lI r v r t r u r l L , u } r @ u J u u r r u v ! u u f b e r J \ I

S r r r o a r r r \ I ' I n ' i r r e r c i f � r r n f M ' i n h i o s n M p d i n e l C e n l - . e r .p 4 v r / v +

Ann Arbor, l4ichigan 4BfO4.

PRXSIDENT]AI ADDRESSCharles F.UniversityAnn Arbor,

TASLE OF CONTE}'ITS

v a o er € _

I1r" err

n f M i oh i oqn

h i f i a l - ' - i nan ' t

J . v [ u ! I J 5 4 l .

f '

i

THE R$TOLUT]ON IN EMERGENCY NEDICAT, SERVICES -

CAISGORIZATION 0F HOSPITALS = THE IMPACT 0N YOUfrvin E. HendrysonChairman, Joint Corualssion on Bnergency Med.ical

Serv ices o f the A.M.A.IJniversity of New NexicoA l b u q u e r q u e , N . M . . . . . 7

CATEGORIZATION OF' HOSPITA]-, S4ERGENCY FACI],TTIES .

STII\O4ARY OF MORNING WORI$HCFSRobert M. Zol l inger, Jr.Case Western Reserve Universi tyCleveland., Ohio

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

Report of Workshop #Thomas S. MorseChild.ren's HospitalColi lnbus, Ohio . , ,25

Report of Workshop #3David. R. Boyd.Northwestern UniversityC h i c a g o , I l l i n o i s . . . . . 2 7

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

New York UniversityNew York, N. Y. . . . . . .3 I

Report of Workshop #5Harold. A. Pa.uIRush Med.ical CollegeC h i c a g o , I l l i n o i s . . , . . . . . . . 3 3

2t

t l l_

39

43

L r

l ?

Report of Workshop #6William MatoryHoward. UniversityWashington, D.C.

Report of Workshop #TLouis G. Britt

Pa€e

University of IennesseeI(nqxville, Tennessee

Report of Workshop #8Gerald. W. ShaftanState Unlversi tyNew York, N. y.

Report o:ll Workshop #gRobert B. Rutherford.University of ColoradoDenver, Col-orad.o.

TIN TRA]NING OF PHYSICIAIIS IN TITE E}4ERGENCY DEPASTI@IilIPA1\]EI, DISCUSS]ON

Roland. FoIseHarborview Med.ical CenterSeatt le, Washington. . . .

TIIE NEED I'OR TRAINING PHYSIC]ANS IN EMMGENCY MEDICINEJohn WiggensteinL a n s i n g , M i c h i g a n . . . , . . . . . , . j 3

Ronald l(romeDetroi t Receiving HospitalDet ro i t , M: ieh igah. . . . .5 ,

James W. A€naCincinnati General HospitatC i n c i n n a t l , O h i o . . , . . . 5 9

James Dineen t

Massachusetts General HospitalHarvard. Med.ical SchoolB o s t o n , M a s s a c h u s e t t s . . , , . , 6 5

. . . . . . . 3 5

P q o o4 e o v

AoQ U E S T I O N A N D A N S W E R P E R I O D . . , . ; , . , , . : . : : ; , . . : . . . . , . . , v 2

TIIE TRAINING OF PHYSICIANS IN TIIE E,I4ERGENCY DEPAfiT}4ENT'-SUI\,[,IARY OF AFTERNOON WORKSII]PS

'i ' ' i' 'Alan Birtch l

Peter Bent BrighamBoston, Massachusetts.

D a n a v * a f T r 7 . t t ^r let /vr v vr v lorKsnop #I

AIan G. Birtch.

Report of Workshoh lfzGeorge Johnson, Jr.Universlty of Nortn CarolinaC h a p e l H i l l , N o r t h C a r o l i n a . . : . . : . . . .

Report of Workshop #3 : I :

John H. CarterAlbany Med.ical Center Hospital

'

A lbany, New 'York. . . . . .81

. l , , . . . . i , t i ;

Report of Workshdp #4Gustave Ad.lerMetropolitan Hospital Centret \ ta\J V ^7 r a\ t v

l '

Report of Workshop #5Thomas J. ZtrkLeLoma Lind.a UniversityLoma !ind.ar' California.

Report of Workshop #6' Christine E. Haycock

New Jersey CoILege of Med.icine & Dentistry\ T e r ^ r o r L \ T e r ^ r J e f g e y . . . . . . . l . . . . . . .* , - , , J e r s e Y . . . . . . . . . 9 3

Report of Workshop #7D. T. Fre ierUniversity of MichiganArrn Arbor, Mlchigan .,.95

Report of Workshop #BWilliarn R. OlsenTTnirror .c ' i l - . r r nf Mi nh' i oqn

"&nn Arbor, Michigan . . .97

Ro

.l

IS

TI]E

HOlli CAt\ YOU MAKE YOL|R EIvIERGENCYAIan R. DimickUniversity of Alabama

CLOSING REMARKS

DEPARTMIXVT SOI.JVENT

, . . . . . . . . r r 9

Page

Report of Workshop /19Ronald. L. I(romeDetroi t Receiving HospitalD e t r o i t , M i c h i g a n . . . . . r . r . . . . . . . , 9 9

Report of Workshop #t-OPeter C. CanizaroSouthwestern Med.ical Schooli J a r r a s , l e x a s . . . . I 0 I

EMERGENCY UNIT - Improving FinancialJames T. HowellPeat, Marwick, Mitchel i & Co.

Management

r03

YOUR I]}4ERGENCY DEPARTMENT SO],VEM?A STUDY IN COMMJN]TY I\MD]CAL ECONOMICS

James R. MacKenzi-eMcMaster University

Michael .I. Mad.denUniversi ty HospltatAnn Arbor , M ich igan . , . I25

On behalf of the University of ltl ichigan and. its Med.ical Center,I welcome you to the Towsley Postgrad.uate Education Building. It w'as atittle over a yeal ago on March 5, L)fO in Birmingham, Alabama that manyof us first met to find. out if we had. enough common problems to warrantformation of an associ-ation. This question has now been answ'ered.. Every-time we get together we find. more problems in common.

One hu:rd.red. and thirty eight ind.ividuals in Alabama agreed. toform an association which now at the time of our First Annual Meetinghas over 352 d.ues paying members from universi-ties of the United. Statesand Canada. T bel ieve this posi t ive response re-aff i rms their need. forour Associat ion which had not been met by any exist ing organizat ion.

What has been accomplished. in the L4 months since the Birming-ham meeting? First : We have constructed. a framework for our organiza-tion in the form of a constitution. Second: We have given d.lmarnic im-petus to this Associat ion through d.ed. icated. energet ic set of of f icers.Third: We have ad.d.ressed. ourselves to keeping our membership informed.about act iv i t ies in the f ie ld of emergency health services at our meetingsand through our cornmittees for the purpose of helping our mernbers improvetheir own emergency d.epartments. We have made a good start on our infor-mational program. In the coming year the Quarterly Newsletter wiLIfol low short ly on the heels of the prol i f ic but i ruegular stream of mai lwe now receive from Carrad.a. Fourth: The Universi ty Associat ion for

Emergency Med.icat Services is nou solvent. Fi f th: To give cont inui ty tothe object ives of the Assobiat ion enunciated. in my opening remarks inDenver d.uring the Charter meeting we have d.eveloped four stand.ing eom-mit tees to which we wiLI soon add. two more. The purpose of these com-nlttees is to focus on the problems of' emergency d.epartment planning,

ed.ucation of med.ical students, and. house staff, and postgrad.uate physi-

cj-ans, the training of emergency medical technicians and. regional plan-n ins o f emersene l r hea1 th serv ices . These commi t tees are a lso meet inga r r . r b v +

d.uring this our first annual prograrn. AII stand.ing committee reports

wiIL be sent to our membership through the Quarter ly Newsletter.

Regard. ing the two new committees. Publ ic pol lcy is based onpublic'awareness and. concern and. is implemented. in our society through acarrot and. stick system of economic reward.s and d-eprivations. Those of

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 im-nrovements- Therefore. T em nnnorrneins the formation of two new cornmit-

f l l v ! v : v f v ,

tees, a resource committee which wi l l keep you informed. regarding sourcesof fund.ing and. pend.ing legislatlon which will have an effect on emergencyhealth services. The second. committee wi l l keep our members informed.regard.ing the costs of emergency med.ical care of the acutely iII and

, injured. pr ior to and. after hospital arr ival .

E

r

I4y opening remarks at the Denver meeting were directed. atdef lning goals for this Associat ion. These remarks are avai lable in theproceed. ings of that meeting which you have received.. The proceed. ingswere published. through the support of the Division of Emergency HealthServices, Health Servj-ces arrd. Mental Health Ad.ministration, Public HealthService, Department of Health, Ed.ucation and Welfare, and. will also bepublished. as a package with the keynote ad.d.resses and workshop summariesin the JuIy Issue of the Journal of Trauma. The Association meeting wiIIbe head.I ined. on the cover and. const i tute the f i rst 20 pages of that issue.

m ^ ^ 6 . ' , T ' - A h + + ^ ^ . . ^ - i .ruq@J, I want to examj-ne with you the nature of our Associationand. the relationship of our association with other organtzations seekingto improve emergency health services.

The nature of' our Association is d.emocratic in spirit and. struc-ture. Membership is open to al l universi ty emergency d.epartment d. i rectors.M o m h e r c h i n i c n n * d p n o n f l a n j : n n e . r - i l - , r ^ ? h r r ' r \ ' l - i n o *Arvv qv} ,e r r -xper r -ence, specra l - l y , o f pupr l -car ] -on .

There are no provisions for retention of an emeritus or old. guard. group

which might tend. to diminish the effect iveness and enthusiasm of thenewer younger contr ibutors. To further democrat ize our Associat i -on, Irecornmend the executive meetings preceed.ing the anrlual meeting be opened.to any member luho would. Like to attend. provid.ing, of course, that heaB ' rees t o keen n .n r r n rn f , eq f np2 r . p f r r l t r l r r r f l r a r T 1 ' egommend t ha t a l lL l b r v v p u v r ! v v } / 4 r J y r v u v p u y u a v v r u ! . r ' q r v r f v r t L -

stand. ing committees be open to any member rulshing to part ic ipate. Fi-ne l l r r - in se lee t ins members fo r nomi -na t ion as o f f i cers to serve our asso-ciat ion, Iet us naintain an equitable geographic d. istr ibut ion represen-tative of our membershin.

In our relat ionship with other orgari izat icrrs, we again empha-

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 improveemersencv medica.I services in the United. States. To this end. I recom-

mend. that we establish liaison with those organizations with similargoals and. purposes. Fed.erat ion meetings such as are held. in the biologic

sciences and. communicat ion between execut ive off icers are mechart isms

through which such l ia ison could. be developed.. We have made overturesregard. in! such proposals to the Society for Cri t ical Care and. the Ameri-can Col lege of Emergency Physicians.

I want to thank aLL the offj-cers and members of this Associationfor your hetp and. support over this past year. I pred.ict ow oganizationwi l l th r .n r ro"h tho reJ : i r ra n r r t in inA l ign Of i tS mefnberS th f iVe and d .eVeLOpv q b r r v r r v

increasing inf luence on the d.et ivery of emergency health services 1n the

United. States.

T}IE REVO],UTION IN EMERGENCY I\,{MICAI SERVICES -

CATEGORIZATION OT' HOSPITAIS - TTM IMPACT ON YOU

Dr. Irvin E. Hendryson

May 14, L97L

T]-IE REVOLUTION IN EMERGENCY }{EDICAI SERVICES -

CATEGORIZATION OI. 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

Services. For that I express my grat i tud.e.

I have been struggling with the word. Revolution in the assigned.t i t le of this d. iscussion for some t ime. At f i rst , having been ident i f ied"

with the Establ ishment for a consid.erable number of years, the pol i t ical

overtones of i ts meaning relat ive to violence and. overthrow'of a system,delivered. in a University atmosphere, caused" some concern. Fwther re-

flection changed. that concern to chagrin as I realized. that it also sug-gested. rotatj-onal motion about an a^:ci-s, which in some quarters may be

id.ent i f ied. as t tspinning of wheels.r t The thought of such a possibi l i tyt . r n o o L a a l : i r n r . n 2 p 3 p 6 f 2 1 1 6 . n . n d i + i . ' ^ ^ h ^ + ^ , ' h h ^ r t e d t r r r t h e f n . n t 5 . F o rwa5 $ ILuua. l - I l5 , u I ld ,LUEP u4u !s , a lq -L u waD r lu u D u l } rwr ueq vJ u r rv r qu v l

most assured.Ly there is revolution d.irected. at the Emergency Med.icalServ' ices Svsf,em- enf. inrraf.ed nnd unable to meet the d.emand.s placed. upon i t .v v 4 v r v u p u l J p v v ! r , \ 4 r u + Y q * v v

It is clear to me now and. I will state publicly that we are

ind.eed" provocateurs. If this be treason then make the most of it.

It is trnparalleled. in the rnagnitud.e of its purpose, its rejec-

t ion of the past, and. i ts explosive change which is even now vibrant, m-

sett led. and. st i l l evolving. We are aII in fact at the epicenter of l t .

Two of i ts bench marks may be ident i f ied.: the publ icat ion of

Accidental Death and. Disabi l i ty, the Neglected. Disease of Modern Society

and. the revision of the Stand.ard.s of Accred.itation of the Joint Commis-

sj-on on Accred.itation of Hospitals. Within the brief time spanned. by

these publ icat ions, t967 to L97Lt a new concept in the d.el ivery of pr ior i ty

med.ical services has emerged.. The Emergency Med.ical Services System has

been recognized. and. the multiple inadequacies in its chain-Iink d.esign

ident i f ied..

If the first bench mark id.entified. the problem, as it d.id., the

second. br ings regulat ion to i ts solut ion. These are excerpts from the

December, 1970 JCAH Stand.a,Id.s for Hospital A.ccr,ed.itation in EmergencyS , e r r r i n c q .

STANDARD I

A wett-d.efined. plan for emergency ca.re, based. on community need-

and. on the capability of the hospital, shall exist within every

hospital .

-9-

-r0-

STANDABD II

The emergency service, when maintained., shall be well organized.,properly directed" and integrated" with other d.epartments of thehospital. Staffing shall be related. to the scope and. natureof the need.s anticipated. and the services of,fered..

]NTERPRETATION

The emergency service must be werl organized. and. compreterydirected.. When warranted. by i ts act iv i t ies arrd. i ts d.egree,of complexi ty, the emergency service should be organized. as ad.epartment.

There should. be a Chief of ftnergency Service who is a memberof the acti-ve med.ical staff .

ft is to be hoped. that this stand.ard. for accred.itation mav betransferred. to the universi ty Med.icat school. faculty structure.

The handmaid.en of Stand.ard I is Categorization for the d.iscrep-ancies in the capabiLi t ies of Emergency Departments to d.el j -ver pr ior l ty(ot, emergency) med.icat services are w'eLI known. Frey and. Huelke workingat this lnst i tut ion conf irmed. i t .

Moreover, the process i tsel f is not so oininous as i t onceseemed.. Simpty stated. i t becomes a method. for c lassi f icat ion of thehosp i ta l ' s emergency serv ice capab i l i t y .

Ostensibly, the basic purpose of categorizat ion is to id.ent i fythe read. iness and. capabit i t ies 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.vanceknowled.ge of the d.esignated. categories of emergency d.epartments in anateat wi l l be able to select the inst i tut ion to which emergent pat lentsshould. be taken.

0f greater signi f icance however is the fact that i t of fers amechanism for inst i tut ional sel f-evaluat ion that inevi tabty must offerthe promise of capabi l i ty improvement which, in the f inar anarysis, wirrposi t ively i -nfruence the d.el ivery of emergency med.icar care.

The d-evelopment of programs to correct d.eficiency and. weaknesscan only lead. in the same d.irection.

Recognizing the ad.vantages of categorization of hospital- emer-gency services, physicians and. hospital administrators in many commurri-t ies have categorized. their inst i tut ions, each using their own sets of

-r l -

cr i ter ia and schemes of implementat ion with varying object ives. Several

physicians, committees, and professional e ganizations have offered.

varying classifications and. guid.elines, criteria, or standards wrd.er

which categorization might be implemented.. These efforts have d-emon-

strated the need. for uni form categorizat ion guid.el ines, represent ing a

general consensus of those working in this area.

Concerned. professional groups, includ.ing the Committee on Trauma

of the American Col lege of Surgeons, the Committee on Injur ies of the

American Acad.emy of Orthopaed.ic Surgeons, the Airlie Conference on Bner-

gency Med.ical Servj-ces, and. others, have conclud.ed. that guidelines or

standard.s for categorization that might be released. nationally should.

come from a multid.isciplinary conference held. und.er the auspices of the

Commission on Emergency Med.ical Services of the Arneri-can Med.ical Associa-

t ion. This Commission is composed. of representat ives of those profes-

sional societ ies ar id governmental agencies having part icular interest

and. voltxttary prograrns in this fietd.. The Commisslon accepted. thischa.rse the Bcra.nd. of Trustees of the A-l4A promptly provid.ed. fund.s, and

the Conference was convened. on February 2T-2Bt L97L.

The conference has been held., and. a working draft of its recom-

mend.ations prepared.. Presently the d.ocument is undergoing its fourth

revision and. only yesterd.ay was exposed. to further ed.itorial honingd r r r i n g n I e n g t h V t p l o n h n n e e n n f e S g 1 1 g g .q q r 4 u 6 q l v r r b u r r J v e r l y r r v : r v

I t wi I I be submitted. to the conference part lc ipants for review

agd. further correction before its final approval by the Commj-ssion forn r r h l ' i a a f . i n n

There is nothing classi f led. or secret about the d.ocument. I t

was d.etermined., in the interest of efficiency, that a small ed.itorial

r,vork force should. bring it to final form and that goal has about been

achieved..

T am priv i leged. to sha,re with you a br ief previ-ew of i ts

contents.

As you know there wiII be four categories d.esignated. und.er

najor t i t les. A subt i t le wi l t broad. ly def ine the scope of the capabi l i ty

of each category in the following fashion:

-L2-

CATEGORY I

COMPREHI]NSTVE E}MRGMICY SERVICE

SCOIE OF CAPASILIT]ES

The hospitat shalt be fully equipped., prepared., and. staffed. toprovid.e immed.iate, complete med.ical care for all emergencies includ.ing

those requir ing the most complex and. special ized. services. I t shal l have

a capacity adequate to accommod.ate the d.irect and. referred. patient load.s

of the region served. arid,be capable of provid.ing consultative support toprofessi-onal personneL of other hospitals in the same region.

CATEGORY II

MAJOR EMERGENCY SERVICE

SCOPE OF CAPA3ILITIES

The hospital shall be equipped., prepared, and. staffed. in allmed ' i ea l and s r r rs i ee l snee i a l t i es to rend.er resusc i ta t ion and l i fe -suppor t

to patients as need.ed.. It shall also supply d.efinitive care for all such

patients except for the occasionat patient who requires foll ow-through

care in very speciat ized. uni ts. Transfer may be necessary and. shal l be

und.er agreement with other hospitals.

CATEGORY IfI

GENERAI EMERGENCY SERVICE

SCOPE OF CAPABIIITIES

The hospital shalt be equipped., prepared, and staffed. in most

med.ical and. surgical speci-alties to rend.er resuscitative and. Iife-support

care of persons cr i t ical ly i l t or in jured.. Addit ional services by pre-

arranged. agreements should. be mad.e with non-staff specialists. Transfer

may be necessary and. shall be und.er agreement with other hospitals.

- 1 ? -

CATEGORY W

STANDABD EMERGENCY SERVICE

SCOPE OF CAPAS]LITIES

The hospital shall be equipped., prepared., and. ad.equatelystaffed. to rend.er emergency resuscitative and. Iife-support med.ical ser-vices pend. ing transfer of cr i t ical ty i l l or in jured. persons to otherhospitals. Transfer when necessary shal l be und.er agreement with otherhospitals. It shall also be capable of rend.ering ad.equate med.ical ser-v ices fo r non-c r i t i ca l i l l nesses or in ju r ies .

The specifics for each category will be found. i:nd.er subtitlesrelating to the ftnergency Department proppr and. the Hospital with itssupport ing services.

Common to al l of the categories wi l l be requirements relat ing

Continuing Education Programs for AII Energency DepartmentPersonnel

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.

This group exannlned. the pros and. cons of categorization and

their concLusion was that categorizat ion, in i ts broadest sense, has

merit. However, eategotization in and of itself d.oes not necessarily

improve the quatlty of care provid.ed.. It can be of assistance in improv-

ing the quality of care if an evaluation survey based. on the stand.ards

is cond.ucted. initially and. continued. period.ically to d.etermine quality

improvements.

The categorization system can best be implemented. if the d.e-veropment process comes from the t tgrass roots Level. t t A locar pla.nningcomcil may serve as both a stimulus arrd. means for implementatj-on. Sucha counci-I or agency should. be representative of a variety of d.isciplinesand. professional associations working in concert to implement the recom-mend.ed. categorization system. Maximurn cooperati-on between this ptanningcouncir and. state and. area-wid.e heatth planning agencies should. bee n r - n r r r e c r a d* o " * '

In this somewhat d.evious fashioncutegortzation i,ril l have on you. The majorcourse, be found. in some of the perplexingmentat ion. Letts consid.er some of them:

T h n r r e g n n r n p c h e d * h e ' i n n q n *

i m m e d i q f a i m n a o f r ^ r - i l ' i ^ f! ! 4 r r e q r Q u u r l r } / a u u w I r ! , u !

questions attend.ant to imple-

There is a probrem in d.etermining an adequate suppry of hearthmanpower. Determination must be mad"e of the need. for the physicians t

assistant and. med.ical technicians such as returni-ng military corpsmen.Provision must be mad.e for continuing education of all emergency servi-cepersonnel.

Economic factors: The adequacy of exist jng faci l i t ies and.equipment against desired stand.ard.s, the need. to alter the physical pland.esign for expansion if emergency d.epartment is upgrad.ed", the economici m n a e f , O f n t r r e h n - - i - n ^ l A . l ! - i ^ - - 1 o n r r i n m a n l . f n r r r n o r q d i n orrrlt,ae u vr Ir@ urrqDJllS aqqr uJ(rrt4r s!1ull l i tclt u I uI uIJb_ *_*--b.

There will be a problem in d.etermining the optimum number ofeach category lever for the rocal commwrity. Al-l areas d.o not need.every faci l i ty to be Category I a.nd. the proper rat j -o of services to meetthe need.s of the commwtity must be arrived at by the Community Councit.This may wel l mean that some hospitals wiI I c lose their emergency d.epart-ments and others wi l l 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, re-gionally or nationally.

The med"ical staff uhich has not only the pr ime responsibi l i tybut also for the total med.ical care siven info r emersener r med ica l ca fev l r v r

b v r r v J ] u v ,

the hospital wi l l need. to face the impl icat ions h-sted. below:

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

What effect will categorization have on professional train-i n r r n rncr r rmq ?

t .

3. What impact wiII categorization have on utilization and-peer prograns?

The'general feeling of the public nrrst be taken into considera-

tion. After aII, the hospital should. serve the community and its need.s.

However, categorization could clrastically alter his view of the health

care d.elivery system. The patient and. the community must und.erstand. and.

accept any new patterns whlch are established..

A major factor in categorization is the legal implications for

the physician, hospital, other allied. med.ical personnel and. the patient.

The following factors must of necessity be consid.ered.:

I. Effect of liability on professional staff

2. Effect of liability of institutlon involving the Board. of

Governors

3. Effect of liability of other parties such as ambulance

personnelr police d.epartment, fire d-epartment, volunteer

rescue squad.s, and. the Patient

For the future, the impact roill be more significant for cate-

gorizat ion of emergency services wi l l most probably be a f i rst step to

a sjmilar kind. of classification for the total Hospital, a not unmixed.

blessing fraught with many traps and. pitfalls. If accomplished., it witl

Iead. Iogically to the regionalization concept of a Hospital system with

a center and. i ts c luster of satel l i tes.

It is d.ifficult in the present state of flux to portray wlth

accuracy the impact it witl- have on you, this organization, and your

colleagues. Patently there will be new Health Care Delivery systems

supported. by financing mechanisms whose form is presently tmknown.

At that time you will be remernbered. as the Revolutionaires with,

I trust, end.earment. As physicians and. teachers, f salute you on this

notable anniversary of the University Association for Emergency Med.ical

Services--may you flourish a.nd. prosper--press onj

CATEGORIZATION OF HOSPITAI EN4ERGENCY FACIIITIES

Surnmary of Morning WorkshoPs

Robert M. Zol l inger, JY., M.D.

Case Western Reserve Universi ty School of Med-ic ine

Cleveland., Ohio

CATEGORIZATION OF HOSPITA-L EMERGM\CY FACIIITIES

O:: May th, tlfl d.uring the first meeting of the University

Association for trknergency Med.icat Services at the University of l4ichigan

in fuin Arbor, ten workshop groups \^rere convened. to d.iscuss the categori-

zafr , ton of Hospita} Emergency Faci l i t ies. These sessions fol lowed. a key

noting ad.dress by Dr. Irvin Hendryson which includ.ed. d.istribution of a

tentative ca.tegorization scheme as proposed. by The American College of

Surgeons Ad. Hoc Committee on categoyization to the ACS Comrnittee on Trauma.

These materi-als were received. with mixed. emotions and. the following com-

ments evolved.

The majority believed. that categortzation is appropriate, d.e-

s ' i rab l e - and nrohoh ' l r r i nar r i i . r t rT a . I t WaS fe l t tha t CategOf iza t iOn Stan-p r 4 a v ! v , ( 4 r q y r v v e v r J

d.ard.s would. upgrad.e the facilities and. services in hospitals by serving

as uniform standarcls which hospital physicians and administrators as well: s f inane i a . l l r r resnons ib l e t r r rs tees and e lec ted . o f f i c ia ls cou ld . u t i l i ze .J 9 l + . ,

The proposed. stand-ard.s Listed- both the manpower and. equipment required. in

emergency faci l i t ies, and many discussants emphasized. the need for speci-

fic training and. conti-nuing ed.ucation of emergency personnel, especially

the physicj-ans who d.eal exclusivety with emergency practice. A means of

monitor ing the capabi l i t ies and performance of the emergency faciLi t ies

was proposed. as desirable d.espite obvious political or economic d-iffi-

cul t ies. I t was projected. that such a monitor ing mechanism should- be

regional in its administration yet fotlow national categorizati.on guid.e-

l i n a q

virtualty al] anticipated that categori-zation of emergency

faci l i t ies could. result in better t r iage by tocal rescue personnel by

imnrorr ins the ini t iat d. istr ibut ion of in jured. pat ients. This system

could. serve also as a basis for arranging further triage once stabillzing

or lifesaving measures had been performed.. Actual examples of several

ci t rr nr st .qte machanisms for t r iage of c iv i- I ian trauma were d. iscussed.

and. most felt that real success would. be obtained. only when there was a.n

effeet ive svstem of communj-cat ions between rescue and med.ical personnel

in hosnif .als tha.t f i :nct ion in a coord. inated. regional manner. I t wasl r f r r v p y r v g * u

feared. that this was a utopian dream in the present system and would work

an- l r r r ^ rhen n l I med i en l nersnnne l and hnsn i i :a . ' l resources ex is ted . in a un i -u r l l J w t l u l l a ! ! r l l u q l v s ! y e r p v r 4 r u r

fied. national health care system.

Several groups actively d.ebated. r,rhether every hospital should.hqr rc ln t rm6a.ocnc1r fee i

- l i t r r - Mar l - - F^ ]+ +r ' ^+ ^ - " ins t i tu t ion w i th the name- . . . - - o - - - - J r 4 u r ! r u J . $ 4 r J I g J - L r t / r l 4 u a r J

hospitat in its titte must have emergency resuscitative equipment arrd.

personnel for 1p-patient use and. therefore these should. be available for

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 -

have irregular geographic spacing,and variable commitments to carine

-20-

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

Many workshops d.j-scussed. the issue of med.ical responsibilityf n r i . h c i n d ' i o a n . F n o l - i a n t . i r . t - L ^rur' uilc lrrqlEerlL .L,d,u-Lctru rr.t r,rL.e city afid. a strong moral commitment wasexpressed. There was d.oubt that increa,sed. fund.ing for such a commitrnentwas likely and the ad.d.itional problem of increased. use of emergency ward.sby non-emergency patients was exarnined.. some feared. that categorizationwould- provid.e aJL easy out for smaller or private institutions to crosetheir debt generating emergency d.epartments with the resultant j-ncreasein the load of non-emer8ency as weII as emergency patients on the nearestopen inst i tut ion. Thus the relat ively smal l nurnber of cr i t ical ly i l lpatients needing real ascend.ing triage may not be gleaned. from the generalpopulation seeking emergency care unless a carefully coord.inated. and. fi-nancial responsible, health care system exists for the local t reatmentof the non-emer8ency pat ients. These people const i tute the bulk of workin 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. notimprove health calre except in that it would. catl attention to the mag-nitud-e of the current problem. For categorizat ion to be effect ive i tr ' ^ ' . ' l ^ * ^ ^ + T i 1 - ^ a -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 re-sources of a nat ionar hearth system. However, the goal of an effect iveand. efficient regional hand.ling of emergency patients was affirmed. as a3important one toward.s which University affil iated. hospitals should. strive.

RIPORT 0F WORKSHOP #I

CATEGORIZATION OF EI'IERGI]NCY MMICA.L SERVfCES

Robert M. Zol l inger, Jr. , Case Western Reserve Universi ty School of

Med.icine, Cleveland., Ohio

, Each of the participants first introd.uced. thernselves briefly

with an outtrine of their own hospital emergency service setting or else

their special relat ionship to this conference. Most part ic ipants repre-

sented. Larger, usually University Hospital systems in d.owntoun cities.

There was very l i t t le rural representat ion.

OnIy a few of the participants were aware of categorization but

eight of the I4 present feLt that their emergency rooms would. faLL in

Category I. Some of the exaet details or criteria for achievj.:ag Category

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.

This then raised the issue of how categorization would. be, first &ccom-plished. and secondly enforeed.. Most felt that self-appraisal would. be

sufficient for each hospital to decid.e upon whj-ch category it wished. to

accept or upgrade its facilities toward.s. This implied. that a given area

had. regionalization such that alt hospital facilities would. have to par-

ticipate a^nd. the participants felt that some form of regional authority

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

monitoring the facllities and. more importantly, the actual performance

of these faciliti-es in hand.ting of emergency cases was felt to be such a

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

which had. begun by ILtinois State Law and. their Department of Health after

l97O leeislative action. Apparently 22 of the pO hospitals in the general

Chicago a.Jrea were felt' to be of rrfull ,servicett emergeney capabitity but

the consequence of this was that several smaller or private hospitals

began closing emergenelr and out-patient facilities so as to increase the

Ioad. on the nearby institutions which in most cases were the overloaded,public supported. or University centers. This generated. a d.iseussion as to

how categorization should. not keep patients away from given facilities--

specifi-cally the minor ilhess from Category I but rather how it should.

-2L-

-22-

enable passing upwa.rd.s or triage onward of the major ones to Category Icenters. It was felt by some that University affil iated. hospitals would.pred.omi.nate in Category I a^nd. that by fully supporting this system, theywould. essent ial ly be preserving themselves and. their own good cases.

The other sid.e of the coin was that these same University cen-ters must not turn away any patient for financial reasons and. this d.egen-erated. into a d.iscussion of how to triage out lesser iII patients. Theexperiences of BeIIvue were unfold.ed by Dr. Stahl, and. the use of nightcljaics or community clinics w'ere d.iscussed as methods of acquiescing tothe patient load. where as others d.escribed. the poor results from pricingout or increasing the length of wait so as to create inconvenience as ameans of d.iscouraging patient entrace to the emergency system. AII par-ticipants felt that some regj-onal coord.ination therefore was necessarybetween not only emergency faci l i t ies but c l in ic and. hospital faci t i t ies;and. most d.oubted. that this could. be accomplished short of a powerful re-gionalization scheme, or more h-kely a national health system.

Dr. Ma:rtz d.iscussed. how the state of Ind"iana had entered. intocategorization arid. how there were really few problems with the hospitalsaccepting it. This apparently was accomplished. with a governors advisorycommittee on emergency med.ical servj-ces which essenti-ally was voluntaryand. regional in its implementation. He stated. how most hospitals basic-ally were fairly good. at self appraisal once the stand.ard.s were set forthand. how not everyone really vanted. to be Category I. Dr. Martz also men-tioned that the ambulance services were categorized. in this system andthis w'orked. fairly weII as it has to a d.egree in the regionalization ofmany large cities by the police who serve as a.rnbulance facility in a citysuch as Boston, Cleveland. and. many others. An extension of this was feltto be a mobile care r.mit as an attempt to bring a higher level of emer-gency service closer to the ci ty pat lents. This in general was not suc-cessful in increasing the salvage of acute life threatenjng illness suchas myocard.ial infarctions or card.io-respiratory d.eath. However, thesecare uni-ts were fairly important in rural areas where they are usuallystaffed. with voluntary personnel. fn the rural setting these arnbulanceservices know fairly well which hospitals have what facilities availablearrd therefore a form of triage or categorization is perhaps more easilyaccomplished. than in the cities where there are competing institutions ofvariable fj-nancial abilities and. commitments.

The question of ed.ucation of the public in the appropriate useof the med.ical facilities, be it the emergency rooms or clinics, was d.i-s-cussed. in the Canad.ian provinces by the McMasters med.ical stud.ent. Hefelt that this was a very significant feature whereas the mqjority of par-t ic ipants fel t that this was an impossible task in most ci t ies.

-23-

fn summariztng the feelings of this workshop, most felt thatcategorization implied. regionalization and. that this was essentially acoming phenomena in which we should. actively participate. Most werew'orried. about third. party interpretation or implementation of these sys-tems and. about the method.s of monitoring the performance of emergencyfaci l i t ies. By this most fel t that nat ional izat ion of the health systemI^Ias a genuine specter and. that accord.ingly some regional method- involvingthe lay people as weII as physicians and. hospital administrators should.be created. now to show that this form of cooperation and efficient util i-zation 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., Chi l {rents Hospitat , Colurnbus, Ohio

Categorization is probably inevitable, and 1s at best a mixed.blessing. PotentiallSr good featureB :

a) May help to improve facilities in some hospitals by servingas ia uniform, sta,nd.ard. which layrnen such as hospital trus-tees or elected. officials can und.erstand..

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

May be used. as a basis for prearranged. secondary transporta-t ion once l i fe-saving measures have been carr ied out.

d.) l4ay serve in nonspeclfic ways to improve emergency med.icalcare by calling attention to the magnitude of the problem.

Potentially bad. features :

Subject to f inancial and pol i t ical abuse.

Basically affects only a small minority of patients goingto emergency rooms.

May provid.e an excuse for some hospitals to refuse to offertheir fair share of care, especially to ind.igent patientsand. may pose unfair econom"lc hard.ships on those hospitalswho are left hold.ing the bag.

Undue attention may be d.evoted. to categorization ratherthan to the larger problems of organization and. trainirg ofparamed.ical personnel and. overall community or regj_onalh ' 1 - - - . i - ^! r 4 [ r r J r 6 .

b )

o )

a l

b )

. l l

kesent categories are unsat isfactory:

a ) They are too broad. , i .e . ,offer superb card.ia,c caresimilar quality.

some hospitals are prepared. tobut not neurosu.rgical care of

-2r-

-ZO-

b) They imply high and. low rank rather thar^l a$jiropriateness toIocal need.. Nurnbers should. be reversed., or better still,aboLished.

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

Even if a perfect scheme could. be d.evised. it would. not solveaII of the problems. If the categories aJre properly word.ed., if the cate-gorization ls performed. on a local or regional basis rather than by edictfrom on high, and. if the potential abuses a,re recognized. and. forstalled.,categoriza,tion can make a positive contrlbution.

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

REPORT OF WORKSHOP #3

ASSOCIATION OF LNWERSITY EMERGTJ{CY ROOMZAT]ON OF EMERGM\]CY T'ACTLITTES

PHYSTC]ANS WORKSHOP ON REG]ONAII-

David' R. Boyd., M.D., Northwestern uni.versity Med.icar schoot

The Morning Session for d.iscussion of categoytzation of Bner-gency Departments was chaired. by D. R. Boyd. and. started. essentiarry bystatements of the experiences of the part ic ipants in regional izat ion 1ntheir oiln cornmunities. The fll inois program for the d.evelopment of aStatewid-e System of Trauma Faci l i t ies as d. iscussed. in i ts relat ionshipto the implementat ion of such categorizat ion is now possible in this stateby virtue of the recent statute public Act 75_IB)B. This cate goriza-t ion plan al lows the communit ies to categorize themselves on a bas1cthree-echelon system: an trAtr category which is comparable to the compre-hensive emergency service system; rB, category which is comparabre to amajor emergency med.ical service facir i ty and. t tcrrcategory which is com-parable to standard. emergency med.i-cal service system. This law allowsfor each areawid.e or conmunity to serect, by written agreement, the hos-pi tar(s) interested. in performing emergency services, and has a tegarrestr ict ion that these hospitals must provld.e emergency services on acommunity or areawid.e basis. This program is und.er the guid.ance of theDepartment of Public Heatth, Divisicn of ftnergency Med.ical Service Coirnciland. the community or Areawid.e trtrnergency service councir.

The San F?ancisco Categorization Scheme was d.j-scussed., whichhas been developed. utitizing the previous Al{A Emergency Room Cate goriza-tion scheme and. is impremented. and publicized. through the agency of theftnergency Med.ical service Ad.visory committee to the Mayor of that city.This program is weII pubticized. and. presumably the cornmunity knows whatthe avai lable services are in any specif ic hospital , especialry in theghetto and. Iower social economic areas. There i-s no formal presentationof this categori-zat ion, i .e. , in the yelrow pages or other d.ocument.AIso, it was not d.etermined. as to what tegal restrictions the EnergencyAd.visory committee may have to implement and. monitor this prograrn. rtis entirely voluntary and. teft to the general cooperation of the community.

There was no disagreement wlthin thecategorization of emergency facilities and thespent d. iscussing the essent ials of an effect ive

group for the need. forrest of the morning was

categorizat ion scheme.

tr'irst of all, it was d.ecid.ed. that one shoutd. d.iscuss emergencyservices and that categorization of ftnergency Departments only would. be arimited' outlook in terms of categorization. The total care potentiat ofthe hospitat, that is the emergency room, d.iagnostic facirities, inten-sive care units, staff physicians and. pararned.ical personnel should. be the

^ Q

d a f a r m ' i n - i n o f o a * ^ u - i - - - - , ^ ^ + ^ ^ -u.crJc].ll lrrrrflB rauuQ.r. t_rl aJty caregorization scheme. The available personnelin the emergency care areas was the most important component of the sev-eral Listed. und.er Question ff2. ft was the feering of the group to sethigh stand.ard.s and to develop a.rr emergency room physicia.n who has to'ua1resuscitat ion potent ial . The varying experience of the part ic ipants withemergency physicians was d.iscussed. but it was felt that rnany of the efler-gency room physicians were basi-caLIy medical or ped. iatr i -c, non-sqrgical lyor iented.. These physicians may be hesitant to ut i l ize the necessarys t t r g i e e l n ? " n a ' o d r r r o q q r r n h r c n r r i f i n o - i n n l r a a . l - ' 1 - , " l .Dq rb rua r ! auuc ! | L { ruD Duuu cD _L /uu ' J l - l l b t - l l u l l eSu UUpeS , end .O- t f aCheaL tUbeS ,

t racheostomies and. many t imes lrai t for this tytrre of care to be d.el ivered.b V a _ S u f g i C a . l 3 6 r n c r r T + o r t - n - ^ + ^ d + + ; r n n : . - i + ^ ^ - r i + n r o " t - ^ n a ^ - - t - + ^ ^ ^ ^ ^ -q p u r b r u a ! u v r r D u ! u a l u . t \ u u 6 c : t / U l - I L 6 q u f U e O I J - O I I a U a J ] g g n l , t r l t c e l l l e - ! ' -

gency room physician was d. iscussed. and. the necessity of having a total lycompetent physician in the emergency care area was fel t by al l but thisd"iscussion was curtaited. because of the afternoon prograrn was to ad.d.ressi tse l f to th is p rob lem.

The terms of a categorlzation prografl and. one that witl workmust evaluate the totar facir i ty, but id.ent i f iable i tems, e.g.. d.ef i -brillators, card.iac monitors and. other equipment that a categorizing bod.ycourd. put their f inger on must be sperled. out. The substance of theequlpment was not as important as the quality of the personnel but theseare def ini tely more readiLy assessed and r.rr fortunately l^ i i l t be the hal l -m a r k s n f n n r r o n f . . a o a y i z q f i n n e n h av q v e o v * - - * . u l l l e .

The evaluation of a categorization program was d.iscussed- and.the sel f-evaluat ion of an emergency area was not to be the basis of sucha system. Financial requirements and pat ient load. necessit ies of a hos-pi tal may inf luence the sel f-evaluat ion of the actual potent ial and. capa-bilities of arr institution. It was thought that an outsid.e agency suchas the Department of Public Heatth shoutd. have a monitoring function inthe categorizat ion process. This would. make for a miform and. fairassessment of the care potent ial given an inst i tut ion. Categorizat ionwould certainly Limit the total care del lvery of an hospital . Enforce-ment of this program by the same agency would be in the best interest ofthe community.

The f i rst steps should" be through the municipal agencies by thediversion of cr i t icatry iLL or injured. pat ients bypassing the l imited.care facj- I i t ies. This is already being d.one in some communit iesl Torontohas a city'w'id.e rule to take the patient to the nearest comprehensive carefaci l i ty. This is working quite weII .

Al though Toronto does not have a categorizat ion scheme, thebasic essent ials of such a prograin is in fact in operat ion by an execu-tive ord.er. The problem of ambulances taking patients to the institutionof their choice for economi-c favors and kick-backs was d.iscussed.. Thistype of patient transfer must come und.er some kind. of regulation. Here

-2a-

a€ain, an emergency servi-ces council or municipal a€ency can augment asensible transportation scheme. Such a system should. be evaluated. byan outside agency, such as the Department of pubric Hearth.

Tn*e basis for categorizaticn shoutd. be the total care potentiatand. emergency care potential of the institution, the most important as-pect of i t being the professional capabi l i t ies in this area and. specif ic-ally in the emergency room, the most qualified. person, either aJr emergencyroom physician or resid.ent-in-training shoutd. be utilized.. kograms thatuse interns and. other general pract i t ioners, ret i r ing plrysicians, or moon-tighting physicians should. be d.iscred.ited.. The categorization of hospitatfacilities by the Department of Prrblic Health should. grad.e the total hos-pitat and. license the hospital to perform certain fi:nctions rather thanspecific personnel. This would. make the hospital responsi-ble for pr6-visj-on of such services and. would. give a hand.le to those enforcing a€en-cies responsible for these regulat ions. the need. for the general upgrad. ingof the emergency area personnel, commwrications and. transportation sys-tems would be possible with a categor: ,zat i �on and. regional izat ion prograJn.

There was consid.erable d.iscussion that the American CoLIege ofSurgeon Categorization Scheme was cutting the things a little too fine,and it was the feeling of the group that there should. be only three basiccare categories. These shourd. be comprehensj-ve care facir i ty; generalcare facillty and a stand.ard. care facility. An ad.d.itional category mightbe a walk-in 24-hour clinlc or infirmaries (ind.ustriat) tnat treat mostlynoh-emer$ency patients. This category should. be incorporated. into a,nyproposed. system to provid.e a basi-s of contror over these units.

A basic problem that was not resolved., and. was the apparentd-ichotomy between the care potential cabegortzation on one hand. d.one bythe professional and. lay agencies, and. the abi l i ty to pol ice these samecategorization programs on the other hand.. As d.lscussed. earlier in themorning, categorization wou1d. not be worthwhile unless hospital capa-bi l i t ies, restr ict ions and guid.et ines were enforceable.

The categorization system of ltl inois was again d.iscussed" and.the monitori-ng function is much easier in a rural area where the competingfacilities are less numerous and. are alread.y self-categorized. as a matterof natural select ion. This process is rather d. i f f icul t in urban areaswhere the competition between facilities for a fixed. nurnber of availablepatients, along with the d.epend.ence on emergency room admissions foreconomic survival . Here again, the d. iscussion of categoriz ing for thewelfare of the emergent patient and. not the hospital was emphasized". Itwas 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 pro-gralns must face the hard. cold. facts of finances and. availabj-ll.ty of ad.e-quate ca.re. Also, the care potent iar of any specif ic inst i tut ion must

J.t-30-

fit into a commwrity-wid.e system, if r,re are not going to go brokb, and. d.oa great dj-sservice to the public, which looks to us for guid.ance in thiscomplex problem. It was agreed. that categorization itself witl not improvethe quality of care but certainly categorization and. the consolid.ation ofresources in a community witl in fact move us toward.s this d.irecti-on.

REPORT OF WORKSHOP #4

Cyri l Cameron, M.D., New york Universi ty

The first topic d.iscussed. was categorization of Emergency Rooms.The ma"in reasons for categorization were felt to be:

I . ident i f icat ion of the capabi l i t ies of a hospital2. promoti-on of efficiency regi_onally on a planned. basis3. impetus to improvement4. publlc information

It was recognized. that these reasons would. not necessari ly ref lect fa-vorably upon a particular hospital. A poII of the mernbers showed. one infavor of categovLzat'ton and. fourteen agai-nst. The overall opinion wasthat categorization may work in cities, but would. be unhelpful in ruralq T A ' A

The other major topic consj_d.ered. was the training of E.R.personnel, chiefly physicians. Ihe presence of Jarnes Agna of Cinciruratiin 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. haveto 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.icalstud.ents and house staff ("yust ' )

3. evaluat ion of the success of such courses ( ' rd. i f f icul t")

4. whether the E.R.P. could. or should. be prepared. for a com-muni ty ro le ( "yes t ' )

, . the use of t rained. paramed.ical persorurel ( t 'essent ial t ' )

6. communj-cations and transportation systems for peripheralor rural pat ients ( I 'essent ial")

7. the necessity for the E.R. or Arnbulatory Care Departmentto seek equality with other Departments so that better-qual i ty personnel may be attracted" to E.R. posts.

-? t -

B .

-22-

the l tdehumanizat iontr associated. with E.R.problem for which no easy solut ion existsgreat d.eal more attention and stud.y need.

care (a ser iousand to which a

to be d i rec ted . ) .

tha-frman I s Reconmend.atio.l i :

D o c t o r D a r r e Iand. is willing to act as

Thorpe proved.chairman of a

an efficient arrd. capable secretary,subsequent workshop.

nrBonr ol wonrsnop #,

REVOLrnrON IN EMERGENCY MIDICAI SERVICES, CATEGORfZAT]ON

Harold. A. PauI, M.D., Rush Med.ical Col lege

The workshop began with a porr of the 'rworkshoppers " on thequest ion, "Do you think that categorizat ion of emergency services is in-evi table (or inexorabre)? r f so, why? what obstacles d.o you see?,,

The group was unanimous in its opinion that categorizatj-on wasd.esirable and inevitable. A Canad.ian colleague (trtonaghanr euebec) spokebriefly of the effect of the "long report" of the Royar commission onHealth which has had. a marked. effect on total categorization of all med.-ical faci l i t ies in his province. In his word.s the hospitals categorized.themselves, but the government regionalized.. Our participant from theusPHs (wottingham, washington, D.c. ) berieved. that categorization andregionalizatLon have alread.y been in progress and that we age now recog-nizing and. stud.ying the process so as to exped.ite it. He named. lnstancesin san Antonio, Texas, md southeastern Kentucky (Hazard.) as examples.As obstacles to categorization and. regionalization many in the group fore-saw the fol lowing factors--habits, plrysicia.n prest ige, hospital f inancialworries, system vulnerability d.ue to sud.d.en curtailment of expend.ituresfor med.ical\y ind.igent by the State, in other areas economic competition(or the fear of i t ) between d.octors and. hospitals.

On further reasons for imptementation of regionalization Conteof san F?ancisco ci ted. a recent si tuat ion there in which there w,as rracr is j-s of I .C.U. empty bed.s. t ' This was ci ted. as an example of expensiveand rxrnecessary dupticatlon prod.uced" by inad.equate regional prarurlng.Zirkle thought that administrators in many hospitats would. welcome re-gionalization. Implementation might be d.ifficult, and. legislation mightbe need-ed.. Arso, the d"everopment of proper triage and. training peopre tod.o a good. job in triage would. be a special challenge. Winkler ot'AnnArbor ind.icated. that great impetus had. been gained. in his area by theorganization of an emergency med.ical councj_r for the commlrnity, by theprovision of acad.emic appointments for staff members of his hospitalwhich is an affil iate at the university, and. by the institution of. agovernment subsid.ized HEAR system of rad.io comrmmi-cation between policearnbulance canj-ers a:rd participating hospitals. He felt that the problemof categorization and regJ-onalization can be solved. without merging hos-pitals into one system. WoIf, University of Kentucky in Lexington, noted.that hospitats should. be categorlzed first a:rd. that emergency room cate-gorization wourd follow. Att felt that a wilringness of a facirily roallow actj-ve medical aud"it of its emergency room activity for quality an4efficiency was ar. essentiar character in rating or categorizing thefaci l i ty.

-33-

-34-

To the quest ion t 'Should. every hospital have an emergency room?tla s u r o r i s i n g m a i o r i t r r r r n t e d l l n 6 l r A n o l n n r r a n f m i n n r i l r r c r . d + o - i h ^ ,r r v ' r r r r v r f , u J o * o r * " . = d " t h c i r

vier,point welr (Monagha"n and. Allen). The minority position pointed. outthat every hospital should. be able to provid.e resuscitat ion and. t i fe-sustaining measures for its local community and. for its in-patients.Further, the danger of even more unequal d.istribution of load. with sub-sequent hazard. to patients mighl result from irnplementation of a positionwhich al lowed. certain hospitals to escape from some o l igat ion for er ier-p ' c n r i l r q a r r r - i a o c

On the other hand., the majority argued.: (f) funergen cy roomfaci l i t ies could. be expensive dupl icat ions, especial ly in cLusters ofhospitals near each other, (Z) " carefully planned. network with good. corn-municat ion would. be more rat ional, *d (3) uetter nat ionar heatth costcovera€e regard-ed. by many as imminent would. red.uce the economic hazard.or el iminate i t .

AII fel t that their o", 'n faci l i t ies rated. in Category f (highcst) ,although careful examination of any system known or und.er stud.y prod.uced.thoughtful qual i f icat ion by severar part ic ipants when they thought ofsuch regulat ions as rapid avai labi l i ty of bLood. or incorporat ion of radiocommunication. In summary, this workshop was characterized. by rmiversalpart ic ipat ion a.nd. enthusiasm. I t fel t that categorizat ion and. regionat i-zatton carefully planned. would be a good. thing and should. be worked. towa.r'cl.Al though several expressed. the opinion that regulat ion or legislat ionwould. be necessary to assist in implementat ion, there also appeared. tobe a consid.erable consensus tha,t many d.etails could. be worked. out withineach system and that this would be prefereable to super- imposit ion ofany categorization that was rigid d.own to minutiae.

nnponr or wonrssop #5

REVOLUTION ]N EMERGH\]CY MEDICAI SERVICES: CATEGORIZATION

Thomas E. Piemme, George Washington Universi ty Med.ical Center, Wash. rD.C.

Workshop ff5 add.ressed. itself to four questions. Available tous were the previously circulated. f ive-class categorizat ion that resulted.from the Air l ie House Conference. Although there wit l be substant ial re-visions, the Workshop d.id. not have these avaitable for d.iscussion. Al-though comments refer to the earlier d.raft, they wourd. be as appricabreto any subsequent d.raft that maintains the same rigid. criteria in thehigher categories. A summary of the d. iscussion relevant to each ques-t ion fol . Iows:

Can or should any hospital meet the crit_eria d.elineated. in categories| ^ T t t ' /

A recent survey in the State of Georgia revealed. that no hos-pital within the Commonwealth was able to meet the criteria d.elineated.within category I or II or the guid.elines; that only two hospitals withinthe State were able to meet the cr i ter ia of category f I I . No hospitalwith which the Workshop particlpants were affil iated. was capable of meetingthe requirements for category I or If. From our knowledge of other insti-tut ions in the United. States, i t is fair to say that no hospital in theUnited. States is present ly prepared. to meet the cr i ter ia 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 min-utes. Inhibi t ing most hospltals would be the requirement for the pre-sence of a burn unit within the emergency center. There is much issueas to whether it is appropriate to mand.ate the presence of a fully equipped.operating room within the emergency unit. Nor is the requirement thatthe fuI I range of speci-al ty services be present within the hospital twenty-four hours a day necessarily a prud.ent one.

Rigid. nat ional categorizat ion f l ies in the face of comprehen-sive hea. ' l th nlannins- The nresence of more than one or at most tw'o burnunits within most large cities is patently outsid.e the realm of good.jud.gment. Rather, effective d.issemination of knowled.ge to the publicand. to transportation agencies vould. result in better util ization offacilities where highly specialized. firnctions might be concentrated.. Onthe 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 theopportunity for appropriate categorization at a high Level for its otherfurrctions. In surnmarfy, the stand.ard.s are entirely too rigid-, and make

' J ) -

-Jo-

the assumption that each hospital d.esir ing status classi f icat ion inventi ts own wheel.

shourd. universlty hospitars 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,sthat unlversities are increasingry becon-lng the d.ominant centers for ed.u-cationar prograrns of alr types, that they provid.e an i*epracable com-munity resol l rce, and that they serve as mod.els for other hospitats with-in their sphere of infruence. These mi-nimum sta'd.ard"s having been id.en-t i f ied' , they shourd. perhaps serve as a basis for red.ef ini t ion of cate-gory f .

Should cate izatiort aud.it be established. on a r onal, or on a nat ion-a I base ?

rt was the strong feeling of the Workshop that aud.it should. beprovid.ed. regionarry, a.nd that the B agency of the comprehensive healthpranning act should. provid-e that aud.it, or at reast bear the responsi-bir i ty for categoriz ing locar hospitars. This is ent i rery in the in-terests of good. pla.nning. r t is unnecessary that a ci ty of )orooo beserved by five category r emergency rooms; it is equarly inappropriatethat a ci ty of SOOTOOO be served. by no hospltals whose services would. en-t i t le them to high qual i ty categorizat ion. Further, pranning agenciesmay increasingry wish to restr ict hospitals from evolving very costtyhighty special ized. uni ts avaitable elsewhere within the region. t rorexample, no more than one hospital within a reglon need. have the capacityto .do renar trarrsplantation or open heart surgery. Nor need. there bemore than one burn unit if the unit is sufficiently comprehensive and. ofcapacity to serve a large metropol i tan area. There is a substant ial r iskthat categorizat ion in one of the higher levels may become a status symboland an object ive of a board. of t rustees, an object ive that may be inap-propriate and. not in the interest of area wid.e ptanning.

Are tLe criteria as stipulated" all_ that should. be required. of catT T T - - l T T T r -aJtcr L-rt nospitals ?

The answer to this was clearry no in that the capacity to de-I iver emergency health services d.oes not guarantee that the hospital y i l lrend.er th,em to all patients without regard. to the economic status of theconsumer or in some areas to his race. fn ord.er that this be j_nsured., weurge the inclusion of the stipulation that all hospitats within categoriesIt rr, and. rrr must receive, treat, and. see to appropriate folrow-up careof al l pat ients vho present themselves without regard. to resource or evi-d-ence of the abir i ty of the pat ient or third. party to pay for servicesr o n a - i r r o r l

-37-

Littre or nothing in the guid.elines is said. of soci_al and.psychiatric services or of the quarity of nursing a.nd paramed.icar con-tributio.ns to patient care in emergency rooms.

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

EEPORT 0F WoRKSHOP #7

Louis G. Bri t t , IJniversi ty of T e n n c c c o a r F a n n o, - - . . . . -ssee

The initial d.iscussion in the workshop was d.irected. at thesuggested. I ist of quest ions:

Question I

I t was general ly agreed. the basic reasons for categorizat ionwere to set acceptable star:.d.ard.s and to genera,Ily improve aII &nergencyRooms in the country. ft was atso fert that this might herp cut d.ornm onwasteful d.upl icat ion of ef fort and faci l i t ies.

Quest ion I I

The group fert that it w'as impossibre to separate the basisfor categorization as listed.j however, personnel and. facilities in theEmergency Department were thought to be far and away the most importantaspects. The relat lonship between these two factors was more i-mportantthen any single factor.

Question Iff

The standards should. be national in scope and. for politicalreasons, regi-onal ad.visory and. evaluation committees would. be most ap-propriate. In ad.d.ition, there are many reglonal problems which are to-tatly d.ifferent from those in other parts of the eountry, so that althoughbasiq nat ional stand.ard.s could be set, var iat ions would. be necessary on areg iona l bas is .

q,uestl_on IV

Arr agreed. that this was basicalty a problem of ed.ucation inthat the patients should. be taken to the proper facirity on the frontend. thus avoid.ing the problem of limiting the abititles to treat. rfregional Emergency Departments were available, then initiat resuscita-tive care shourd. be availabre in any Emergency Department, with thepat ient then referred on to a more complete center.

Question V

The group was quite d.efinite that every hospital should. not havean Emergency Department, if the legal and. the accred.itation stand.ard.scoul-d be adequately hand.Ied.

-39-

-4U-

Question Vf

There l^ ias an r. ;nqual i f ied I 'yest ' to this quest ion with the und.er-sta:rd.ing that regional centers were mand.atory. Ad.d.itionally, the rurarand urban problems in many ways, al though interrocking, wi l r have to beconsid.ered. separately. Specif icaLLy, i t would. seem appropriate that mariyurban and. suburban hospitals could. easi ly inter lock faci l i t ies whereas,those in smal ler towns would. have to be associated. with one or two speci-f ic centers in a large urban populat ion.

Quest ion VfI

Ad.equate record. keeping a:rd. aud.iting, of course, was consid.ered-mand.atory by all participants in ord.er that the problems in d-elivery ofemergency care cart be und.erstood and qua^ntitated. Ed.ucational programsboth in the hospital having Emergency Departments and. ad.d.itionally inr ao i nnq l aa r l a re wou ld . be mand -a to r v f o r e , , t ego r i " . a f , i on t n wn rk n rnnp r l r rv u r r r s r q q v v r J r v a u q u v 6 w r ! a G U r u l r u u w u r n } / I u } J g r J J .

Quest ion VII f

The part ic ipants, of course, were famil iar with the scheme setout by the Ad. Hoc Commi-ttee on Trauma of the ACS but they felt that theywere unrea l i s t i c .

Question IX

There was general agreement that no hospitat could. real ly placeitself 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 tocategorize the level I I I and. IV faci l i t ies.

The d. iscussion cont inued-, one of the major points being, thatwhere trauma centers have been set-up specif ical ly in Chicago, that someof these smaller suburban hospitals had immed.iately cLosed. their Bner-gency Roor,s a:rd. had. "d.umped.r'a large number of patients on the more com-pLete faci l i t ies. Unfortunately, these pat ients were not necessari lyemergencies or traurna so that it was felt that the categorization and. re-n ' i a n o f i p n + ' i ̂ h ^ r ' t e n c o u l d . b e s e l f - d e f e a t i n r r - e s n e e i a l l r r i n f , h e l , rEl-onaL]-zaufon orlen coul-q pe sel^ -. trge

urban centers. Because of these problems, regional izat ion was thoughtto be important ln terms of d"ivid.ing the problems into the urban areasoften associated. with medical schools arid. Large ind.igent populations and.categorizing rural areas where the problems are consid.erably d.ifferentt h e n t h e v a r e i n t h e

' l a r s e r r r h p n c e n t e r s .

About half the group were strong for categorization but had.it would. work efficiently. One major point thatsome strong d.oubts that

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. alongwi thvi-ces

Further d.lscussion ind.icated.as outlined. by the Ad Hoc Committee onand referred. much too often to hospitalgency Card.iopulmonary Resuscitation and.

the coordifration of an overart change in the delivery of hearth ser-to make i t real ly meaningful .

to mar.y people that the stand.ard.sTrauma were basical ly impossible

faci l i t ies rather than to Bner-support ive personnel and. faci l i t ies.

kobably the most important aspect of categorization are thecategory rv hospitals, rather than the category r hospitals. Thrs crea-tion of stand.ard.s, care, equipment and. personnel.should. be much more im-portant in terms of ad.equate emergency management of the targest nurnbero f nenn l e r : t hc r t han hn r r i n , g e \ r e? l r . ne s t r i r r c f n r J : ho Oa toon r r r T f on i T i i r rv r r ( A r r r q v r r r S u v L r J v r r u D U ! f v u r u r u f r u w a u e 6 u r J J r d . u - L - L l u J .

F n r . i n c t q n n o t h e n z ' p s e n n c n f h - l O O d . W i t h i n O n e m i n r r t e _ e e r d i n n r r - l rr vr r r rDeqrvu, urru ! r uDurtvu vr u!(J(J( l Wlt / I lJ-J l OJlg JI I*- -*- - , nonafy

bypass, renal dialysis, etc. , are important only in a smal l numbers ofpatients as opposed. to the rather large volume of peopre injured. on thehighways and. outsid"e of instant contact with category r facir i t ies.Therefore, it was felt that the Category III and fV facilities should.be concentrated. on, to encourage hospitals to at least reach these stan-dard.s rather than close their emergency faci l i t ies, thus actual ly d.e-creasi-ng the amount of emergency care avaj-Lable rather than improving it.

The essence of most of the d.iscussj-on was that orgNtization andcategorizat ion were important i f they were incorporated. into an overal lTegional system of del iverying emergency a.nd. other health services.

REPORT OF WORKSHOP #B

Gerald. W. Shaftan, M.D., State Universi ty, New York

General agreement on any topic on categorization of frnergency

Med.ical Services was not obtained. al though al l members of the d. iscussiongroup d.id. confirm the need. for interlocking of ftnergency Facilities in

Hospitals in close proximity in ord.er to provid.e high level emergencycare to a cornmr- lni ty in al l d. iscipl ines. In a broad way i t was the con-

sensus of the group that categorization of frnergency Departments was aT T e c e s s a . r v a n d e v p n t r r a l r e n r r i r e m c n t f o r s r n e r i n r m e d i e a . l e m e r g e n t C a J e .r r u v v D D @ J a r q L v u r r v u q r p e . ! / v r

It uas felt by maJryr however, that categorization was premature and. would.

be pract ical only as part of a regional hospita} categorizat ion plan

since so ntuch of the basis for &nergency Department classi f icat ion rest-

ed on the backup faci l i t ies avai lable in-hospital . I t was noted., inn r o o - i n n + r , 1 - + + h c h n s n i t a l a d m . i s ^

j ^ * - ^ - r ' i ̂ . ' n , r d + b e c o n s i d . e r e d i n f t n e r -I J d 5 t j J - 1 1 | i , t J l l i 1 ' t , t r l t ' b f u l l y u r r u J I u u D u

gency Department cLassif icat ion, for no matter how adequate the staff ing,

equipment, md faciLi t ies in the frnergency Department i tsel f , a restr ic-

t ive (possibly for economi-c reasons) admi-ut ing pol icy should automatic-

aIIy red.uce that hospital 's Emergency Department to the lowest category.

It vras suggested. that nationally estabLished stand.ard.s would

place a floor for minimum accred.itation of a hospitat and. cause community

pressure for upgrad. ing the avaiLable faci l i t ies. I t was the consensus of

the group, that based. upon these nat ional stand.ard.s, specif ic categoriza-

t ion assignment should. be carr ied 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' i r Finersenerr T)enertments and this was consid.ered. the pr imary value4 u v f b v . . v J s v l s +

of such classi f icat ion. Second.ar i ly, 1t was fel t that with ad.equate classi-

f iea f , ion- in assoc ia t ion r , l i th a reg iona l hosp i ta l p lan and a we l l -coor -

d.inated. communication system--that is one that permits arnbulance to phy-

s'i c'i an or nhvs:i ci an tn nhrrsi e-'i a.n consultation a mechanism nould. evolvev r f r r J v v y { r J

for proper and. equitable d.istribution of patients accord.ing to the need.

of the pat ients for Emergency Department a:rd" hospital faci l l t ies--1n

other word"s intelligent informed. triage.

The categorization for Emergency Departments as suggested-hrr tho arl Tfna committee of the Committee on Trauma was consj-d.ered. faru J u r r u n u l r v v v v

better than that proposed. by Dr. Henderson. Whi le 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

emersencv na t ' ien ts - . i t uas fe l t tha t aL I ins t i tu t ions us ing the namev l r v r b v r r v J

"hospital" in their t i t le should. have equipment, with personnel to operate

-43-

-44-

this equipment, for the resuscitati-on of both in and out-patients whileawait ing referral t ransfer.

Discussion arso centered. on a changing emphasis in EmergencyDepartment orientation, away from the perhaps more spectacular but lesscommon traumatic problem toward.s the routine med.ical d.ifficulties thatare consid.ered. emergencj-es by the patients presenting themselves to thesefaci l i t ies. koblems of categortzat ion aLso were d. i -scussed. includ. ingresj-stance to categorizat ion because of the inevi table ensuing pressureand. monetary consj-d.erations, resistance to transfer of patients to otherfacilities for much the saine reasons and. the d.ifficulties in enforcementof categorizations of tsnergency Departments because of local hospitalpr ide. Whi le no concLusions were reached. on the solut ions to these prob-lems it seemed. to us that with National Med.icat Care, many of these d.if-f icul t les would solve themselves.

In summary, our Group believed. that categorization of EmergencyDepartments should. be d.etermined. at a local level on stand.ard.s d.eveloped.nat ional ly, ut i l iz ing these categories as part of a regional med.ical plan,and. that unt i l such hospital regional izat ion was effected. there was l i t t leratj-onale for their categorization other than to stimulate the upgrad.ingof existing Bnergency Departments.

REPORT 0F WORKSHOP #g

CATEGORIZATION OF HOSP]TAI EMERGFJICY }4MICAI SERVICES

Robert B. Rutherford., M.D,, University of Colorad.o

The group unanimously approved. the basic concept of categoriza-tion of El4S.

The proposed cr i ter ia for c lassi f icat ion were thought to befair ly real ist ic except possibly for Category I , but i t was fel t that theseparat ion between categories should. be more d. ist inct, part icutarLy be-tween Categories I and. II, If and. III whereas the gap between III and. IVwas 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 theUnited. States, as opposed. to Canad.a, which has stronger national controlsand is already more ad.vanced in regard. to regional planning for emergencymedical services. However, because of the great d. i f ferences from oneregion to another in the United. States, the group fel t that these guid.e-Iines probably would. have to be mod.ified. and. ad.opted. to fit ind.ivid.ualneed.s .

It was anticipated that categorization would. be d.etermined. onthe basis of a sel f-eva,Iuat ion quest ionnaire fot lowed. up by a si te vis i t .The question of just who would. d.raw up the questj-oru:aire and. make thesite visit has not been recommend.ed.. Carried. further, the need. for somerecognized. authori ty in sett l ing matters pertaining to categorizat ion tocategorize hospitals ini t iat ly and. per iod. ical ly reassess their status, toassure 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-zat ion, i t might fair to have much last ing impact. rn thisregard., i t was suggested that i t was unreal ist ic to expect the Joint Com-mi-ssion on Accred"itation to provid.e any reverage in this regard..

Generally, i-t was agreed that since categorization would. proba-bly have to be a regional matter, its implementation would. Iikety fallto some regional med.icar planning a€ency, such as a community ad.visorycounci l on emergency med"ical services. That is, the f i rst step toward.scategorizat ion would have to be to ei ther convi-nce the exist ing regionalpranning group to take thi-s on, or, in other regions, require the forma-tion of such a group, d.e novo. Thus, categorization wourd. serve as astimulus for regional planning of EMS, but in many regions, categorizationcould. not be accomplished. until a solid. for.u:d.ation for regional med.icaln l ann ino har l f i rg f , been es tab l i shed. and there fore be - in a l ' l n76 | ro l - ' i

- r ; + ' -u u v v v g u o u q w r r D t r s q q t q U t r s r s I u I L - _ , } / * v J a U _ L I J _ L r y ,

-

t -

-45-

ad.d.ition, following the actual categor1zation, therema.lty years away. Inwould. be consid.erablyform of an organized

more time consumed. beforereglonal or conunllnity plan

its implementation 1n thegoverning the transporta-

and. other rescue workerstion of the acutely iII and injured. by ambulanceto the appropriate hospital .

In regard. to other factors which might be taken into consid.era-tion in determining categorization, in ad.d.ition to ED space, equipment,personnel and. i ts backup faci l i t les, i t was suggested. that i t wourd. bed-esi-rable to have some means of measuring performance. The form thatthis should. take was not elaborated., except for the suggest ion of a ut i l i -zat ion review of the emergency services, includ. ing al l d.eaths and. com-pl icat ions ar is ing from emergency d.epartment admissions.

I t was fel t that the factors current ly d.etermining t ,he hospiralto which acutely i l l or in jurer i . pat ients are taken in each community, wereusually 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 el ther the pat ientrs cond. i t ion or the abi l i ty of thereceiving hospital to provid.e prompt and. ad.equate management of that con-d-ition. It was suggested that many of these extraneous factors rvould. haveto be recognized and. d.ealt with, before categorizat ion could. be success-fully implemented.

rt was generar ly fert that, i f nothing else, categorizat ionwould. Iead. to an upgrad.ing of the emergency med.ical services of a signifi-cart t 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 busi-n p q o t l a n l - i r o l r rrrsDD s*urrsl .J. I l r rwever, i t was fel t that in implementing a regional p1anbased on hospital categorizaLion i t would. be important to also obtainspecif ic commitments from the var ious hospitals in the communicy or re-gion, regarding their role in the management of the 'hon-emergency" pa-t ient. That is, i f j -ncreasing numbers of emergency pat ients wourd. bereferred. to the higher category hospitals, i t would. be unreal ist ic forthem to also be expected" to hand.Le increasing numbers of non-emergencypat ients. As possible sotut ion would. be for certain of those hospitalsthat were not expected. to provid.e care to the acuteJ-y iIJ- and. injured. atthe higher levels to maintain open cl inics for the }ess ser iously i l l ornon-emergency pat ients.

There were no strong sentiments regard.ing a preference for fouror f ive categories, but several fel t that the names of the categoriesshould be more obvious in their implications regard.ing the ability of theinstitution to provid.e emergency med"ical care. The current names werecr i t ic ized as not provid. ing any obvious d. ist inct ion between the four cate-gories. For example, possibly as an attempt not to offend. any institu-tion, the Lowest category was currently id.entified. as a stand.ard.. rathertha,n a l imited enerB'ene\r serr- inc

-47-

It was felt by some that it might be just as vell if the public

r,'rere not involved. in categorization. That is, categori-es could. be assigned.and. a regional plan based. on this d.rar,'rn up, and. all the appropriate ambu-lance and. rescue workers given specific d.irections accord.inglnr with lit-tle need. to involve the general public. With the general public out ofthe picture, hospitals might be less threatened. by their assigned cate-gory. 0n the other hand., it was countered. that, particularly in ruralatreas where transportation to the hospitals was frequently not by arnbu-Lance, it would. be important for the general public to know exactly rrhat

the d.ifferent categories implied.. It was generally agreed. that whilenurnbers probably should. not be used., that the names of the various cate-gories should. be more expl ic i t .

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 JointCommission, should. in no way d.etermine patient d.istribution.

FinaILy, it uas felt that it would. eventually be important tohave some system of evaluating just how weIL categorization was working.This evaluation plan should. be d.esigned. prior to the implementation ofcategorizatlon and. not as an afterthought later.

It was felt that the emphasis should. be on not restricting anyhospital from improving its emergency servj.ces or limiting its participa-tion in the d.elivery of emergency med.ical services, but it was importantthat each hospital perform effect ively at the level of categorizat ion theychose to attain.

Most of the remaind.er of the d.iscussion centered. about the prob-

Iems of implementation which were thought to be the place where categori-zation would. either succeed. or be aband.oned..

THE TRAINING OF PHYS]CIANS IN TIfi EMERGENCY DEPASTMENT

PANEL DISCUSSION

t : O O 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 thesame content. kobably the most important area that we can d.evote our-selves to as physicians in university centers has to d.o with the trainingof other physicians. The need.s are extremely great at this time and. weare d.everoping around. the country a rarge number of emergency centersthat require physicians to man them on a 24-hour basis. The numbers thatwe 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 Leastraise tod.ay. we have a group of experts who each in their own way aJeworking ln this area who will try to give us in perspective the problemsrelated. to each area and. then we will have some genqral d.iscussion afterthese brief presentations and. then we wiIL be able to carry much of' thisquestion and. d.iscusslon period. into the workshops.

Our flrst speaker is Dr. John Wiggenstein, who is the Chairmanof the Board for the American colrege of Enrergency physicians. He hasbeen very active on the natj-onar scene and. has talked. to many, .many phy-sicians who are working in this area and. he vilt tark to us about theneeds in this cormtry for the training of this type of physician.

- q 1 -

TIIE NEED I'OR TRAINING PHYSICIANS IN EMERGH\]CY MEDICINE

Dr. John WiggensteinLansing, 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

are financial and. acad.emic d.isasters. Unfortr:nately, in many areas much

of what they say is true. Numerous factors contributing to this dilemma

have been suggested.. some of those more commonly heard are:

f-) the increased. use of the emergency d.epartment by the general

public for non-emergent reason

2) the pub l ic ts inc reased med. ica l awareness

3) the rising incid.ence of traffic accid.ents and. trawna in

s a n c r a I

4) the mobi l i ty of o*r pat ient populat ion tod.ay, etc. , etc.

I think we can aII read.iJ-y agree that these are legitirnate factors con-

tributing to our emergency d.epartment problem. but what is absolutely

amazing to me is the fact that seld.om is one of the most significant fac-

tors implicated., that is, the d-eplorable lack of training that physicians

receive tod.ay in emergency care. The average physician is d-efinitely

short chalged. by his med.ical ed.ucators in this respect and therefore

calnot practice effectlveLy in a.n emergency d.epartment setting.

Let us examine his acad.emic background.. Where d-id. he receive

th is r ra in ins? The chances aJe s l im tha t he rece ived. much emergency d .e -

partment training in med.ical school. tr'ew schools ind.eed. includ.e emer-

s'encv med' i c ine as a4 ind"iv id.ual ent i ty in their curr icula. During intern-

ship this luckless fellow may be forced. to pult emergenci department d-uty

but because of poor supervision this seld.om results j -n a sat isfactory

Learning experi-ence. The picture is much the same d.ur ing his resid.ency.

And. finally as a private practitioner and member of the med.ical staff of

e hosn i ta t he mer r f ind h imse l f aga in fo rced. to pu I I h is share o f emer -a r f v D t , r u e ! , r r v r u * J

gency d.epartment responsibillty in ord.er to maintain his staff privileges.

Gentlemen, I need. not suggest to you that involuntary service

is not conducive to high quality emergency care. I am suggesting to you

that at no t ime in the average physicianrs ca,reer does he receive ad.equate

training in the efficient marla€ement of patients in the emergency d.epart-

ment and at no time in his career has he received. sufficient properly

-r3-

->4-

supervlsed. experience in this d.epartment. And. I also suggest to you thatunless appropriate ed.ucational progra.lns become more read.ily available,this so-cal led. t 'cr is i-s i -n emergency carerr is only beginning. we d-es_perately need. programs in emergency med.ic ine at alr levels of th: med.icaleducationar }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 emer-gency med'icj-ne to provid-e med.j-car school grad.uates with sufficient know-ledge to support a career in this special ty. We need. short concentrated.coLllses in emergency med.icine to prepatre those experienced. physicians whowish to refresh and. upd.ate their knowled.ge in emergency care. Also forthe benef i t of part- t ime emergency physicians such as the pont iac planphysicia:r, an ongoing in-service training prograrn wourd. seem to be mostappropriate.

How marry physicians atre we talking about? rn the state ofMlchigan we have more than Boo ptrysicians employed., either furl or part-t ime, on a regurar basis in our staters emergency d.epartments. Al thoughan annuar survey has yet to be cond.ucted., i t can be conservat ively es-Nimated" that lorooo physicians in this country are d.evot ing a signi f icantportion of their ca"reer to emergency med.icine. This virtual army ofphysicians, increasing in ni.rmber d.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 arLphysicians in the community regard. less of speciarty, at least they should"be trained. in the basic erements of emergency care--such as cardiopur-monalry resusci-tation and. the latest ad.vances in the treatment of shock.Attendance at per iod. ic courses of this nature should. be mad.e a reouire-ment for medical l icense renewal.

r have attempted. i-n a very brief period. of time to emphasizethe desperate need- that exists tod.ay for training physicians in emergencycare. r s incerely hope that each of you wirr return to your respect iveuni-versi t ies fut ly recognizing these need.s with renewed. enthusiasm forinstituting the necessary progra.lns in emergency med.icine.

Dr. Ronald. KromeDetroi t Receiving Hospital , Detroi t

I think for the benefit of my professor and. chairman I ought to

say that my opinions are not necessari ly his or that of the med.ical school. .

And. he is not held" responsible for anything I say and. he uill tell you

that he is not responslble for anything I ever say.

Dr. Wiggenstein has alread.y allud.ed to the fact that inexperi-enced. house staff attend.lng or voluntary staff on a rotational basis orpart- t ime physicians, are al l ut i l ized. present ly to cover the emergencyd.epartment. This sort of med.ical staff arrangement makes continuity aJldcare impossible and d. i f f icul t , i f not impossible. This sort of care canrt- i ' n - l I n r . r o h r r ' r r h ' i i r r n f n r r ? n n q a n r n r i n n i n l e T a l h q f . T r r a e r F r c a l l \ r e A rl o r r o w a J r y u n r u y v r l q s r v p v v * r - - - 3 1 n 9 ] - s

an attempt on the part of the hospitals to resolve a problem created. bya shortage of physicians--this being a basic economic law of supply andd.emand.. The only problem is that the medical schools who are the sup-pliers of physicj-ans are not keeping up uith the d.emand.s that the com-munity is making. Nursing care, teaching ald. the patient aII suffer from+ r ^ . i d ' 1 ̂ ^ r - ^ - F r 6 - j m c l n r r n l t r r o n t h e n a r t o f t h e i r m e d . i c a l s t a f f s . N o t o r i _U I I J D ! @ U A U r ! I I I I I S l U J @ ! U J U r f V r r v } / s r u v r u r r u r r l

^ r . ^ T , - h ^ A - i ^ ^ 1vuDrJ, 'rsqrwq! ochools have exhiblted. an attitud.e of what my fellow BaI-timorian m:ight caLI benign neglect toward. the emergency department.Really, the med.ical schools have never d.eveloped. any sort of holisticapproach to training in the emergency d.epartment, for the stud.ent, forthe intern or for the resid.ent and. what is even more startling and fright-ening is that med.ical schools do not seem to real ize that they have a res-ponsibility to return to the community vell-trained. physicians and thatnow the community is d.emand.ing experienced., full-time, well-trained. phy-

siciaris in the emergency d"epartments.

In mater ial previously d. istr ibuted. to aIL of you, the AmericanCol lege of Emergency Physicians has focused i ts attent ion on the training

as well as the d.efinition of the emergency physician. Tentatively, atleast, they have formulated. the following d.efinition of an emergency phy-

sician as a physician wtro (n) provid.es f i rst contact, emergent, urgentand. immed.iate halth services to al l pat ients of aLI a€es; (B) evaluatesi h a n o f i a n f I q e m..- - -.*ergent, urgent and immed.iate health need.s and provid.es

such services that are immed.iately ind.icated. and. then refers the patient

to the appropriate other physician for further d.efinitive care when 1n-

d.icated.. (C) He also insures that the patient wiII have available to

him appropriate follow-up care in or out of the hospital as ma41 be re-quired.. This attempt at a d.efiniti-on d.oes meet, we think, academic stan-d.ard.s for a specialty d.efinition. We also think that the acad.emic d.efini-tion 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.

-r5-

- )o -

Qne obligation of med.ical school.s really should. be to identify

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.ic ine extracts from aII the exist ing in-d.epth special t ies and there is

also no d.enying the fact that no specialty truly stands completely, autono-

mously alone.

The material which you have received. from the American College

of Emergency ?hysici-ans has out l ined. the basic essent ials of the resi-

d.ency and. emergency medicine which will consist of 35 months of training

in the var ious in-depth special t ies with the pr imary focus being in the

emergency care and the recognition of treatment of acute med.ical prob-

Iems with ad.d.itional training in hospital ad.ministration and med.ical Law.

We think that the d.evelopment of such highly trained. med.lcal person-nel

will irnprove oi-rr ability to d.eliver good. med.ical care in an efficient and

meaningful manner and. to d.evelop ed.ucational prograrns which wiII also be

meaningful for al l the al l ied. health professionals and to be able to teach

stud"ents, all stud.ents, in an easier and. more efficient and meaningful

way. No specialty really need fear that the physicians trained. in emer-

gency medicine intend. to go onto the ward.s, into the operating rooms,

into the d.el ivery sui tes, into the off ices and abscond. with their pat ients

and. their special t ies, and. we d.on' t feel there is any necessity to train

the emergency physician in so much d.epth.

The very real ist ic facts of l i fe are that competent, wel l -

trained. plrysicians who d.evote their time and energi-es to emergency med.i-

cj-ne are not presently in sufficient nurnbers to meet the current d.emand.s

and no other specialty, surgery and orthoped.ics includ.ed, is prepared. tofi I I +.hi s necd nor can this d.emand. be met by moonlighting house staff .l r v v * , r . v r

This time we who represent the teaching hospitals and med.ical

schools real ize that our profession and. our schools need. to, or rather

are, obligated. to, provid.e highly trained. rnedical professionals to deliver

specialized. care in a restricted. environment and. set without anybody

feeling the need. to go on a.n ego trip or without anybod.y becomi.ng paLa-

noid..

Thank you.

Chairman:

That is what you call bringing it right on down front, isn'ti t? Nov we are going to cont inue on and. talk a l i t t le bi t more speci-fically about the programs that are underway, or at least in preparation.

Dr. James Agna, who is d.irector of the outpatient services for Cincinnati

General Hospital , wi l l cont inue in this vein with some of ' their experi-a n n a q

-57-

Dr. James W. AgnaDirector, Outpat ient Services

Cincirurati General Hospital, Cincinnati, Ohio

At the r isk of sounding evangel ical or at the r isk of bor ing

some of the members of the d. iscussion group in which I part ic ipated. this

morning, I wi l l recount to you some of the reasons why we fel t 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 sett ing. The program's major emphasis is d. i rected.

toward. d.evelopment of a new breed. of primary physician, the emergencyphysician, who wi l l be the leader of this nev health team.

The aims of this prograrn are as fol tows: ( l ) To train the

physician to become expert in the d.el ivery of med.ical care to a broad

spectrum of med.ical problems encountered. in an emergency u:nit t (2) fo

d"evelop ad.ministrative quatlties necessaJry for the physician to attain

Iead.ership in this f ie ld. of end.eavorl (3) To stress the physicianrs

role as a teacher in al l aspects of emergency med.ical care. Resid.ents,

interns, med.ical stud.ents, nurses and. other al l ied. health personnel wiI I

come und.er this aspect of his responsibi l i ty; (4) To encourage research

in two categories: a. c l in ical research, d. i rect ly related to the im-provement of care to the pat ients with specif ic emergency med.ical prob-

lems. b. research as related. to the total concept of the emergency

health team and. i ts relat ionship to cont inui ty of care.

It is evid.ent that the status of emergency rooms has changed.

d.ramatical ly over the past twenty-f ive years. No longer are the act iv i t ies

of' an emergency unit limited. to rather cj-rcumscribed. emergency med.icalproblems. 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

only in ghettoes, i t is v ir tual ly impossible in the evenings and early

morning hours to obtain the services of a physiciart for cond.itions which

the patients themselves would. acknowledge are not emergencies. The ac-

t iv i t ies of the emergency unit in some respects represents a microcosm of

the ent ire community 's health problems. The spectrum of what is con-

sid.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 func-

tions as a primary care source for routine med.ical problems. In a sense,

a form of neighborhood. health center is also cond.ucted. through the emer-gency unit. Rend.ering this type maintenance care and episod.i-c care for

minor il lnesses may not be a d.esirable activity for an emergency r:nit but

-r9-

-50-

i t is evid.ent that most emergency r.ur i ts offer this service. Many peoplef ind' the only access to the health care system is through a hospital emer-gency unit because of being transients in the community, new arr ivals, orpeople without fina.r:clal means who have not aligned. themselves with theprivate sector of med.ical care. I t seems unl ikely that med.ical care d.e-livery will be reorganized. in the near future in a mar:ner which wourd. sig-ni f icantLy amel iorate emergency rooms with respect to involvement in thisbroad. range of health care servj-ces.

The judgments required. of the personnel who work i-n emergencyunits are of consj-d.erable gravi ty and complexi ty because interspersed.anong the more mundane med.ical problems are gravery irl peopre in need.of the basic armamentar ium of a uel l -equipped. emergency unit . Therefore,health personnel in such a unit , especial ly in a lead.ership role such asa physiclari, must have a sensitivity to the community need.s along withbetter than average ski l rs for managing ser ious med.icar problems. un-fortunately 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 ixr l t physicians, a two-year resid.ency program has been d.ever-oped at the University of Cincinnati lr{ed.ical Center. This resid.ency hasbeen approved. by the Resid.ency Review Committee for General l\^actlce ofthe Al4A Cor-rncil on Med.j-cal Ed.ucation and. by the Ameri-can Aca.d.emy of FamilyPract ice. The number of resid"ency posit ions approved. is s ix per year and.the length of the prograrn is two years. A total of t2 resi_dents can bein the prograln at one tjme. There is one resid.ent in training but therewi l l be six resid.ents in this prograrn on Juty t , L9TL. This trainee inemergency med.ical care will supervise transportation and communicationsystems, part ic ipate in emergency unit d.esign, and interrelate with per-sonner incruding nurses, at tend"ants, ord.er l ies, crerks, rad. io operatorsand. ambulance dr i-vers. WhiLe d.eveloping his specif ic professional ski I Is,the trainee i-s expected. to observe or part ic ipate in the other steps inthe process of d"el iver ing emergency med.ical care. He is expected. to par_t ic ipate in in-service training program for at l the members of the emer-gency unit staff. These prograJns, as well as the knowled.ge gained. whileservi-ng as emergency unit physicia-n, wi'l.l allow the resid.ent to d.evelophis own i-d.eas concerning the relationships of an optimum emergency unitteam. The rerat ionship of this r .rni t to comprehensive health care isemphasized. The program is interd.epartmental. when the resid.ent isassi-gned to a part icular service, the d"ai ly supervision of the resid.entis the responsi-bi l i ty of the d. i rector of that servj .ce and. his staff . Theresid.ency rotation offers the trainee the optimum exposure to a wid.e spec-trum of medical problems which are encountered. in an emergency unit. Asignificant portion of the resid.ent t s time is spent in training outsid.ethe emergency unit but oriented. toward. problems encountered. in an emer-gency unit .

It is expected" that a certain nurnberthis program wi l l assume responsibi l i t ies for

of physici-ans completingo m ? T o a n ? \ r r r n i i n .u u r u r 6 s r r u J u t r u u & I e I f I

-5t-

commwtity hospitals. Other trainees may embark on a catreer in the aca-d.emic aspeqts of emergency physician training. It seems justified. thatestablishlng departments of emergency care would. be an appropriate fi.nc-tion of an acad.emic health center. These d.epartments could. then be thefocal point for ed.ucation of physicians who intend. to make emergency carea primary career and. for short-term training for second. ca.reer physicianswith special educational need.s. FinaIIy, the role of the emergency unitphysician in an acad.emic health centerin which resid.ents and. internshave training rotations through an emergency unit is somewhat d.ifferentfrom an emergency unit pLrysician d.elivering primary care in a communityhospital. These physicians would. continue to participate in care butwould obviously have a d.ifferent type teaching and. administrative rolethan the emergency physician in a non-teaching hospital.

Chairman:

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

I

-l

-oJ-

Dr. James DineenMassachusetts GeneraL Hospital

Instructor, Department of Continuing Ed.ucation, Harvard. Med.ical School

I think the stage has been set very r,vell by John, Ronald. a.ndJim. The message that comes to me from what f have heard. is that forr r n r ' ' i n + ha i r r ^? " tOWef S i L iS t ime t ha t r r o r l r o l I un l r r r t r r s l ec r r cs a .nd sne r f v f v v r J u v v v e ! D f u l D v r u r u u r r q u J v q r v r ! q !

J U q r D r u u v u D @ r u 6 v

to work. f t is c lear that somewhere out there there are perhaps 51000n h r r c i n i : n q r ^ r h n r r o n ^ r ^ r n e l l i n o i . h a m s o ' l \ r c q o m o r o c n n r z n h r r c - i n - i o n - Q . r r r n dy r r J D r v r % r D w r r u e r u l r v w v @ ! . ! r u 6 u r r L l r p u ! v u D u r l l u ! b U I J U J l r f J D I U J @ r D . D J 4 I q

large, they are d-ocs who close their of f ices, took d.own one shingle,walked. to the emergency room, walked. in and- became emergency physicians.hTe n I I knnr^r t .hprr : re ro: I I r r nnf .

What I would l ike to d.escr ibe is our experience at MassachusettsGeneral Hospital . With a very short course we have had. experience at-tempting to teach some of these physicia;rs some of the ABCs of emergencymed.ic ine and my reason is purely to st imulate others of you who are insimi lar academic sett ings who might be ablc to do the same to develops imi la r courses .

Le t me s ta r t w i th a b r ie f ' descr lp t ion o f the course . I t i stwo weeks. We take six stud.ents at a t ime and our goal is very l imited..I t car: be expressed in two vrays. One is that we real ly try to zero in onis attempting to teach these people to at Least be able to hand.Ie any-thing for lO minutes, always with the d. i rect assumption that there ishelp corrring axound. the corner. The second. way we could express our goalwould- be to lake the physicians as they come to us and. get them to taketw'o steps forward. uhether they are on the five-yard. Iine or the fifty-yard. line. If you Look at the students who come and. f look at the }astthlr ty-- the average age is )0, two-third.s have a general pract ice back-s r o r r n d . n n e - s ' i x r - . h h a v e a s r r r s i e a l b a e k s r n r r n d . a n d 6 n g - g i x t h h a V e e i t h e rv l 4 J * ,

a ped.iatric or internal medicaL background. The key to educating any-bod.y obviously is d-iagnosing what they need. to learn. In an attempt toform some sort of ed.ucat ional prof i le on these doctors we gave them awri t ten examinat ion on d.ay I and just a few of the results of this examm ' s h t i ' l

- l r r m i n a t e u s a . l l . T s ' l r r e t h e m l O e m e r s e n e v e . a r d i o s r a m s - - c l a s s i cr b f v r v v q r e r b v r r v J e ( A q r v b r 4 u D - \

MLs, e tc . , e tc . - -average score , !O percent . I show them gram s ta ins o fmeningit is. A lot of them say we d.onrt have to read. gr.am stains ofm e n ' i n B i t i s - T h a n n a n f . n d i q t o ? o a T h e i r q n ^ T p D E n a v n a n + v ^ ' l S i tt 1 t ! t ' v t t v (

d.own and. ask then a half-dozen basic questlons about hand.Iing apatientw - i i ' . h n r r l m ^ n t ? \ r a d p m a 5 f ) n a r n a n J - . h o q d i n i r r r r r 7 5 n a v n a n ! - r r ' h a v tw f u r r I r u I I r U t r r u J s u - - r r w , / v I : - - t r E d I _ L r r J L , t � J , ( , / y - - a r . - . e 1 5 a

wid.e range of talent that comes to us for ed.ucation.

The second vay we attempt to get to know these d.octors is thatthere are smaller classes and. there is a }ot of d.ynamic i-nterchange go-- i n n ^ - ^ f I + L ^ + 'J- l r8 Ql l aI I UI le U].me.

''l

-66-

The actual course structure in mechanics is that during two

weeks we spend. approximately twenty-five hours in Lectures. You couldnred ' i r . f . m:nr r n f lhe s rh iec ts tha t we cover because the or ig ina tors o f the

v r r v u u v . J v v v u

course have an internal med.ic ine bent. Our two-week course is clear ly

oriented. toward. internal med.i-cine--blood. gas, ECG, gram stains, card.j-acr o q r r q n - i t o f i n n n a d i q f r j n a m o r r r p n a r r d r r r r r s r e s n i r n t n r r r f n i l r r r e - e 1 , . or s D q D 9 l u o u l t J l f , } / s u l a u a ! e u l l r u f b u r r u J , q r u 6 D , r s D y f r a 9 v f J t @ l u r v ,

etc. We give about twentyfive hours of that type of Iecturing in very

smal l informal sessions.

The meat of the course takes place in actual work in the emer-gency ward.. We have the students each spend about thirty hours per week

donn rvorking with the acutely i l f pat ients. The sett ing is the typicalIrOOO-bed. rmiversi ty hospital sett ing of roughly 2rO pat ients a d.ay, artabundance of fairly competent house staff. At the same time that wehave the stud.ents down there we have a preceptor whose pr ime job is to

search out appropriate case mater ial that is in the hou.se at that t ime

and. to get i t 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 Massa-chusetts General Hospital so they are covered- medical IegaIIy. IdeaIIy,they get to manage the sick pat ients with the help of the preceptor.

The preceptor 's big goal is to look for pat ients whom the d.ayrs lecturescan be appl ied. to. That is a very lnterest ing experience--both for thepreceptor and for the stud.ents. I have certai-nly had. the experi-ence ofgiving very clear lectures on coma and. walking d.own with the stud.entsand. sweating like hell trying to figure out what uas going on with this

comatose pat ient. They al l Look very intel l igent si t t ing there smil ingj-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 real ly get a feel

of where we stand.

In terms o:[ master ing technique we ut i l ize whatever area in the

hospital seems to be the best. We try to get the stud.ents to try to ex-

press what techniques they real}y feel weak in. They al l have to go to

the OR and" Iearn how to intubate. If they feel they need. to know bloodgases and. heart fai lure sick we take them to the respiratory care unit .

It is obvious that you rnobilize the resources of your institution lo get

them to master these techniques. We have a couple of iazzy things going

on in terms of the computer world., with at least tuo emergency procedures

as problems. One is the cardiopulmonary resuscitation progran in the

computer and. the student sits d.own and. plays with it for a couple of

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 com-

puter.

What are the results of this course? WeII, Letrs take a few

comments. First , Dr. R. R. Hannas, Jr. , Vice Chairman of the Americart

-6r-

colrege of Bnergency Physicians, frequently refers to the emergency phy-siciar:.s as tigers. I agree entirely. These docs are formally scheduled.to f in ish at p:00 at.night, but f requentty they are there unt ir L2 orI a.m. They real ly get turned. on. And. simultaneously these instructorsget turned. on. They are so pleased. to be teaching people who are outthere d.oing it in contrast to the third. year med.ical stud.ents who aregoing to be psychiatr ists or publ ic health off ic ials and. real ly couldn' tcare about coma at all.

We give them a test when they leave too, and we get a 40 percentimprovement in score. We d.on' t think thatts terr ibly great, but we real-j-ze we stirl have to d.iscount that by po percent when you come to theactuar apprication d.own 1n the emergency ward. But we d.o feel we turnthese stud.ents on and. get the ball rolling.

The initial group that got us involved. in this is fortunately ina hospital that is ten miles away in Lynn. r was a resid.ent when theycame throwh in l-p68 and. now r have the occasion to go out there onceevery mont[ or two. There is no d.oubt that the level at which they arefunctioning at now j-s terribly exciting. They sit d.own and. you just tarkat 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 of f icesin the f i f t ies, and they refer to themselves as the old retread.s. Wel l ,for old retread.s with just a little bit of nud.ging they have come anawfully long way.

QUESTION AND ANSWER PERIOD

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 streetgoing 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.oc-

tors how to be pol i te to pat ients-- for opners, but i t goes way beyond+ l ^ - +

DR. AGNA:

Dr. Dineen, did-ntt you say you had a result of one of your stu-

d.ents uho d.ecided. af'ter tw'o r^reeks that he shouldnrt be working in art emer-o a n n l r r r n i t ?

DR. DINEEN:

That is t rue and i t may have been our biggest single success.There is nolhins uorse than to run a two-r,reek course and. real ize that some

of your trgra.d.uates t' may go off wearing a T-shirt that says "I graduated.f r an r i \ . fATJ t q amc roAnn r r med i r ' ' r ' n c eo r r r se - l t and T wa -s n l eesed t hn . t f , h ' i s gen t l e -I l U i l r l Y I u l t o U l l l u r 6 9 l l u J l l l g q J v l l r g U v u ! D 9 , q r * J v v Q p y l v q p v 9 v l ] g v v l f + g o v * { v ! v

man ret i red..

DR. TOM PEIlAm, George Washington Universi ty, Washington, D.C.:

I rrvoutd. tike to open up Pandora's box here for a second. nx-

cept for J im Dineen there was a consonance about the other three discus-

sions about which f would. Iike to quarrel a bit, if T might, ild see what

the responses there aJ.e to this.

First of all, I am concerned that what we are really talking

about here i-s primary care for emergency problems. On the other hand., it

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

choice and. as we know our emergency rooms are Largely occupied wj-th minor

i lJnesses and. the worr ied. weLI and. not necessari ly those pat ients who

may have that which we would. d.eem to be a true emergency. And. if we go

a,bout training exclusively emergeney physicj-ansr PoPulate our emergency

rooms, attract a la.rger nwnber of patients, for many of whom there should.

be a more comprehensive approach to health d.elivery, then we are really

pound.ing tacks with sled"ge ha.mmers. ft is a very high-trained., highly-

specialized. person. The emergency rooms wiLL continue to clutter wlth

the worr ied. weLIs.

-Ao-

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

I think we have another problem if we go about creating resid.en-cies in emergency care exclusively. We st i l l have the problem of gett ing

these pat ients, some of whom come to us repeated. ly and appropriately,into a health maintenance organization, if I can use that phrase. Thenthat makes some sense. I wond.er if we shouldnft be, rather than trainingresi-d.ents exclusively in emergency med.ic ine, become involved. in the train-ing prograrns now evolving to train resid.ents in primary ca.re, communityh e a . l t h e a . r e - w h : t e v e r t h r 1 , i s . f i , r f ' r ' n n a r n n n o l - o r r n 6 l g l O n e a d m i n i s t f a t i V e

and. training umbrella all of those ambulatory facilities, all of that^^*^^ i+ - - +L^+ - ' ^ ha .ve- n f wh ieh the ins t i tU t ion in te r faces and re la tesu c l / 4 u f u J u f f o , u w g l f o v s , u r w l t t u l l

to the connnunity. I think this would. be much more proper. Then we cand.evelop total ambulatory systems. We have an emergency room that feed.son ambulatory service. We can provide service that d.efines geographic

areas and solve much Larger problems than creat ing exclusively a resi-d.ency in emergency med.ical care which I think I would. be opposed. to.

DR. I(ROME:

In a word., I agree. f think we have a very complicated. problem

ard. I d.onrt participate in this program out of the context with the com-m r r n i t r r m o d i c i * ' i - L ^ ^ ' i r ^ - - ^ r ^ * L ^ l t e r s r r s t e m s t h n . t d . e l i v e rr l r l x r l u J l l s q J u f r r E ! r u 6 r d l l l - L I l 1 T L J I J I I T 6 u u u E v E I U } J u E u u L r D J D u e l u p u t r r @ u

in terms. There are a Lot of ways to go about this. But for the presenttime and. for the foreseeabLe future this is the focal point which may bea.n ind.ictment on our health care system. It has broken dovnr and this isthe only place that d.elivers at the moment, in terms of a certain type ofneed. of people, and. the worried. weLI are aIL over the place and- maybe wehave oversold ourselves ever;place, but i t hasnrt been a i rnique experi-ence in the emergency care area.

CHAIR}4AN:

John, how about in a smaller community? How about this d.is-tinction between the worried. weII and those that are acutely emergent?

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,

of course, is not really r,rhat its nanre ind.icates. We see so marl1r non-emergent cases. Out of rea"l pract ical i ty, i f you would. conf ine your ac-tivities to life-end.angering problems the emergency d.epartment would. prob-

ably not be able to support a ful}- t lme group. So this is just being prac-

t ical . The non-emergencies pay the bi l ls. Now I agree with everything

- / r -

that was said., that this is not the best system. I think we need. to workon our health derivery system. The kind. of physician he was tarkingabout as far as a pri-mary physician you think of when you are thinkingof health maintenance organi-zat ions--this is another type ind. iv id.ual.And. perhaps this emergency physician and. primary physiciaJr car1 be oneand. the sa. lne, but I don' t real ly see i t that way. I think that there isa place for a person to be trained. str ict ly in the emergencies that would.present themselves to a busy emergency d.epartment. furd. I think there isa place for training the primary physician for health maintenance orsanl-za t ions .

C}IAIR}4AN:

Part of the hangup in the past has been the d.efinition of theso-cal led" traumatologist , the fel tow who takes care of the major emer-gency facl l i ty versus now the vast numbers of physicians who are takingcare of community medicine in an emergency d.epartment. Now we have toface this d.ilemma by training probably both of these or more than onecategory. Here is a quest ion.

ART LEADER, McMaster University:

r was wond.ering why does it have to be a physician and if, per-haps the panetist coutd. d.iscuss the qualities that they want in an ind.i-vidual who is staffing an emergency facility. I arn thinking particularlyabout the corpsmen or perhaps the nurse practitioner as an alternativeto the very expensive training of the physlcian.

DR. ]GOME:

r would. like to respond to that, and. would. rike to respond. tothis at the same time. I agree with what you said. and. with what my col-reagues said. in the panel, but what r think you are talJcing about isutopia. Continuity and c&T€--w€ d.on!t want our patients fragmentized..We want everybod.y to take care of the patient from the tjme he entersthe hearth care system to the t ime he reaves. f would. l ike 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 emergencyphysician 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 emergencyd.epartment. I see a very real role for the nurse pract i t ioner, i f youwiI I , any of the al l ied. health professionals, the new al l ied. health pro-fessionals, or whatever we want to caII them--to see the pat ient in i t ia l lyperhaps 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 eff ic ient ly, 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 ofn h r r s i r - i q n c

DR. IGRL MANEGOI,D, San Leandro, California

I am not a member of the University Association of EmergencyDirectors. f am JJ years ord. and. have d.one emergency ned.icine foy 5years--2 years part- t ime and- 4 years furr- t ime. r sort of seem r ike aplatrt, because I am a member of the AECCP, f am a mernber of Ron l{rome'scommittee on educat ion 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 ofAgna's course. I would just l ike to make a very blunt plea. f t is t imefor y:u gentlemen to get off your ass and. on your feet and. take care of6O miltion people that are coming to emergency d.epartments. In no way d.id.f ever ant ic ipate gett ing into this f ietd.. We now are gett ing commrmica-tions from med.ical students, from interns and resid.ents, who r^rant to joinus fulr-time. There aJe no stand.ards. There j-s no training. r had. tot rave l 3 r0OO mi les across the count ry to take J im D ineents course , wh ichwas the onry course avairable of its kind. rf you gentlemen who ared-irectors of universi ty d.epartments d.on' t d.o i t , who is?

CHAIRMAN:

That rs a good response. Le t rs jus t take a show o f har rd .s . Howmany emcrgency d.epartments have some type of ongoing postgrad.uate coursenow that cart train some physicians who want to come and. spend. some time.Raiseyour hand. How many? WelI, there are four or five available whichmeafl.s that the potential for doing this is great. r would. say that everyemergency department courd. do this, but the big problem we are rearlyfacing is how much taboratory space does an emergency d.epartment offerfor training paramedics, medicaL stud.ents, nurses a:rd. postgraduate phy-sicians? How maJty people can get into a room to see a f la i l chest?T ; - L ^ " I s n l r r e t h n t n e r i . i r . r r l a r n r n l . r l e m ? l l n r ^ r m o n r r n o n n - l o r< J L l L t t I r U W q U J O U D u r v s u r r a u ! i l u J v u r * r } , 4 v v ! v ! r . J a . n y O U

take and. br ing in successful ly to 1o that?

DR. DTNEEN:

The first year and. a half we took only four stud.ents at a timeand. only allowed trlo of them at any given time working d.own in rhe €rrr€r-gency room working as an extra load. Our physical plar: t is qui te stressedin terms of space although it has improved. in the last few months. fthink you put a f inger on rearism. There need. to be a rot of centersdoing this. We train only six at a t ime. We run the course three t imesa year because lre rely on volunteer labor and you can wear out the welcomemat 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 timeabout every six weeks and. then starting over. I would. be interested. ifwe talk about the med.ical students because they are also a part of thissame problem. They clog the wheels as much as anybod.y. .whether we areutilizing the community hospital. as part of our med.ical stud.ent emer-gency training course they go out to the type of a hospital that is setup 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. Sothat is another avenue.

COMMENT FROM T}M FLOOR:

I came here because of the fact that I was hoping that you asan association would. guid.e us in the establishment of the d.epartmentatstructure and faculty recognition that we can seIL not only to our ex€cu-t ive committees but also to the universi ty. I would. I ike to ask mernbersof the panel and I will ask it again in the workshop this afternoon. Itis qui te d. i f f icul t to establ ish al l of this. I see you have some problemshere. I t is di f f icul t in the establ ishment. The stand.ard.s wi l l have tobe set. I hope this assoeiat ion, and. i t is the only one I can think of,I am hoping it will give us guidance in how such an emergency d.epartmentcan be set up and what the academic qualifications should. be had. so thatit can be worked. into the curri-culum of the med.ical stud.ent.

CHAIRII{AN:

Tel l us some of your problems in sett ing that up.

DR. DINEEN:

You donrt want to hear them aLIl We have srrpport from aII ofthe d.epartments for this, and. it is need.ful. At the present time I amreaLly not certain which is the best way to go in terms of ei ther estab-Iishing a d.epartment of emergency care or a d.epartment of outpatient ser-vices. I feel at the present t ime I have some opt ions and we are workingtoward. a d.epartmental status of some type. It might be too narrow afield. to establish an emergency u:rit d.epartment in terms of thlnking ofcomprehensive care services.

DR. IGOME:

We have d.epartmental status at a hospital level, but not at thec n h n n l ' t a r r a r - z a # . T h e t a c k . w e h a v e t a k e n n r e s e n t ' l v ' i s i n t h e l t n e s o t i a -

I f r v u a v r ! w L I r q v u u w l u r l y r u D u r r u + y J p r r l u l l u r l v 6 v u l a -

t ionrtscore. That is to have the d.epartment of community med.ic ine atWayne make a division of community med.icine und.er whom we would. f\"rnction

^ f - ^ r ' ^ ' n l d a n n r i m a n l c - - f h e d e n q r f . m o n f . n f a m a r o a n n l r m a d i a i n p f . h aaD ur lE ur D s v s r o ! * - I 'w* . . . - * - -_L I IC, u l l c

d e n a r t m e n t o f f . q m i l w n r a . e f , i c e a . n c l n e r h a n s e v e n a s e n e r p i , e d e n n r t m e n t o f\ 4 r * } / v r q v v $ v l q f v r

arnbulatory care. We have talked. to the chairman of the d.epartment ofconrmunity med.icine and. he seems very receptive to this idea. We are pre-sent ly try ing to d.evise bhe mechanism of gett ing i t through. Gett ing i tthrough at a hospital level was not too d. i f f icul t at aLI.

CHAIRMAN:

I think one caution many of us have to entertain is that we canr r c v ' r r c q s i l r r h e r , n l n g e n t a n g l e d i n l - h a n v ^ ] ^ ' 1 a n ^ F i ' . e g i n n - i n g f a . m ' i l w O f a C t i C eu * p f r J v u v v r r f e r l b ! ( a u r l J / r

prograrns in our own university. Many of these are going through somed.ifficulties and. growing pains and. I hope this will not interfere withour ability to get emergency training und.erway because if we wait forsome of the fam:i ly pract ice problems to be solved., i t is going to be tooIa te .

DR. CIAISTINE E. HAYCOCK, Ner,r Jersey College of Medicine, Newark,

I wond.er if there are not two t;pes of emergency physicians thatwe have to train. One, who is in a large hospital center and. who may bein a departmental speclalty and the second man who is in the communityseeing everyone because certainly in my emergency d.epartment med.icalpeople are seen by med.ical people and surgical problems are seen by sur-geons and. there is not an overlap except in the triage area. When you

have the tr iage special ist t r laging through the d.epartmental area, andcertainly the fel low who is seeing the surgical pat ient doesnrt requi-reaLI the knonled.ge of EKGs and vice versa, and. yet the man who is in thesmall community hospital in our saJne area where I worked. for three years,then I had. to know everything because I was the only one there. Thereis a d. i f ference.

DR. ]GOME:

We have that kind. of setup at Receiving Hospital. However, thearea of t r iage, i f you wi l l , is so Large that we think that economical lyto use our surgical staff they should. not necessari ly see every ' rsurgicalrr

problem that comes in. That we like our emergency physician to see hj-minitially and perhaps he d.oesnrt belong in the emergency d.epartment ataII. Now, if this is a simple triage then the man with the hernia whohas some d.iscomfort would. be seen by the surgical resid.ent that night ifi-t nere a simple kind. of triage. If it is an emergency physician who canevaluate whether or not i t is incarcerated- or not incarcerated., etc. ,a ro l han na rhon< he ncn f aad n im OUt tO t he CL jn iCa I a1 .eas - - t o t he OUt -

patient d.epartments--get him out of the emergency d.epartment.

-75-

DR. }IAYCOCK:

what r arn gett ing at is the nurse tr iage--the tr iage is one ofthree areas--minor, med.ical or surgical--and. not one that is referred. outbut is seen by a physiciaf,i or intern or someone much higher than that,or perhaps your pract ic ing physician.

C}IAISMAN:

I think this d.oes emphasize that there are d.ifferences 1n thesize of the hospital as to what our training need.s are, which is probablythe story of med.ical t raining in general .

DR. HAROLD A PAUL, Chicago, Presbyterian St. Luke Hospital

In the problem that is going to be with us of interfacing emer-gency physicians with community physicians, or pr imary physicians, o:rwhatever you cal l him, wourd.n' t i t be ad.visable to try to get in al t ofthose 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.equateknowled.ge that is nor^r being proposed. by the kind.s of progra.rns that yousuggest so that this program in the f inal result may not, unless we d.onftsorve the other problem, turn up a neu speciarty which everyone admicswi l l not be id.eal.

PANELIST: ( l r . Dineen)

We have a j r- :nior intern elect ive in the emergency unit started.this past year for senior stud.ents. r t is very popular. we have notonly a general emergency unit experience but also the med.ical d.epartmenthas one for specif icat ly medical emergencies. They are quite possibteand. many of the stud.ents participate, obviously not going into a prima.ryemergency unit career.

CHAIRIvIAN:

This really should.think as part of their early- l

a t e r e l e n f . i r r a J - . i m o r | h i cI T T T D ,

school. This is something weown med.ical school.

be basi-c for all med.ical stud.ents a:rd. Icurriculum and. as a part of their probably

too, is our most popular elective j_n med.icafn o n A ^ r ^ , . , + ^ . i 6 ^ + - ! + r , + ^ + u : ^ . - .uir l l qo r lQW, rJo l- I lslJt-ruIe In1s yeal t-n our

DR. DONAr,D M. THOMAS, university of Louisville schoor of Med.icine,Lou isv i l le , Ky . :

I would like to know if any progress is being mad.e with thepowers that be towards establ ishing cr i ter ia in resid.ency review commit-tees. we are trying to start one at our place and. r have got guys who

-75-

want to enter i t , but unt i t we get someone here to approve i t f canrter ren ge t n s f , i nend. fo r i t .

C}IAIRMAN:

The American College of Emergency Physicians have estabLished.what in our opinion are guid.elines for the establishment of emergencyphysician resid.ency. fn ad.d.ition to that we have submitted. these guid.e-

Lines to the American Medical Associat ion appropriate committee. fthink i t is the counci l on educat ion, ui th the request that a resid.encyreview committee in emergency med.ic ine be establ ished.. This is st i l } incommittee. I t has been about two months since we submitted. this. Thisis the f i rst step. The establ ishment of a resid.ency review committeein emergency med.icine so that the particular prograrns d.o not have to faLIund.er the heading of some other part icular special ty, as i t uas in Dr.A o n n I c c r e o - i n o e n p r n l n r n c t i n o

PAIVELIST : (lr. Rgna)

I have had. several Letters in the past few months from the AlvlACounciL on Med.ical Ed.ucation--rather grumpy type letters remj-nd.ing methat I was a pi tot project and" that I was categorized as a general prac-t ice resid.ency. I think this is an ind. icat ion of the inquir ies they arereceiving about establ ishing the progra. ln.

CIIAIR]I4AN:

It is obvious that this is quite popular, but you know this isthe frost ing on the cake because we have 51000 physicians who are cal l ingthemselves emergency physicians who are Lookj-ng for training of d.ifferentnature now and I think we need to add.ress ourselves very much to thesephysicians. This is something that can be d.one j-n our hospitals pre-

sently and can even be d.one at a commuriity hospital level.

DR. STUAIT M. POTICHA, Northwestern University, Chicago, ILt.

One of the panel ists suggested a three-year residency prograf lfor training this type of physician. f wond.er if everyone on the panel

feels that that is the r ight amorxrt of t jme or isn' t i t a bi t long?Could. we get an opinion as to the amount of time that you think is ad.e-quate to train emergency room physicians ?

DR. W]GGENSTEIN:

I think that Dr. I{rome mad.e that statement and he based., Ithink, 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:

We went to a three-year resld.eney without an internship. Ifthere W'as an internship then there would. be two years. The group that

was with me in Florida where we di-scussed. this, actually we mad.e a list

of what we thought everybody should. know to d.o this and. make in our own

mind.s an approximation of how long it would. take to d.o it. lhe only way

to get all of that in and. to includ.e a broad scope a,mount to, I thlnk, a

llttle less than 16 months

C}IAIRII{AN:

There are obviously going to be d.ifferent problems in d.iffer-

ent hospitals as to how this should. be set up. I am going to call this

panel d.iscussion to a close because we wiII be able to contjnue this in

the workshop sessions. f want to thank the panelists for their participa-

t ion.

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

on

TMINING OF PHYS]CIANS IN THE EMTNGENCY DEPARTMENT

AIan B i r tch , M.D.Peter Bent Brigham, Boston, Massachusetts

SU}O4ARY

To summarize the concert of opinions expressed. in any one ofthe ten uorkshops, where lO to 20 people uith d-ivergent backgrounds and.n r e - i r r d . j e e s h a r r e ; ^ . i - ^ ^ + ^ , t ; t r a . i n . i n g n f n h . , d . i n . i o r a . i h + L ^ I l m e r o . e n n r ry r u d u q r u u D f l q v c < J U l r r s q U U q a D u U D - v 4 w + r - r r r o - , f , . . J b _ L U l d . t l , s l _ l l t J l l e

Department, is di f f icul t . To attempt to present an accurate consensus ofthese ten d.iverse summaries is both hazardous and in ma:ry ways red.und.ant.However, several common thread-s of posi t ive concern ran through the fab-r i -c of the ten workshop d.el iberat j -ons and i t wit t be these po: i .nts thatI shal l at tempt to underl ine.

The increasing need for improved acute health care d.eli-very i-:nthe Emergency Services of both the Universi ty and Community hospitals wasa n n a r c n t f . n e l I T ^ L - i - ^ - L ^ ' " + m e a n i n o f l l s h n r f . r n d l n n o r o r mq y y + e r r v u u e r - r . _ L U U I J _ t t B d , U O U U u ! o r r v r l _ m p f o v e -

ment in this area requires the recrui tment of qual i f ied. d.octo:, .s, t rainingthem adequatell/, and changing the image of the Bnergency Service into thatof a respected. and. progressive d. iv is ion of the hospital .

The solut ion to the ini t ia l requirement Lies in the st imutat iono f i n t e r e s t a f . a n e e r l r r s t : p e n f t r e ' i n i n c r i n i h e n a a d c q n d n r ^ 'u r J I I u c r s ) u , d , t J a r e q r r J p u e 6 v v - _ p e f C a J e

of the emergency si tuat ion. Present ly avai labLe courses in ad.vanced"f i rst-aid. (real ly pr imers in elementary emergency care) offered. in Med.icalSchools are met with a.n enthusiast ic response by the f i rst year med.icalclasses. This enthusiasm should. be carr ied forward by lnclusion of emer-gency medicj-ne as part of the t 'Corerrcurr iculum or as ueII planned e}ec-I i r r p c d t r r i n o l - h o e : r ' l \ r l r a r T c a f m e d i r . p l s r . h n n l e n d S h O U l d . b e f U f f n e ft . y J U q 4 ! a ! D v r r v v r t q

j n n r a n a n t . n h - ' - e s u l a r a n d / o r c f e c t " i v e a s s i p ' n m e n t o f S t u d . e n t S i n t h er u b u l a r @ r q / v J g l u v u r v u a D D + 6 t l t r r u J l

c l in ica l years to the Emergency Serv ices (e .S . ) . The i r exper ience in theE.S. as weLI as that of the yourg resid.ent staff should. be supervised. and.coordinated by a fulL-t lme f tnergency Service Dj-rector artd. his staff . I tis not surpr is ing that interest in the Emergency Room is not sustaineda . t n f e s e n t - s i n c e o e r e o i i r e n f ' h o r " e i c r e l a o e i . o d i n n o n r r i n c i i + " + ' i ^ - - + ^v ' . , 4 u b ! v L r r u r l u r e r D r 9 r s 6 a u s q , I f t l r a l J t f , l D U f u u u I ( J I f ) , u L ,

t h g v o u n s . e r r e s i A ^ a + ^ + ^ , . _ L + i . ^ f r o n r r p n t l r r h r r t h a r o o r r . l e r h n < n . i f r - 1 d + n f fu r r u J v w r 6 ! r r L D l q s l l U D , U d , L r 6 l t U f I I I a U g t l C I I U T J t J J t r l l L - - . 1 , l - S U a I l . ,

and supervised. rargely on a t t t rouble shoot ingrrbasis by a part- t ime Emer-g e n C V S e f V i C e D i T a o f ^ v r . ' h ^ - ^ n a i r y 1 e 7 1 7 r A q n n n c i h i l i t . , / . n / l n a o c j l r t .uur v rvu ur r su uur wt IUbc ! I ' I ! rvu J r uD j /v r rp rwr r l - Uy \ anq pOSSI-DIy p f J -mafy

i n te res t ) L ies in o ther a reas .

Ma:ry participants felt that the establishment of d.epartmentalstatus for the Emergency Services, with a ful t - t ime Director who had. theabl l i ty a-nd the authori ty to enlarge the teaching responsibiLi ty of thehospital staff inthe Emergency Room would. invest this area with previouslyIacking respectabitity and contribute much to the immed.iate a;1d. Long rangesolution of this probrem. rn ad.d"ition to improving teaching in our pre-sent system at the med.ical stud.ent and. resid.ency levels, d.epartmenta1status would. faci l i tatethe training of a potent ial new subspecial ist , theEmergency Physicia^n.

-o r -

-Bz-

General agreement was expressed (B of p workshops) tfrat a need.existed. for Bnergency Plrysicians and. that llniversity hospitals shoutd.accept responsibility for trai-ning in this area. No I'unani-mj-ty of opinionemerged. as to how to best train these individ.uats but several pertinentpoints w'ere mad.e. This new subspecialist must attain both training and.respectabi l i ty in the sett ing of a universi ty Residency program. r tmight, therefore, be ad.visabre to require one or two years of training ina 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 intensi f ied. t raining in the emergency as-pects of care. This type of prograrn seems more workable than to attemptto integrate the Bnergency Resid.ent, starting as a neophite, for 2 to Jyears into the acute aspects of many established. services where he admit-tedly would. have much to learn but littte to contribute and. would. Iiketybe regarded. as a trfifth wheel. " The short intensified. program would. havethe ad.ditional ad.vantage of allowing physicians, who d.esire to leave es-tablished. practices to obtaln training, to become Bnergency physicians.

REPORT OF WORKSHOP #I

Alan G. Bir tch, M. D., Peter Bent Brigham Hospital , Boston, Massachusetts

There was general agreement that a need. existed. for an adequatelytrained. Emergency Service Physician. This need. stems from the combinationof increasing Emergency Service pat ient load. of both emergency and. non-urgent type coupledL r^rith the unwillingness or inability of the CommunityHospital to staff thelr Emergency Services to meet this need. and. the in-creasing resistance, in the Universi ty sett ing, to hand.Ie this mushroomingpat ient load. by lengthening House Staff ts Emergency Service rotat icns fur-ther. Therefore, by default , i t would. seem better to have a mal withrecognized training i-n emergency care fiII this void. than contj-nue ourn r e s e n f n q L f . o r n n f n o t n h r ^ r a r F a a nt , r v u v u e y q u l L r r r u r l r e u u r l w L r r n u u u l p l O l l l J - S e C O V e f a g e .

There was no unanimity of opinion as to how the training of theEmergency Service Physician would. be best und.ertaken in the context ofotrr present d.epartmental structure. Most agreed. that where a Departmentof tr'amily Practice existed., that it would. be the most approprj-ate areafor this progran to or iginate. rn the sett lng of the Department ofFamily Practice, it was hoped. that the proper attitud.e of concern for thepatient would. be engend.ered which might encourage the Emergency ServicePhysician to organize folLow-up caffe, especiarry for the non-urgentn - t i ^ - . * ^! @ u a s r t u b .

I t was agreed. that the Emergency Service physician (p.S.p. )should. have responsibility for the initial evaluation and. care of thepat ient with consultat ion immed.iately avaitable to assume total care res-ponsibi l i t ies when admission or involved. out-pat ient proced.ures were in-d. icated. (examples of later: cast ing of f ractures, tend.on lacerat ions,e tc . ) . The ab i l i t ies , i -n te res t , and. exper t i se o f the ind . iv id .uar E .s .p .might al low except ions to this later point but the results obtained. mustalways be judged. against the stand.ard. of care available by other membersof the staff . fn the Community Hospital sett ing, the total responsibi l i tyfor emergency service care would. likely fall to this man. It was hoped.that in the Universi ty Hospital sett ing, his act iv i t ies could. be coor-dinated. 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 probablyneeded. to give training in sufficient d.epth to arlow the physician tohandle the ini t ia l care of emergencies in al l d. iscipl ines.

Three of the 12 mernbers present felt that their institutionwourd be wi l l ing, at the present t ime, to ini t iate a program of EmergencyPhysician Training once fuII guid.eLines were established..

-oJ-

o t ,

Discussion of the present status of ed.ucat ional out lay in ourEmergeney Ward.s revealed. that only 2 of our services fraa a futt-timed'irector who spent his working d.ay teaching and. supervising care withinthe Emergency ward., while one had. a part-time visit carrying on this func-tion. In the remaind.er of units the teaching by hospital staff was on aconsultant basis with most of the expert ise being passed. from Senior toJunior House Staff and. in turn to the med.ical stud.ents. Although thisratter system may work fairly well, it was unanimousty agreed. that it wasnot id.ear. fn the acad.emic sett ing, therefore, an E.s.p. of high car iberwould or courd. fufilr a major teaching role, if properry utirized..

nrponr or wonrsnop #e

TRA]NnIG OF T}IE EMERGXNCY ROOM PHYSICIAN

George Johnson, Jr. , M.D., l ln iversi ty of North Carol ina

The training of the emergencylooking at three overlapping areas: the

room physician was d. iscussed. bymedical stud.ent, the house off icer,

and. the emergency room physician.

The Med.ical Stud.ent:

a) Al though instruct ion in emergency med.ical servj-ces per seneed. not be a part of the core curricurum, viabre andexc i t ing e lec t i ves are necessary .

b) kinciples of card. iopulmonary resuscitat ion must be taughtal l stud.ents.

The House Off icer:

o ' l i / l n n m r r n - i l - - r t - , ^ ,aJ vururLrr.ruy ilospi-tars have a rot to offer the house officerin the emergency room si-nce they are generarry better super-vised. than unirrersi ty hospitals.

b ) Universi ty hospitals have a d. i f f icul t t imetend. ing coverage.

in gett ing at-

c) Emergency room physicians are good. in teaching techniquesand. pat ient relat ions.

d) Universi ty hospitals must st i l t teach basic biological pr in-ciples of t rauma and i l lness.

e) Emergency room aud.it important concept.

Emergency Room pliysicians :

a) In general , a good. concept--are here to stay.

b) Two-week crash training programs stop-gap measure--need.n c q i d o n n r r n - ,j,. ogrann.

c) Not sure about need. for three yea,rs, but no one has stud.ied..

-86-

d.) would. seem a person with in-d.epth training in emergencyroom services wourd. eventuat ly reprace ind. iv id.uar speciar-ists in the emergency room. This is true even in ed.uca-tionar centers and wou.rd. be und.er Division of communityMed ic ine .

nnponr or 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 roomphysicians should. be able to recognize ar l 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. train-ing progratns and. courses for physicians before being employed. in am emer-gency room, it was not felt that a new Board. or a new speciarty groupshould. be set up.

r t was fel t that exist ing organizat ions such as perhaps theAcaderly of General Practice could. ad.equatety hand.Le training and. certi-fication for physicians managing emergency d.epartments in most hospitals.

fn Large teaching hospitals or large urban hospitatsi t was fel tthat there was a need. for a d. i rector of emergency services with ad.equatecert i f icat ion in one of the major speciart ies in med.ic ine, surgery--butmore important with enough administrative and. professional authority toru:' a coorclinated. and. authorized. program of emergency services and. train-r r t6 .

Alr in the group fert that training in emergency room caJ.eshould' 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 in-volved' in the training of stud.ents, house staff and. the grad.uate physicianin emergency med.ical servi_ces.

Q n

REPORT 0F WORKSHOP #\

Gustave Adler, M.D., Metropol i tan Hospital Centre, New york

The d. iscussion covered several aspects of emergency med.icalcare, but concerned i tsel- fpr imari ly with physicia: i staf f ing. Basic tothis d. iscussion, was that general sol-ut ions for emergency d.epartments wered. i f f icul t to present because the need.s were d. i f ferent from community tocommunity and. from hospitar to hospital. some participants fert thatemergency departments should. have a Walk-In-Ctinic ro provid.e better carefor both groups of pabients-- the emergency pat ient and" the non-emergencypat ien t .

Physician staff ing was discussed.. I t was noted" that few phy-sicians choose emergency medicine as a career. Therefore, i t was thoughtthat medical stud.ents should. have more exposure to the emergency d.epart-ment through elect ive t ime in this area. Training prograf ls for physiciansshould. be estabrished. some part ic ipa:r ts fet t that famity physicianscould. f i r r this need, whi le others fert strongry that this is a specialf ie ld. requir ing speciar training and ski l l , md that the emergency d.e-partment physician needs to feel a higher status level than he has pre-viously real ized.. r t was arso strongly fel t that the med.icar schoorshourd. 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 wi l r ing to pay good. sarar ies i f they want good.physicians and thus, good emergency d.epartments. These physicians mustnot only be good physicians but also good. coord.inato::s and rnust assumesupervisory respons ibi l i t i es .

-Ro-

REPORT 0F WORKSHOP #'

Thomas J. Zi-rkLe, M.D., Loma Linda Universi ty, Loma Lind.a, Cal i fornia

Inter-reLat ionship of present Emergency Service l r i th the FamilyPract ice or Community Medicine resid.encies avaiLabLe at var ious centersand how this r^rould. conflict or complement the training of emergency roommedical personnel.

Only one member of our group had. an emergency room resid.ency att h p n r e e a n f . i . - i n p

In several places the emergency room is a d. iv is lon of the familyn r a r l ' i a o n a a i d a n n r r q n d - i n a h n r r f a n p n r r n ' l n r r m h a r n f n r n o r q m q t h e r e w a s, 4 r * v r y r vbr @uD, u f , r (

no relat ion between the emergency service and. the family pract ice unit .The suggest ion was mad.e that baccalaureate d.egree persons be trained. foremergency med.ical use. This was suggested. in l ight of the Large numberof persons \^rho have been exposed. to Nhis type of care in the mi l i taryservice. By and. Large the group fel t that this would. be an unvise plan.

The next major d. iscussion was the use of med.ical stud.ents inthe emergency room and. how this related- to emergency teaching. The useof med.ical students in the emergency room varied. wid.ety from one area toanother. Some larger ci ty hospitals have regular student rotat ions; how-p \ r A T L h o r e i c q l r o - A o h n - ? a h f l - n a i f h a r 1 6 c c 6 h + h a a + r l . l a n * n o r l ' '*! * ure'q apyar 'rru to ei ther lessen the stud.ent part ieipa-t ion in the emergency room, based largely on medical- Iegal t iabi l i typroblems.

The f inal port ion of the workshop d.ealth with the plans of thevarious med.ical centers represented. for emergency room resi-d.encies. 0fthe twelve med.ical centers represented. one has ar: . emergency room resid.encynow functioning. None of the other workshop members favored a"n emergencyroom resid.ency. TVo members suggested. that short courses in a Cont inuingMedical Ed.ucat ion sett ing, such as is carr ied. out in Boston, would. ben r . n c n t n h l e t n i h e ' i r r r n ' i r r e r s i t r rD r v J .

In summary it was the feeling of the workshop that there is nocuruent great need. for a full separate specialty in emergency room med.i-c ine and the universi t ies represented" had. no specif ic plans for movingin this d. i rect ion.

-ot -

REPORT 0F WORKSHOP #6

T}IE TBATNING OI' PHYSICIANS IN THE EMERGENCY DE?A.RTMENT

C h r i s f . i n p t r l { q r rv r ' u ! . . r " u / cock , M .D . , N .J . Co I Iege o f Med . i c i ne & Den t i s t r y , 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. bedeveloped as soon as possible to d.o this.

2. The Workshop felt that tlie Emergency Room should. have d.epartmentstatus with a ful l - t ime d. i rector uho spent part of his t ime with ad.-ministration a.nd. the rest of his time teaching. Und.er him should. betrained Emergency Room physicians supervi-sing and. trainlng resid.entsand. interns. About half of our group were surgeons and half intern-ists. The group strongty opposed having the Emergency Room as partof an ttAmbutatory caretr Department. They felt this woutd. tend. todowngrade the critical care aspects of the Emergency Room and. makeit more of a 24-hour thalk inn cl in ic.

A query of the present status of each of the workshop mernbersrevealed. 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 wasd.iscussed.. Here it was felt that the cornmunity need.s, securityr good.f inancial rewards, regurar hours, etc. would. ent ice a good. nrmber ofstud.ents into the f ie ld. i f such tralning were offered..

Stimulation of the students is being carried. out at thoseschools where the Emergency Room Department is part of the curriculum oris offered. as an elect ive. I t is a very popular one at the Universi ty of 'Nebraska.

The quest ion of manpower shortage to staff al l these posit ionsas they should. be was brought out.

Another problem is the d. ispari ty between faculty salar ies vs.the community group emergency room salary, which is much higher.

I t was fel t that the attract ion to an exci t l r ig new special tywas more important than salary.

The group cond.emned. the current practice of placing the Leastexperienced. man (t t ie intern) in this most d. i f f icul t area. I t is stronglyfel t 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-

REPORT oF woRKSHop #7

TIM TRAINING OF PHYSICIANS TN T}M E.MERGENCY DEPABTMEIVI

D. T. Frei-er, M. D., Universi ty 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 andresid.ents (alr special t ies); und (3) postgrad.uate emergency ed.ucat ion,includ. ing residency for t remergency physicians. ' r

No one disagreed. with the need. for beginning the orientation ofemergency med.ic ine in the freshman year. Three schools represented., of fertr'irst Aid. courses. OnIy one has a formal first two year curriculum setup for the subject of trauma and. acute injury. Most effort in this fietd.began vith the ltfi lfD program and. has continued.. AIL schools have a Looselyformed prograJn of minimal emergency room exposure d.uring the clinicalyeaJs consist ing of nights spent in the emergency room and. tutor iars.Some clerkships are offered. for some pract ical experience. Most of theact iv i t ies are quite popurar. The teaching in the cr inicat years israrely done by staff faculty. Little is offered. in the way of maniklnCPR pract ice.

The training of all interns and. specializing resid.ents wasemphasized.. The required. knowled.ge and. skill-s includ.ed. formal CpR train-ingr arrhythmia recognition, arl d.raina€e proced.ures (pleural, pericar-dial , blad.d.er, etc.) , hemorrhage control , ut i l izat ion of al l intravenousroutes, and. knowled.ge about overdosage and. poisoning. !.ormar programs

must be formed. to includ.e aII of these skitts. Haphazard. acquisition isunsatisfactory. If the intern is exclud.ed. from the emergency room, uhatspecial t ies wiI I Learn these ski I Is except surgery? The quest ion of whohas to teach brought a strong consensus of opinion that Emergency Depart-ments must be formed. with hospitat and. acad.em c status so these formalprograrns can be carried out. The d.epartment head. should. have this res-ponsibi l i ty. One half of the hospitals represented., have interns as theprimary physieian in the emergency room with resid.ent backup. Most agreed.the resident is very competent, but a strong feer ing was expressed. thatpermanent staff, 24 hours a d.ay, was the id.eal for experience, maturity,e n d f . c q n h ' i n o

The need for postgraduate training is obvious. Numerous pro-gralns exist for technicians and. med.ical help personnel but few if any forthe specif ic purpose of review of emergency med.ic ine for physicians. Manyother specialty prograns are given but few concern themselves with thatcr i t ical f i rst hour of care. This need. wi l l not be met unt i t EmergencyDepartments are established. and. recognized. acad.emically. It vas agreed.

-95-

-96-

that emergency resid.encies must be estabtished. and. guid.elines of the ACERPwere agreed- on as acceptable guid.eh-nes. The subcommittee on grad.uateed.ucation of our own organization has been charged. with the d.uty of con-sid'ering this problem and we await d.iscussion on their recommend.ations.

rn summarxl most of the 7 posed. questions were answered.. Arrphysiclans must be trained in emergency med.ic ine, not necessari ly beforeworking in the emergency room, but certainry before they act as primaryphysicia.ns. The skirrs were carefully outlined. as suggested. by the com-mittees of ACS, NRC, etc. There is a strong need. for Emergency Departmentphysicians and. especialry a need. for his recognit ion as a speciar ist .His part as a ttcommunity med.icinetr specialist d.epend.s on his location andthe size of the hospitat . AtI subspecial t ies must take part in the teach_ing und.er a coordinated. program. The training should. be carried. out atalr revels from freshman stud.ents on up. The emergency physician resi-d.encies shourd. be limited. to those d.epartments seei.ng at reast 3oroooemergencies annually as suggested. by ACERP. Nurses can be trained. toaugment the physician wherever possible without consid.eration of replacinghim.

ruponr or worucsuop #B

THE TRAINING OF PHYSICIANS IN TIA M,IERGENCY DEPABTMENT

Wi' . I iam R. OIsen, l ln iversi ty of l [ ichigar, Arrr Arbor, Michigal

There was genelal agreement that the need. for Emergency Roomphysicians is a manifesbat ion of a change in the system of d-el ivery ofhealth care services. Therefore, planning should. be d" irected. toward. theproject ion of what the health care system wiI I be rather than a.n attemptto f l t in to the ex is t ing sys tem.

The Emergency Room physlcians should. be prepared to rend"erd .e f in i t i ve cane fo r one v is i t p robrems (u .g . , con tus ions) , in i t ia r carefor minor problems reguir ing forrow up care (" .g. , place sutures but notremove them), resuscitat ive care only for acute ser ious problems (unt i- f+ i , r ^ ^ , ' 1 * - i r - + i - ^ ^ Lune a,cunrt,tl-ng pnyslcian or suJgeon arrives), zu:d triage servj-ce only fornon-acute probLems requir ing prolonged fol lou-up (mifd. congest ive heartfa i lu re , pept ic u lcer d isease, e tc . ) . Th is imp l ies tha t each sys temoffering Emergency Room type care should also be able to provid.e followup caJe convenient ly.

There l^Jas a majority but not unanimous opinion that the Emer-gency Room physician eventual ly should be a special ist in his own r ight,not a general pract ic ioner who has Limited. his f ie ld. of end.eavor.

Consid.er ing the urgency of the need. and. the logist ical problemsinvolved., the training of Emergency Rocm physicians should. be viewed. intwo phases .

Phase I - The need for Emergency Room physicians now:This can: be achieved" best by a combination of d.id.actic andn r a . c t i e a l n n s f . s r a d r e | l . e t . r a i n i n o n f n r e c t i n i n o n h 'yvv vb ! __ 5_ r - _ys t_c t_ans

now involved. in Emergency Room r^rork or planning to d_o so.These sessions should. be two to four weeks in d.uration atbusy Emergency Rooms in teaching hospitals. Most workshoppart ic ipants agreed. that i t would. be easier to teach aninternist or a general pract ic ioner the surgicaL ski l lsinvolved. in an Emergency Room practice than to teach a sur-geon med ica l sk i I I s .

Phase I I - The eventual need.: Best met by start ing now toform formal residency programs, preferably of two yeaxsd.uration.

a )

h l

-97-

REPAPT nI' TTTnPKSHflP #Qr l l r v r l r v r y rv r r r \p r tv4 7 l /

Ronald. L. Krome, M. D., Detroi t Receiving Hospital , Detroi t , Michigan

A general d.iscussion concerning the use of full-time EmergencyPhysicians was held. Although there Tdas no unanimity of opinion, manyf e ' l t t h a t t h e n r ; n a i n r d r ^ ] d f ^ F t h e c a n h r r q i n i q n s m . i o h f . h p i n f . h e S m a I I e fv r r v } / r r v r v r v r u r r u p u } / r r J p J v r 4 r D r u ! 6 r r u v v t r I t u r l r

corununity hospitals and,for those that have little or not house staff.Sotne d.iscussants d.id. feel that even in the larger hospitals there m:ightbe some benefit to having Emergency Physicians in ord.er to more efficientlyand. meaningfully train their house staff. ( "Does a surgical resid.ent orintern have to do aII the sutur ing"?)

The consensus of the Workshop r,ras that the med.ical schorl.s areobligated. to provid.e the trainlng for the Emergency Physician, but themethod and d.uration of such training was in some question. Most concernwas about the use of these trresidentsrrwhi le they rotate on the otherspecial t ies. Several d. iscussants were concerned. that they would. be usedin l ieu of surgical resid.ents, etc. The posit lon of the ACEP would appear,h"rt"""rJ" be that these resld.ents were to be used. to| tsupplementrrexisting house staff. Bnergency Physicians need. not know how to performsurgery, etc. , but to properly d. iagnose and. ini t iate treatment.

The d.iscussion then turned. to the training of students and. housestaff in the Emergency Department, and the Logistical difficulties inusing this Department as a teaching arena. The d.iscussants agreed. thatthe use by many d.ifferent d.isciplines of this area mad.e for great confu-sion and. d.ifficutty. The overcrowd.ing by patients further compound.s theproblem. I t has become obvious that the Director of the Emergency De-partment wiI I have to establ ish the pr ior i t ies of ed.ucat ion ( j4-, who cancome into the hnergency Department to be taught and. to teach?).

The Workshop agreed. that there has not been enough focus on thecontent of t raining for medical stud.ents, etc. We discussed. the varyingmethod.s of teaching med.ical stud.ents.

-99-

nnponr or, 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 trainingphysicians who have a speciar interest in emergency med.ic ine, but therewas a general consensus of opinion against a two or three year resid.encytraining progra-In. The progra.m as outlined. by the Arnericarr correge or.Emergency physicians is consid.ered. too na,rrow a speciarty in regard. totraining a'd. would. be a'arogous to training a pre-operative or a post-operative surgeon. An alternative approach would. be a six or twelve monthtraining prograln taken after the completion of a starrd.ard" resid.ency inany of a number of speciatt ies. The choi_ce of resld.ency programs mightinclud-e generar surgery, generar pract ice, famlry med.ic ine or internarmed'icine' Emphasis then wourd. be upon training an alr-around. physicianfirst, folrowed. by a short period. of ad.d.itionar training as an emergencyphysician. Another d.rawback to the furl resid"ency progra.rn i-n emergencymed'icine is the fact that a significalt percentage of ind.ivid.uals whocomplete this prograln may, in fact, become d. is i l tusioned. in the futurear: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 pro-gram for physicia.ns who have been in private practice for a number ofyears and now wish to special ize in emergency med.ic ine. I t is I .eLt thatthe 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. probabtysuffice. rdeatry, the programs wourd. be d.esigned" and. implemented. bythe emergency room d.irector in a setting where d.epartmental status had.been achieved-. However, it is recognized. that cond.itions in ind.iviclualhospitars wirr vary consid.erably and. require d.ifferent sorutions.

The remainder of the time was spent d.iscussing the need. forbetter training of interns, resid.ents and stud.ents in the emergency d"e-partment' rt was fert that much courd. be accomplished. now without ad.d.i-tional expense or ad.d.itional staff. The use of variou.Sp"" of aud.io-visual equipment was d.iscussed., although it was recognized. that thesewere simply methods of increasing the efficiency of the time spent inteaching' Although long-term planning for comtrrehensive training prograrnsut i l iz ing the best avai lable 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.is-cussion and- the workshop had. accomprished. at reast one goal-_arl of themembers fert they had. received. consid.erabre sti_mulus to improve thequality of training in their emergency d.epartments.

- l 0 l -

T}M EMERGENCY UNIT

Improving Financial Management

James T. HoweIIPrincipal

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 flow many ofthe major issues facing American med.icine tod.ay.

Primary med.i_cal care

Second.ar.y med.ical care

Tert iary med.ical care

The respect ive rores of the garnut of hearth professionarpersonnel

Who d.ecid.es what is an emergency? The pat ient or the physician?

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

Payrnent for non-hospital med.ical care

Med.ical legal problems

Can the medical team concept real ly 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. tobe asked. to talk on this subject. Having the meeting in Ann Arbor is aspecial d.ivid.ent for me since Michigan is home to me and my family. Then,I arn very d.el ighted. to d. iscuss emergency unit issues with this d. ist in-c ' . - i ^ L ' ^ ' ]E u J D r r E U 6 l U ( , L } J .

To d. iscuss emergeney units, med.ical caJe, and f inancing i t wiI Ibe importa::t to our communication if I d.efine some terms. I characterizean emergency unit as fol lows:

For the d.iagnosis and. treatment of trauma and surgical emer-g e n c l e s .

For the d.iagnosis and. treatment of med.ical emergenci-es includ.ingped.iatrics and. psychiatry.

The pubric, however, ut i r izes the emergency unit for a generalmed.ical c l in ic. In some instances thevisi ts are emergenciesbecause the patients are frightened. and that d.efinition

-r05 -

- I U O -

suj-ts me. In other j-nstan.ces the patients arive at theemergency unit because of convenience, accessibi l i ty andavai labi l i ty.

To get a bi t c loser to the d. iscussion of the f inances of anemergency unit , I am making a ser ies of assumptions most of which f feeln r r j { - a n a v * a 4 n . . ' i - 1 T f i r d r r n r r i - . o r c e m e n f .Y u r u s U E I U O ] I I W I I I r l l l q J U U f l l d , b r v v r r l u r r u .

The emergency unit T,{e are both thinking about is part of amed.ical center.

The emersencu r r n . . i I j c r ao l l r r n r . r na6 f and . COn t fOL led h r r n hnsn i t e . l .+ v k r r J v ! ! v e u J q r r v D l r u s ! ,

but i t d-epend.s upon i ts relat ionship with i ts medical staffto d.el iver med.ical care.

There are no ur i t ten object ives concerning the programs and.services uhich the hospital and. physicians intend. to carryout .

Because of the nature of this associat ion, f am assuming thatthe quality of' care is excellent and. r.rnder your control and.that pat ients are sat isf ied..

I am assuming also that the med.ical staff of the emergencyunit , again because of the nature of your associat ion, isfof the most pa;.t in the full-time med.ical mana€ement ofpat ients in the emergency u-ni t .

tr' inally, I am assuming that both the med.ical staff and thead.ministration of the hospital have raised. the problem off inancial solvency of the emergency funct ion. I place thead.ministrator jn this posi t ion because the faci l i t ies,equipment, md overhead are his responsibi l i ty. Both themed.ical staff and ad.ministration share the responsibilityfor the medical prograJns arrd. servlces for the community.

The charge which we have before us, then, is to improve thef inancial status of the emergency unit . Further, thesolut ion should con-sid.er the sat isfact ions of both the medicaL staff and. hospital adminis-trat ion, as weII as cont inue the pat ient sat isfact ion. Based upon ourdefinition of the emergency prograins and services and. the assumptionswhich we ci ted, our approach wiI I be to set out al l the costs for d.e-Livering care and all the revenues for having given it. While we havesomeone gathering these data, there ale many other things we should. krrow.

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

-r07-

what are the mixes of patients, that is: trauma, med.icar and.surgical emergencies and. generar med.icar ca,re. (tn ttris tam rooking for the physicianrs d.eflnition of emergencymed.ical care. )

where d.o the patients rive and. d.o they have responsible physi-cians ?

What med.ical resources exi-st in the areas where the patientsI ive? (physiciar is, hospitals, emergency units, neighbor-hood. 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 and col_Iect ing? (How effect ive are these systems?)

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 in-cluding the number, compensation and. the shift which eachperson works ?

what is the rore of each person on the emergency care team fromthe 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 expenseand. lncome of the emergency unit relating one to the other. In the analy-sis we should expect to lsorate the camse(s) of rxrfavorabre cost-revenued'ifferences. Generally we can expect these to fatl j.nto external a.nd. in-ternal problems.

Potential external problems :

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

The patient group may not have third. party covera€e or the typeof coverage necessaffy for the manner in which they are usingthe emergency servj_ces.

?

1 n o

The patient group may be a ghetto popuration who canrt afford.med.ical care and. there is no neighborhood. crinic yet es-tab l i shed.

It would' be very significant if the analysis of the patient load.. revealed. an emphasis on general med.ical care of & Rofi- erh€r-

gency nature. An emergency r-mit is a very expensive way todel iver general med.ical care.

So often there j-s no agreement arnong institutions in a geograph-icar area which usuarly resurts in high costs for arr .

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

t ion should. be sought.

Potential Internal problems :

f f no object ives concerning the programs and. servj-ces whichwiI I be offered., we can ant ic ipate prol i ferat ion of ser-vices without guid.arrce. We can expect that we may d.upticateservices of othermed.ical resources. These elements of plan-ning failure may become quite expensive with little chanceof recovery of cost. By the same token a€reement should. bereached- about what emergency progra.tns and. services are notgoing to be operated.. In both instances med.ical and. ad-ry1 ip i c1- . r r1 - . i r ra nn- r i n i . sg shou ld . be es tab l i shed. and. en forced. .

If no penetrating administrative and. med.ical cost analysis sys-' tem has been estabrished., then we can hard.ry expect eharges

and. fees to re f lec t cos t .

After knowlng accuratery the costs of seeing a patient in theemergency unit, we must then stud.y the proced.ures by whichcharges and. fees are set and caruied. out includ.ing finan-ciar screening, bi t r ing, charging, colr-ect ing cash and.charges.

rn the absence of a stud.y of the dairy patient road., a seriesof problems may emerge.

rs the staffing pattern matched. to the low road. period. asrlrell as the peak load?

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 emergencyunit part icular ly because of the d.upl icat ion of supervisorystaff 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 bed. i f f icul t to charge the fees necessary to cover cost.

It is for this reason that triage becomes important 1n the d.ailyoperatj-on of the emergency turit. Those patients who can beseen in the outpatient department should. be d.irected. therewith arr appointment as soon as possible.

If the emergency unit were staffed. and. operated. as a true emer-gency unit , i t would. be less d. i f f icul t to recover costssince most third. party plans do cover these medical prob-lems and in ad.dition, maJry of them d.o become hospitalized.which further assures third party coverage.

I t is more important that the business representat ive in theemergency unit becomes a scholar of aI I t i r i rd. party sys-tems on both the hospitat and. the physicia.n sid.e. FuIIad.vantage must be taken of aII allowances provid.ed. in thesesys tems.

In the deflnitlons and. assumptions that were mad.e earlier the emergencyunit was designated. as belonging to the hospital . This is important tothe d.iscusslons of the role of clinical laboratories and. X-ray equipmentin the emergency unit . CLearIy the cost of operat ing the emergency uni- twill 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, i t wourd. beIess costly than also provid.ing d.uplicates in the emergency r-rnit. Natu-ral ly this requires that such services are read. i ly accessible for emer-gency pat ients.

The cost analysis about which we have been talking has related.to aII med.ical v is i ts in the emergency unit . The analysis could. be carr ied.further to show the costs of specif ic cases such as fractures or coronariesor strokes, but probably the mcst important cost d. ist inct ions are betweenthe emergencies and. the general medical v is i ts. General ly the costs ofthe emergencies are covered by the third. party plans and. the general vis-i t s a re no t .

Q t r m m o v r rv w r s [ | 4 _ y

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

- t to-

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

The med.ical resources of the geographic area shoutd. befied. and. coord.inated..

A penetrating cost study matching expenses and. income should.h o n e r f n r m e d f n r | ' h e p m e r O p n ^ . - ' . - ; + " - i ^ i + ^v v y v r r v r l l l E q _ _ _ - - - , _ - _ _ _ o _ - _ u J u M v t D t u D .

Staffing of all professional levels should. be carefully matched.to the pat ient hourly load. Ievels.

Increased. partlcipation should. be sought from paraprofessj_onalpersonneL.

Major problems can be ant ic ipated. in the emergency vis i ts r ih ichara r lanare l med. iCa l in na tUfo f l "enono l ' l r r +he fe la ted . COSI

for these visi ts is higkr in regard. to the other emergencyvisi ts and. seld.om are general v is i"bs covered by third. partysystems in the degree as true emergency vis i ts.

I t would be wise to tr iage the general v is i ts with parapro-fessional people and arrange for these pat ients to be seenand. cared. for in a much less expensive facility such as ageneral QPD cl inic. This would. also d.ecrease the personnelin the emergency unit , thus, d.ecreasing cost.

In increasing income, a knowledgeable ad.ministrative employeeshould be placed in the emergency tmit to ca.rry out d.e-tai led. f inanciaL screening, pr ic ing, appl icat ions of ap-propriate charges and. fees, bi l l ing and col lect ion proce-dures .

The emergency unit special ist should. seek the best sched.ulewhich uses hj-s expertise on the true major emergency prob-Iems. It is most Likely that third. party systems wiIIcover his services. Again, he should. make the best usepossible of paraprofessional personnel. In d.oing this, theobject is to make greatest use of the physicia,nrs t ime and.creat ing a volume service.

The fee pol icy within the emergency unit is to cover the costa f n c r f n r m - i n r r f . h c c p y r r i n er v r 4 r 4 r r b v r v u .

Finally, the emergency rmit is not completely boi-lnd. by the hos-- pital 's reimbursement formula, thus provid.ing ad.d.it ional in-

cent ives for looking to cost red.uct ion.

]S YOUR EMERGENCY DEPA3TMENT SOLVENT?

A ST{.IDY IN COMMUIV]TY I\MDICA], ECONOI\trCS

Janes R. MacKenz ie , M.D.

Is your Xmergency Department solvent ? The question is especiallypert inent at the present t ime when the total costs of pat ient care in theEmergency Department can be recovered. by both the hospital and the phy-sician through third. party payrnents. However, the costs can only be re-covered. if the hospital and. the physiciar: are able to id.entify the appro-priate costs and bitl the ind.ividual or the agency involved..

This talk wi l l d.escr ibe: the method.s used. by my hospital toid.entify the costs of Emergency Department care; and. those used. by theOntar io Hospital Services Commission, ( the government run prepaid. healthi : rsurance agency), to reimburse the costs to the hospita! the totat costto the community of seeking convenience care in a hospital emergency d.e-partment versus seeking i t in a d.octorrs off ice; at ld the inf luence totalhealth care costs have had. on the d.evelopment of emergency medical carefaci l i t ies within the community.

Our hospital onl .y id.ent i f ies the direct costs for Emergency De-partment pat ient care, i .e. , the cost for salar ies, med.ical and. adminis-trative supplles and. repairs for equipment. The indirect costs which in-clud.e capltal depreciation for equipment and space; and for heat, Light,telephone, md cleaning, are not cost accounted. against the Emergency De-partment budget, but rather against the hospitat capitar bud.get or ser-vice d.epartment invol-ved.. The sum totals of the hospital costs are thenpresented. without specific frnergency Department id.entification to theOntar io Hospital Services Commission for payment. Thus, the actual costsfor Emergency Department care in our hospital were not read.ily availablefor analysis until they uere separated. from the capital fr.:nd., and. theaccounts of the service d"epartments involved..

In L97O the total costs were $390,872 ana were d.er ived. in thefollowing manner:

f ) D i rec t cos ts . . 3321162

2) Ind . i rec t cos ts . )o ,4yn

3 ) T o t a l c o s t s . . 3 9 O , 8 r 2

Since the number of patients admitted. to the Emergency Department in I!/Owas J)1206, the average hospitar cost per emergency d.epartment visit inl l fO was $10.00

Casualty offi-cers and. physicians staff our Emergency Deparrmenron a rotational basis for L5 hours per d.ay, while other physicians, suchas general pract i t ioners and- special ists, also see their own pat ients inthe Emergency Department. In ad.d.ition, interns and. resid.ents staff our

- ' t I ? -

-rr4-

Emergency Department 24 hours per d.ay. The staff physicians and. casualtyoff icers charge a fee for service for nnJ: i eni a;and interns do not. rt was ;r;;:t:;: ffi:::l.i3'i::liHrii: ;;:t*ill:"n n l - l a n f a d A r " r . i n , o ^ - - n , - - - - - - - -Lurrevus\.r. \rr.rr-Lug the year rplo for Emergency Department plrysiciansr ser-vices. I therefore, aud. i ted. the charts of pat ients seen in the f tnersencvDepartment d.uring a two week perio,L in tr'ebruary, and. assigned. a ciraqgeagainst each chart for physician services in accord.ance with the lplO feesched.ule of the Ontar io Med.ical Associat ion. I f aI I of the services andproced.ures had. been charged. for d.uring the period. und.er investigation,the average physician charge per Emergency Department visit would. havebeen B./) . ! [ is average fee crosery a€rees with physician charges inother North American Emergency Departments. The Lowest fee would. haveUeen $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 atleast 60/, ot our yearly Ernergency Department visits. The highest chargewould have been $r8o.OO for the resuscitat lon, d. iagnosis and. ini t iar t reat-ment of a multiply injured. patient. On the other hand., this type of pa_tient and. others who need. card.io-pulmonary resuscitatlon, constitute lessthan J/s of our Emergency Department population.

fnterns and. resid.ents t salaries must also be ad.d.ed. to the costof physician 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 pat ient gets one laboratory test per vis i t ,whlch costs $6.0o. Thus, the average cost for pat ient care in our Emer-gency Department can now be cornputed.:

L. Hospital costs for services rend.ered.

a. Direct costs 332, j62

b. Ind . i rec t eos ts . 58,2gO

2. Physicians charges per patient

a. Servj_ce physicians. . . . $g .f>

b. In terns and. res idents. $O.gO

3. Laboratory costs per visit $5.00

4. Total average cost per Emergency Department visit VG.65

I

d{'t.l

)I. 1

fr1i

r,l;:i

. l

, l

)lI

i

),

,

- t t 5 -

Does this mean that the cost for treating the non-urgent or minor emer_gency in our Emergency Department is $26.65 per vis i t? certainly not.r have arready pointed. out that physician charges vary from $:.oo for 6o/oof this type of our Emergency Department popuration, to $r8o.oo tor 5% ofthem' simirarty, the costs for raboratory services vary between o for25%t and $:-3o.oo for L/o of the Eniergency Department visits. rt must arsobe assumed that the Emergency Department d.irect and. ind.irect costs whichaverage $:-r-$:-a per patient per hour wourd. be ress for the patient beingtreated for I ! minutes ($s.oo) t t ran the one being treated. in the Emer_gency Department for 2 hours ($eL.oo). Therefore, i t might be assumed.that the cost for treating the non-urgent or minor emergency in our Emer-sencv Department wourd not be $26.6j , but $8.!o (prus r ;bor; t ; ;y charges).r f the cost of interns and. resid.ents were d.ed.ucted. from this cost, theaverage charge for the non_urgent patient would. Ue $B.OO. In comparison,the average cost to vis i t one of our most respected. generar pract i t ionersin his off ice is arso $B.oo. (muoratory charges have been reft out ofthis comparison on the assumption that the cost wourd. be the sa.me whetherthe pat ient v is i ted. theEmergency Department or the d.octor,s off ice).

The preced.ing cost anarysis of our Emergency Department whichmay not be absorutely correct, was nevertheress a revelat ion to me. r tis now possible to specurate that there may be an economic reason r.or non-urgent and minor emergency patients to frock to our Emergency Departmentin ever-i'ncreasing numbers. rf so, this reason may be a more powerfurstimurus to increased. Emergency Department utirization by this group, thanthose usualry referred. to, such as rack of physicians, t ransient popula_t ion, etc ' For instance, i t is certainly more economical for the workingportion of the popuration to seek ca.re in our frnergency Departmenr attheir convenience, than i t is to seek i t in a d.octorrs off ice at the con-venience of the d.octor. Let me elaborate.

rn Hamirton the average worker changes shif ts at J or L o,crockin the afternoonr e.g., dur ing the t ime most d.octors have their of f icehours' I f they wish to see a d.octor, they must take two to four hoursoff work at one end of the shi f t or the other. This amounts to a loss ofJ fo Lo/ ' of the total work weekr md represents a f inancial Loss to theworker or his compairy. The loss amounts bo $5.00 perhour in the averageHamirton industry, or $r5.oo for J hours he i-s off work. Thus, the totarcost of health care to the person who misses work or to the cornmunity isno t $B.OO but ra ther $8 .00 prus $ t_5 .00 or a to ta t o f $23.00 . f f on theother hand., he d.oes not mlss work, the totar cost to the community formedical care is onry $B.oo. No wond.er the pat ients with rurny noses a'eflocking to the d.oors of our Emergency Department.

The d'octor and the hospital ad.miaistrator have aid.ed. and" abetted.this trend., for str ict ly sel f ish reasons. The hospital which has an Emer_gency Department nlrst provid'e expensi-ve space and. equipment an4 in-hospitalback-up faci t i t ies, staff them with highry ski tred. 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 themajority of the time when Life-threatening of major emergencJ-es are notpresent in the Emergency Department. The non-urgent patient then becomesto the Emergency Department what the Loss leader is to the supermarket,i .e. , a method. of contr ibut ing to the overhead. and" thus cutt ing the unitcost care of the true emergency. The wi l l ingness of the hospital toaccept the non-urgent pat ient has been a grand. solut ion for the d.octor,because he now has an alternative mechanism to provid.e for his patientcare d.uring the unattractive hours of the night and. the weekend..

Is this solution, even though it is based upon sound. economicprinciples the best one avai lable to the average m4jor hospital BnergencyDepartment or to the community as a whole? I think not. Gradually,over the past several years, the non-urgent pat ient load has surpassed.the capacity of many Bnergency Departments to cope with i t . As a result ,an increasing number of d.octors who are ill trained. in true emergency careand an equal number of u-nskilled. nurses are being mobilized. to care foral l of the pat ients in the Emergency Department. This solut ion is econo-mical ly sound. to the hospital because their l imited. t raining wi l l copewith BO Lo 90% of the load.. It may, on the other hand., be a d.isastroussolut ion for the person who need.s expert care. Converselyr mmy of theEmergency Departments are training, and therefore having to pay for per-s o n n e l - w h o a r e e x n e r t s i n a . l ' l a s n e e t s o f e m e r B ' e n c v e e r c - W h i ] e t h i s i sp v r $ r 9 ! ,

med.ically sound it d.efeats the economical ad.vantage of caring for the non-urgent pat ient. (75% of the Emergency Department costs are related" tosalar ies and. wages. )

What are the alternatives to this d.ilemma? I would. like topresent only one tonight, although there are many others that are worth-whi le. The most obvious one is to concentrate the true emergencies of theirnmed^iate and. regional communities, med.ical or surgical, into one re-^ ^ . i , . . i - d r . ^ ^ - - . i + ^ 1 w h . i e h i s g e a r e d f n n l r r r a a m a r o a n e 1 ; e a 1 a e - T h e S t a f fv g l V J I I 6 I I U D } / I U A ! w r r r u r r r o 6 u a r v q r u l u r u u e r t l e r 6 v ! v J v 4 u . r r r u p '

would. be trained. and. facilities availabel to d.eal with the emergencyd.iagnosis of disease or injury, card.iopulmonary resuscitation and. d"efini-tive initial care and. d.isposal of the emergency patient while the highd.ensity of major and life-threatening emergencies would. allow a moreeconomical util ization of stafflng patterns and. facilities. The minoremergencies and. non-urgent cases would. be cared. for in convenience clin-ics, where the med.ical and paramed.ical staff were not as highly skilled.

and. therefore less costly than those in the true ftnergency Department.I bel ieve that the solut ion would. accomplish two object ives. First , i twould. cut the total cost of med-ical care to the community for both thetrue 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.evelopski l ls related. to the pat ients ' need.s. This has obvious ad.vantages forresid.ency and. continuing med.ical and paramed.ical ed.ucation.

I-l

-LL7-

rn summary, a method. for cost analysing emergency d.epartmentsin Grtario has been presented.. Attention was d.irected. to the fact thatthe utilization of the Emergency Department for non-urgent care may beeconomically sound. for both the hospital and. the community, but possiblymed.ically unsound. for the patient uith major or life-threatening injuries.An alternative aJrrangement for the care of the emergency and. non-urgentpatient has been posed. which is both med.ically and economically soundfor the community.

tr' inally, I would like to pose the question again to you, ttisyour Emergency Department sorvent?" or should. r have started. with thequesti-on, rri.s your community emergency med.ical service solvent, and. if iti-s, d.oes the solvent state imply safe treatment for your true emergencyn n f . ' i a n f c ? l tf w v 4 v r 4 v p a

HOW CAN YOU MAI{E YOURE}trRGENCY DtrPASTI/ENT SOLVENT

AIan R. D lmick , M.D.T I n i v e r s i t v o f A l a b a m a

HOI,I CAI\T YOU MAICE YOIIR EMERGENCY DEPABTMHIT SOIVEIVI

DR. DIMICK:

Apparently we are rxrique for a University Hospital. Here arethe financiat figures for the fiscal year L959-7O for our UniversityHospital:

Universlty of Ataba.ma Hospitals and. ClinicsDetail of Bnergency Department CostsFiscal Y"ur

Amount

Direct Expenses per FinancialSalariesFringe BenefitsSuppliesDrugsrr la 1 anh nn ar v !v}rrrv. .v

RepairsGeneral Expense

Cred.it to EmergencyHospitalrs SuppliesAd.justment

L e s s :

Adjusted. Direct Expenses

Add: Emergency Dept 's. pro rata share of

overhead. from General Service Depts.

Build.ing DepreciationEquipment DePreciationAdministrati-on, and. GeneralReception, Mail artd. ElevatorsPrint ShopRrrchasing, Receiving and. SuPPIYCommunicationsLinen ServiceHousekeePingPlant 0perations, MaintenanceSecurityPharmacYOxygen TheraPYMed.ical Record.sHouse Staff

Statement:

Dept. forInventory

$298r.t4L9852

' t 1()qo?' L / / / J

2 h < h <- V J V J

2679a a n l .1>v+

N A A

M

LOO29

aB3B:-3896190

9948L985

2722827\ao394L9!o13

r4064237532\5

LL66B7

g\697\7

( t5r4

$458073

292L32

- l a - )

Totat Emergeney Dept. Costs-Fy L969/TO

Total Emergency Dept. Revenue W L969/70

QUESTION:

$z:53r.3

How much of the revenue d.o you collect?

Mrss oLAIRE UI\DERWOOD, ASSISTATIT ADMTNISTRATOR, UNWERSTTY HoSPTTA.L:

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 EmergencyT ) a n q r i m e n t

MISS U]\DERWOOD:

One point I think you ought to know is this d.oes not incl-ud.e

Iaboratory and x-ra,X charges. Revenues generated. from each hospital are

based. on the d.ifferent criteria and we cost ourselves by laboratory and

x-ray costs. As far as average (per d.iem) costs a^re concerned- the ex-

pense of these services, as weII as the revenue, go to the Laboratory and.

Rad.iology Departments. That is why it is so difficult to come up with

the sarne figures from hospitral to hospital in cost accounting.

QUESTION:

Isn't this actually fund.ed- by the Energency Department?

MISS UNDERWOOD:

No. In add.ition, we have solutions and central supplied. as

well, and. we also charge for our d.rugs. Laboratory and x-Toff costs and-

charges are in other dePartments.

-12 " -

DR. IIAYCOCK:

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

DR. DTMTCK:

But that revenue goes into the Ra.d.iology and. Laboratory De-nn r " tman # cf w . v . g e r 1 v u .

DR. HAYCOCK:

But that should. be cred.ited. toabout the charges for your patients seenadmitted. to the hospitat?

DR. D]IIICK:

the ftnergency Department. Whatin the ftnergency Department and.

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

M]SS UNDERWOOD:

You get into d.ifferent method.s of payment. BLue cross paystotar charges for Emergency Department care and. we receive money fromthe county for the indigent Load. on a per d.iem basis.

CLOSING REMARKS

Michael J. Madd.enAss is tan t D i rec to r

I T n i r r e r s i t r r H o s n i t a lA n n A v h n a l f i n l - r i rfultt f!r'uur. , wtr urrr$aJl

Given the very ad.equate presentation presented. by Dr. Howelland. Dr. MacKenzie, I will keep r4y remarks very short and just try to em-phasize some of the points made by these gentlement. As you are probablyaware from your vis i t to our emergency service today, the accessibi l i tyto our emergency ur:it is not exactly true in our case, since our emer-gency room j-s on the 4th level of the Outpatient Build.ing.

When we start tatking about the cost in the emergency room wehave to think also about comparability of costs. T worked. with the Uni-versi ty Hospital Execut ive Counci l special committee on ambulatory costsfor the Last six months a.nd. this group has had. a great d.eal of d.ifficultyin cost j -ng arnbulatory services because each of the inst i tut ions uses ad.ifferent format and. different criteria for the costing of their serviceslthus, their costs are not compa,:rable. We need" not apologize for thisfaet,, but must make great efforts to try to get costs that are acceptablefor each of the inst i tut ions operat ing ambulatory care services.

A point raised. by Dr. Howell shoul"d. be emphasized. and. that isthat revenue versus costs are important. More important is that incomeversus cost. fncome being d.ifferent from revenue in that revenue is thecha. rses made in f .ha emoroonnr r -^Om a.nd . tha t inCOme iS the CaSh feCe iVed.o v ' r v J

f rom those transact ions. This can be a great ly d. i f ferent f igure, giventhe collection problems which are common to many emergency services.

Dr. MacKenzie mad.e an assumption in his presentation that ifyou give good services to a pat ient in the emergency service that yourlould. receive payment for those services rend.ered.. This may be true inthe Canadian health systern and I arn sure is, but in the U.S. healthsystem, the one who is more likely to pay is the traumatic emergency,who is covered. under BIue Cross-Blue Shield. or other insurances. Thenon-eftergent walk-in patient d.oes not often have insurance covera€e. Soour ability to have an economically sowrd. system rests not only on just

the charges rend.ered., but on our abit i ty to col lect cash for those charges.

We havE noted in many of the speeches that there has been abreakd.own in the d.elivery system. Here in Arue Arbor there has been thedevelopment of the F?ee Peoples Clinic of Ann Arbor, Incorporated., whichis d.esigned to service both street people and. stud.ents in the Ann Arbor,Miehisnr, A:r IA.- Resid.ents and. staff men lrom the Tlniversi tv of Mich' i B'a.nprovide the physician staffing for this clinic at no-pay and. patientsreceive free care at this clinic. We have an arrangement where patients

are referred. to our arnbulatory setting or our emergency service for careafter being seen at the Free Peoples Cl inic, but i f th is happens, thepat ient himself is bi l led. for the services received" at the U. of M.

One thing should. be said. regarding the emergency services--i h c f t h a . r a r a n q r f n f o - l u r c ^ T ; n S t i t U t i O n

a n d . t h a t a l a r g e r i n s t i t U t i O ns r q r b v 4

-r2B-

has to d.evelop policies whlch relate to what type of patients a.re seenand' served. and what the changes are, who staffs the Energeney Room and.other considerations. With this consideration there should be a policyregard. ng whether or not the emergency service has to be sorvent. rfit has to be sorvent we can do things to reetify that. rf it can becamied. at a ross because of a^n jnstitutionar poricy, that is arso pos-s ib le .

-120.-

DR. FROM SAI\] FRANCISCO:

We have large numbers of walk-in patients. This interfereswith the acutely i l l pat ients. This is true, but we need. to care forthe walk- in pat ients in the emergency faci l i t ies ofthe hospital . I tj-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 Hopkinsexamining this situation, when analyzed. they found that 87 percent ofthese patients received. no care. And. a certain nurnber of patients re-ceived bad. care.

CIIAIR]vIAI{:

I certainly a€ree with you.

DR. II{ACIGI{ZIE:

I donrt think it is a question of for or against. When youget the follow-up care i-n marrJr cases where they have looked. at such thingsas the routi-ne hemoglobin, you d.on't get any better level of care. Itis not right that the emergency d.epartment should. provid.e all levels of

CHAIRII'iAN:

One question f would. like to ask Dr. HoweII. What column d.o

we put interns and. resid.entsr salar ies in?

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 irrespectiveof whether the hospital pays for the interns and resid.ents salaries orwhether the med.ical school d.oes i t . The services are rendered. by theinterns and resid.ents for the time they are in the emellgency room.

DR. WILLIA]VISON OF CLEVEI,AIID:

The patient who comes in who is not sick--that bothers me.

There is the breakd.ovn. The rise i-n med.ical costs has put us in thisposition. I would. suggest that the best thing we could. d.o is to set upnight cl in ics and. staff them with house off icers.

DR. PLATT OF DENVER:

We find. that non-emergency patients in the emergency room keepsus from caring for the real emergency patients. We dontt like triaging

1 ^ n- J "

them out. We caII i t screening the people out.te rns use is the I ' sc reen ing c l in ic . r l

DR. HO}i-ELI,:

The term that our in-

Obviously to triage them out is not the answer. There has got

I see is triaging them out with open appointments in an outpatient cllnic.

DR. WAGNER OF P}tr],ADELPIIIA:

to be somewhere for them to go.fn r rnrr Tf r rnrr |69]1 at i t f fOmv v J v u . + ! . y v 4

the pat ient in Iesser faci l i t iesctinic that operates through the

You d.o triage and. still they come backa pure cost point of viewr you treator you create yollr Olill nOn-emer$encf

main hours of the d.ay. Another thing

about our Philad.elphia situation which5o to /O percent are '\uorried wellsfta.bout one third..

the ed.ucation ofto spend that money.

DR. PEIMME:

Perrnsylvania is a special and terrible problem.

DR. HOWXLL:

Obviously, I thlnk what you are saying is this is one of thecosts that has got to be in the picture of rend.ering the care of thistype in an emergency unit and face the issues of 'what the costs real lyare matched. up a€ainst your revenues. We have been facing this in themed.ical world. where the public program d.id not pay the cost and. it isnrtnew to us, however d.eplorable it is. Our continuing argument with thegoverrunental 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

poslt ion to argue.

DR. PEilO4E:

Although Pennsylvania pays only $4.00 per visit, every med.ical

school is subsid. ized by the state. In Washington we have the reverse ofthat.

DR. WAGNER:

I want to ask a question

I think is difficult. Mainly aboutand our true emergency patients are

The State of Pennsylvania pays FrlOO foreach med.ical stud.ent. It depend.s on where you wantMost schools will get that rei-mbursed.

- t ? t -

DR. PATN SCUDDER OF'NtrW YORK:

The New York BLue cross is plcking up the ent ire emergencycare b l I I .

CIIAIB}{AN:

This is the f i rst state to d.o so.

DR. MYCOCK:

Is this a matter of ' semantics?