Rural Emergency Department Staffing and Participation in Emergency Certification and Training Programs

ABSTRACT:  Context: The practice of emergency medicine presents many challenges in rural areas. Purpose: We describe how rural hospitals nationally are staffing their Emergency Departments (EDs) and explore the participation of rural ED physicians and other health care professionals in selected certification and training programs that teach skills needed to provide high-quality emergency care. Methods: A national telephone survey of a random sample of rural hospitals with 100 or fewer beds was conducted in June to August 2006. Respondents included ED nurse managers and Directors of Nursing. A total of 408 hospitals responded (96% response rate). Findings: A majority of rural hospitals use more than one type of staffing to cover the ED. The type of staffing varies by time period and ED volume. On weekdays, about onethird of hospitals use physicians on their own medical staff; one third use contracted coverage; 18% use both; and 14% use physician assistants and/or nurse practitioners with a physician on-call. Hospitals are more likely to use a combination of medical staff and contracted coverage on evenings and weekends. Advanced Cardiac Life Support training is common, but Pediatric Advanced Life Support, Advanced Trauma Life Support, and training in working as a team are less common. More registered nurses working in rural EDs have taken the Trauma Nursing Core Course than the Emergency Nursing Pediatric Course. Conclusions: Rural ED staff would benefit from additional continuing education opportunities, particularly in terms of specialized skills to care for pediatric emergency patients and trauma patients and training in working effectively in teams .     

Frequency and management of emergencies in primary care offices: A cross-sectional study in northwestern Germany

BackgroundLittle literature exists on emergencies within primary care offices.ObjectivesWe aimed to study the occurrence of emergencies and confidence in dealing with them among primary care physicians (PCPs) in Germany.MethodsWe conducted a cross-sectional study among all PCPs with licences to practice with an own office (n = 915) in a northwestern region in Germany in 2019. Participants were asked to estimate the frequency and type of emergencies that occurred in the last 12 months in their office and about their confidence in managing emergency situations.ResultsAnswers from 375 PCPs could be analysed (response: 41.0%); 95.7% reported at least one emergency in their office within the last 12 months (mean 12.9). PCPs from rural offices reported more emergencies (on average 13.7 vs. 9.6). Acute coronary syndrome, cardiac arrhythmia and dyspnoea were the most common emergencies. A greater likelihood of feeling more confident in managing medical emergencies was found among male physicians, general internists, PCPs additionally qualified as emergency physicians and those with previous training in the emergency department and intensive care unit. In contrast, more general practitioners felt secure treating paediatric emergencies than general internists (highest level of confidence 22.1% vs. 16.3%).ConclusionIn Germany, emergencies in primary care offices occur on average once a month and more often in rural than urban areas. While most PCPs are confident in managing medical emergencies, some differences related to the training path became apparent. Ongoing training programmes may be tailored to improve emergency skills.     

Pediatric emergencies in the office: are family physicians as prepared as pediatricians?

OBJECTIVE: Our objective was to assess the occurrence of pediatric emergencies in the offices of family physicians and pediatricians, the preparedness to respond, and the perceived importance of being prepared. STUDY DESIGN: We performed a cross-sectional random mail survey of physicians. POPULATION: Surveys were sent to 187 family physicians and 129 pediatricians practicing in North Carolina with 75% and 86% response rates, respectively. The 169 total respondents were in community practices regularly treating children and were included for analysis. OUTCOMES MEASURED: We measured the incidence of 8 types of pediatric emergencies, the availability of 11 items for resuscitation and stabilization, whether the physician had Pediatric Advanced Life Support (PALS) training in the previous 2 years, whether the office ever conducted a mock emergency, and beliefs about the importance of preparing for and providing emergency care to children. RESULTS: Six types of pediatric emergencies were seen in one third or more of all practices during the year. The average practice saw 4 or more pediatric emergencies in a year (family physicians = 3.8 vs pediatricians = 4.9, P <.001). Family physicians had fewer resuscitation and stabilization items than pediatricians (5.7 vs 8.6 items, P <.001) and were less prepared in terms of PALS training (19% vs 51%, P <.001). Those with PALS training were more likely to have an intraosseous needle and Broselow tape and to have conducted a mock code. Family physicians considered it is less important than pediatricians to provide such care or to be prepared to do so. CONCLUSIONS: Pediatric emergencies in the office are likely for either specialty. Family physicians may be less prepared, and they discount the importance of the problem and need for preparation.     

To give or not to give: Approaches to early childhood immunization delivery in Oregon rural primary care practices

Context: Little is known about rural clinicians’ perspectives regarding early childhood immunization delivery, their adherence to recommended best immunization practices, or the specific barriers they confront. Purpose: To examine immunization practices, beliefs, and barriers among rural primary care clinicians for children in Oregon and compare those who deliver all recommended immunizations in their practices with those who do not. Methods: A mailed questionnaire was sent to all physicians, nurse practitioners, and physician assistants practicing primary care in rural communities throughout Oregon. Findings: While 39% of rural clinicians reported delivering all childhood immunizations in their clinic, 43% of clinicians reported that they refer patients elsewhere for some vaccinations, and 18% provided no immunizations in the clinic whatsoever. Leading reasons for referral include inadequate reimbursement, parental request, and storage and stocking difficulties. Nearly a third of respondents reported that they had some level of concern about the safety of immunizations, and 14% reported that concerns about safety were a specific reason for referring. Clinicians who delivered only some of the recommended immunizations were less likely than nonreferring clinicians to have adopted evidence‐based best immunization practices. Conclusions: This study of rural clinicians in Oregon demonstrates the prevalence of barriers to primary care based immunization delivery in rural regions. While some barriers may be difficult to overcome, others may be amenable to educational outreach and support. Thus, efforts to improve population immunization rates should focus on promoting immunization “best practices” and enhancing the capacity of practices to provide immunizations and ensuring that any alternative means of delivering immunizations are effective.     

ED crisis presents a new set of quality challenges

Emergency department (ED) coverage crisis may affect not only specialist care but basic emergency services. Finances and lifestyle issues keep many specialists from covering the ED. Fee-for-service programs and stipends for physicians can provide a coverage incentive.     

Cost Reduction Strategies for Emergency Services: Insurance Role, Practice Changes and Patients Accountability

Progress in medicine and the subsequent extension of health coverage has meant that health expenditure has increased sharply in Western countries. In the United States, this rise was precipitated in the 1980s, compounded by an increase in drug consumption which prompted the government to re-examine its financial support to care delivery, most notably in hospital care and emergencies services. In California for example, 50 emergency service providers were closed between 1990 and 2000, and nine in 1999–2000 alone. In that State, only 355 hospitals (out of 568) have maintained emergency services departments (Darves, WebMB, 2001). Reforming hospital Emergency Department (ED) operations requires caution not only because the media pay a lot of attention to ED operations, but also because it raises ethical issues: this became more apparent with the enactment of the EMTALA which stipulates that federally funded hospitals are required to give emergency aid in order to “stabilize” a patient suffering from an “emergency medical condition” before discharging or transferring that patient to another facility. While in essence the law aims to preserve patient access to care, physicians assert that the EMTALA leads to more patients seeking care for non-urgent conditions in EDs (GAO, Report to Congressional Committees, 2001), leading to overcrowding, delayed care for patients with true emergency needs, and forcing hospitals to divert ambulances to other facilities resulting in further delays in urgent care. Also, fewer physicians are willing to be on-call in emergency departments because the EMTALA law requires on-call physicians to provide uncompensated care. Thus there is a need to find a balance between appropriate care to be provided to ED patients, and low costs since uncompensated care is not covered by state or federal funds. This concerns, first and foremost, hospitals that provide a greater amount of uncompensated care (e.g. hospitals serving communities with a higher population of illegal immigrants). Looking at the intrinsic causes of high ED costs, the paper first explains why costs of care provided in EDs are high, and look at a major cause of high ED costs: overcrowding and ED users’ characteristics. This is followed by a discussion on a much-debated factor: the use of EDs for non-emergency conditions, a practice which has often been accused of disproportionately raising costs. We look at various mechanisms used either to divert or prevent the patient from using ED: these include triage services; and the role of HMOs in the ED chain of care: though the US government has increasingly relied on Managed Care organizations to contain costs (e.g. Medicaid and Medicare Managed Care), do HMOs make a difference when it comes to ED costs? Of particular interest is the family physician acting as a gatekeeper, and the legislation that was enacted to protect those who bypass the referral system. We then look at the other end of the ED chain (i.e. the recipient): the financial responsibility of ED users has increased. Alternative providers such as walk-in clinics are increasingly common. EDs also attempt to reengineer their operations to curb costs. While the data are mostly applicable to a private health care system (e.g. the US), the article, using a critical assessment of the existing literature, has implications for other EDs generally, wherever they operate, since every ED faces similar funding problems.     

Health care reform and emergency department services

EDs are the access of last resort for many Americans, and cost-driven reform initiatives that restrict ED utilization could deter people from seeking necessary and timely medical services. The experience in Canada under universal coverage suggests that major reform could lead to a substantial increase in ED utilization, especially in view of the relative shortage of primary care physicians in the United States. Many hospitals could face short-term overcrowding problems that compromise the quality of care provided in EDs, and rural hospital EDs face specific and unique problems relative to competition and cost efficiency. Integration of emergency services into comprehensive health delivery systems under the concept of managed competition is essential to ensure access and cost-effective delivery of services. The hospital ED may well serve as an important focal point in the development of alternative physician-hospital relationships.     

Complementary and alternative medical practices: training,experience, and attitudes of a primary care medical school faculty

BACKGROUND: Interest in alternative and complementary medical practices has grown considerably in recent years. Previous surveys have examined attitudes of the general public and practicing physicians. This study examined the training, experience, and attitudes of medical school faculty, who have the primary responsibility for the education of future family physicians. METHODS: A 24-item, self-administered questionnaire was distributed to all 200 faculty at a medical school with a mission of training primary care physicians. RESULTS: Of 30 therapies listed, 5 were considered legitimate medical practices by more than 70% of the faculty. Eighty-five percent of the respondents reported some training in alternative medical therapies, and 62% were interested in additional training. Eighty-three percent of the faculty reported personal experience with alternative therapies and most rated these as effective. Eighty-five percent of the respondents indicated that their general attitude toward alternative medicine is positive. CONCLUSIONS: The results indicate that respondents have had substantial exposure to complementary therapies, are interested in learning more about these therapies, and have generally positive attitudes toward alternative medical practices and their use. Because of the role of these therapies in prevention, the positive attitudes might reflect the mission of this medical school to train primary care physicians.     

Life-threatening emergencies: patterns of demand and response of a regional emergency medical services system

This study focused on the nature and disposition of life-threatening emergencies. The data were drawn from hospital records (1,266 cases) from a 15-county area in the southeastern United States, consisting of a central metropolitan area surrounded by predominantly rural counties. The most important finding was that rural emergency departments transferred 7.4 percent of their patients. This proportion seems particularly low in light of emergency department categorizations and physician training data for the area. It may suggest underutilization of the region's resources by rural emergency care providers. Over a third of the life-threatening emergencies studied were cardiovascular, 17.9 percent medical, 13.3 percent trauma, and 9.7 percent neurological. The emergency department mortality rate for rural hospitals (11.5 percent) was nearly twice that of nonrural hospitals (6.8 percent).     

Why Do Rural Primary Care Physicians Sell Their Practices?

This study evaluates why rural primary care physicians sell their practices. A random sample of rural primary care practices in California, Utah, Ohio, Texas, and Virginia were surveyed to investigate changes in ownership of the practices during the period 1995-1998. These five states were selected because they represent areas with different experiences with physician-hospital integration and varied rates of managed care penetration. A series of logistic regressions were conducted to examine the factors that led independent physicians to sell their practices to either nonlocal buyers, local hospitals, or local physicians. Findings suggest that sales to nonlocal buyers represent the majority of practice ownership changes. The motivations for ceding control to nonlocal buyers center on managed care concerns, recruitment concerns, and administrative burdens. Sellers were also concerned about their level of net income prior to being acquired. However, the preacquisition financial concerns of sellers were not significantly stronger than the financial concerns of practices that remained independent. The environmental conditions that motivate rural physicians to sell their practices are not expected to improve. Therefore, additional sales of rural primary care practices to nonlocal buyers are expected. Further research is necessary to determine whether this shift in control will lead to changes in the quality or accessibility of care.     

Colorado family practice graduates' preparation for and practice of emergency medicine

BACKGROUND: Family physicians provide care in emergency departments, especially in rural areas; however, no published data describe how they perceive their preparation for emergency practice. We surveyed graduates of Colorado family practice residencies concerning their emergency medicine practice, their comfort working in emergency departments, and their perceived preparation for practicing emergency medicine. METHODS: Seventy recent graduates of Colorado residencies were surveyed regarding their location, work in emergency departments, contact with emergency medical services (EMS) personnel, and perceptions about their emergency medical training. RESULTS: Forty-five percent of respondents practiced in rural settings, 33% worked in emergency departments (56% rural, 14% urban), 60% reported contact with EMS personnel (91% rural, 32% urban), 54% believed their training adequately prepared them for working in emergency departments (82% rural vs 32% urban), 63% of rural and 22% of urban respondents indicated they wanted more major trauma experience during training, 70% reported discomfort with managing trauma, and 44% were interested in a 6-month emergency medicine fellowship. CONCLUSIONS: Most respondents believed their training in emergency medicine was adequate; however, most also reported discomfort with trauma management. Improved training for family physicians who provide emergency care could include expanded trauma care opportunities, increased work with EMS personnel, and postresidency training.     

Retention of Physician Assistants in Rural Health Clinics

CONTEXT: Improvement of rural health care access has been a guiding principle of federal and state policy regarding physician assistants (PAs). PURPOSE: To determine the factors that influence autonomous rural PAs (who work less than 8 hours per week with their supervising physician) to remain in remote locations. METHODS: A qualitative exploratory study was undertaken in 8 rural Texas towns, including direct observation of clinics, semi-structured interviews with PAs, and focus groups with community residents. FINDINGS: The major factors contributing to retention among autonomous rural PAs include: confidence in the ability to provide adequate health care, desire for small-town life, residing in the community, and being involved with the community. Both PAs and residents thought the level of their town's health care was moderately good but could be improved. The clinic allowed easy access for primary care and minor injuries. Town residents and PAs also expressed a desire for major improvements including a pharmacy, visiting specialists, and additional medical equipment. Not all residents sought medical care at the clinic, with some electing to travel to physicians in larger towns. CONCLUSIONS: Rural community residents have more confidence in and satisfaction with PAs who have remained in a clinic for several years. In order to increase retention rates, PAs committed to autonomous, rural primary care would benefit from additional training, particularly in emergency medicine, the benefits of community involvement, and adaptation to the local culture.     

Physician Staffing of Small Rural Hospital Emergency Departments: Rapid Change and Escalating Cost

We surveyed all 37 rural Washington state hospitals with fewer than 100 beds to determine how rural emergency departments are staffed by physicians and to estimate rural hospital payments for emergency department physician services. Only five hospital emergency departments (14%) were still covered by the traditional rotation of local practitioners and billed on a fee-for-service basis. Ten hospitals (27%) paid local private practitioners to provide emergency department coverage. Twelve other hospitals (32%) hired visiting emergency department physicians to cover only weekends or evenings. The remaining 10 rural emergency departments (27%) were staffed entirely by external contract physicians. Thus, 86 percent of rural hospitals contracted for emergency department coverage, and 59 percent obtained some or all of this service from nonlocal physicians. Most of the 32 hospitals with some form of contracted services have changed to this emergency department coverage in the last few years. The cost of these services is high, particularly for the smallest hospitals that have fewer than eight emergency department visits per day and pay physician wages of nearly $100 per patient visit. Emergency staffing responsibility has shifted from local practitioners to the hospital administrators because of rural physician scarcity and a desire to improve quality and convenience. The cost of these changes may further undermine the economic viability of the smaller rural hospitals.     

Why Rural Residents Migrate for Family Physician Care

Several studies have examined why rural residents bypass local hospitals, but few have explored why they migrate for physician care. In this study, data from a random mail survey of households in rural Iowa counties were used to determine how consumers' attitudes about their local health system, health beliefs, health insurance coverage and other personal characteristics influenced their selection of local vs. nonlocal family physicians (family physician refers to the family practice, internal medicine or other medical specialist providing an individual's primary care). Migration for family physician care was positively associated with a perceived shortage of local family physicians and use of nonlocal specialty physician care. Migration was negatively associated with a highly positive rating of the overall local health care system, living in town, Lutheran religious affiliation and private health insurance coverage. By understanding why rural residents prefer to bypass local physicians, rural health system managers, physicians and policy-makers should be better prepared to design innovative health organizations and programs that meet the needs of rural consumers.     

Availability of pediatric services and equipment in emergency departments: United States, 2002-03

OBJECTIVES: This report presents estimates on the availability of pediatric services, expertise, and supplies for treating pediatric emergencies in U.S. hospitals. METHODS: The Emergency Pediatric Services and Equipment Supplement (EPSES) was a self-administered questionnaire added to the 2002-03 National Hospital Ambulatory Medical Care Survey (NHAMCS). NHAMCS samples non-Federal, short-stay and general hospitals in the United States. The EPSES content was based on the 2001 guidelines for pediatric services, medical expertise, small-sized supplies, and equipment for emergency departments (EDs) developed by the American Academy of Pediatrics (AAP) and the American College of Emergency Physicians (ACEP). Combined response rate for both years was 86 percent. Estimates were weighted to produce average annual estimates of pediatric services, expertise, and equipment availability in EDs. RESULTS: One-half of hospitals (52.9 percent) admitted pediatric patients, but did not have a specialized inpatient pediatric ward. One-third (38.3 percent) admitted pediatric patients and had a separate pediatric ward; the remainder did not admit pediatric patients. Among those that did not admit pediatric cases, 30.4 percent were in counties that had a children's hospital. One-quarter of EDs had access 24 hours and 7 days a week to a board-certified pediatric emergency medicine attending physician. Only 5.5 percent had all recommended pediatric supplies, but one-half had greater than 85 percent of recommended supplies. Most hospitals without pediatric trauma service (90.7 percent) or pediatric intensive care units (97.5 percent) transferred critical pediatric patients to hospitals with these services. EDs in hospitals with specialized inpatient facilities for children were more likely to meet the AAP and ACEP guidelines for pediatric ED services, expertise, and supplies.     

Characteristics of all, occasional, and frequent emergency department visits due to ambulatory care-sensitive conditions in Florida

We studied characteristics of all, occasional, and frequent emergency department (ED) visits due to ambulatory care-sensitive conditions (ACSCs). We used a cross-sectional, split-sample design with multivariate logistic regressions using encounter-level, all-payer ED data from all Florida hospitals for the year of 2005. We evaluated associations of key patient characteristics, characteristics of ED utilization, and availability of primary care physicians in the area, with ED visits for ACSCs. We concluded that factors associated with ED use for ACSCs were similar for occasional and frequent ED users. Therefore, universal strategies for reduction of ED overutilization by increasing access to, timeliness, and quality of primary care for all patients likely to experience ACSCs should be used.     

Emergency contraception in emergency departments in Oregon, 2003

OBJECTIVES: We sought to learn about access to emergency contraception (EC) in Oregon emergency departments, both for women who are rape patients and for women who have had consensual unprotected sexual intercourse ("nonrape patients"). METHODS: We interviewed emergency department staff in 54 of Oregon's 57 licensed emergency departments in February-March 2003 (response rate = 94.7%). RESULTS: Only 61.1% of Oregon emergency departments routinely offered EC to rape patients. Catholic hospitals were as likely as non-Catholic hospitals to routinely offer EC to rape patients. The hospitals most likely to routinely offer EC to rape patients had a written protocol for the care of rape patients that included offering EC (P = .02) and access to staff with specialized sexual assault training (P=.002). For nonrape patients, 46.3% of emergency departments discouraged the prescribing of EC. Catholic hospitals were significantly less likely than non-Catholic hospitals to provide access to EC for nonrape patients (P=.05). CONCLUSIONS: Oregon emergency departments do not routinely offer EC to women who have been raped or to women who have had consensual unprotected sexual intercourse.     

To Stay or Not to Stay: Issues in Rural Primary Care Physician Retention in Eastern Kentucky

An important aspect of primary care physician availability is the retention of physicians once they have located. While retention has been under-researched compared to recruitment, it is especially important in rural areas where physician shortages already exist. This study reports the results of a retention survey completed by 132 primary care physicians in rural eastern Kentucky. The survey sets up an objective, hypothetical retention scenario and asks physicians to respond to structured questions and to an open-ended question about factors not appearing in the survey. In response to the structured portion of the survey, physicians indicate that relief coverage is the most important factor in rural physician retention. A content analysis of 75 open-ended responses reveals that besides the other factors in the survey, "sociocultural integration" is the pre-eminent retention issue for rural practitioners. This article concludes that the role of the local rural community may be more important in retention than in recruitment. Finally, it is suggested that additional in-depth qualitative research be conducted within the local contexts to enhance the understanding of rural physician retention processes.     

Presence of a Community Health Center and Uninsured Emergency Department Visit Rates in Rural Counties

ABSTRACT: Context: Community health centers (CHCs) provide essential access to a primary care medical home for the uninsured, especially in rural communities with no other primary care safety net. CHCs could potentially reduce uninsured emergency department (ED) visits in rural communities. Purpose: We compared uninsured ED visit rates between rural counties in Georgia that have a CHC clinic site and counties without a CHC presence. Methods: We analyzed data from 100% of ED visits occurring in 117 rural (non‐metropolitan statistical area [MSA]) counties in Georgia from 2003 to 2005. The counties were classified as having a CHC presence if a federally funded (Section 330) CHC had a primary care delivery site in that county throughout the study period. The main outcome measure was uninsured ED visit rates among the uninsured (all‐cause ED visits and visits for ambulatory care sensitive conditions). Poisson regression models were used to examine the relationship between ED rates and the presence of a CHC. To ensure that the effects were unique to the uninsured population, we ran similar analyses on insured ED visits. Findings: Counties without a CHC primary care clinic site had 33% higher rates of uninsured all‐cause ED visits per 10,000 uninsured population compared with non‐CHC counties (rate ratio [RR] 1.33, 95% confidence interval [CI] 1.11‐1.59). Higher ED visit rates remained significant (RR 1.21, 95% CI 1.02‐1.42) after adjustment for percentage of population below poverty level, percentage of black population, and number of hospitals. Uninsured ED visit rates were also higher for various categories of diagnoses, but remained statistically significant on multivariate analysis only for ambulatory care sensitive conditions (adjusted RR = 1.22, 95% CI 1.01‐1.47). No such relationship was found for ED visit rates of insured patients (RR 1.06, 95% CI 0.92‐1.22). Conclusions: The absence of a CHC is associated with a substantial excess in uninsured ED visits in rural counties, an excess not seen for ED visit rates among the insured.     

Impact of physician training level on emergency readmission within internal medicine

OBJECTIVES: The research question was whether training level of admitting physicians and referrals from practitioners in primary health care (PHC) are risk factors for emergency readmission within 30 days to internal medicine. METHODS: This report is a prospective multicenter study carried out during 1 month in 1997 in seven departments of internal medicine in the County of Stockholm, Sweden. Two of the units were at university hospitals, three at county hospitals and two in district hospitals. The study area is metropolitan-suburban with 1,762,924 residents. Data were analyzed by multiple logistic regression. RESULTS: A total of 5,131 admissions, thereby 408 unplanned readmissions (8 percent) were registered (69.8 percent of 7348 true inpatient episodes). The risk of emergency readmission increased with patient's age and independently 1.40 times (95 percent confidence interval [CI], 1.13-1.74) when residents decided on hospitalization. Congestive heart failure as primary or comorbid condition was the main reason for unplanned readmission. Referrals from PHC were associated with risk decrease (odds ratio, 0.53; 95 percent CI, 0.38-0.73). CONCLUSION: The causes of unplanned hospital readmissions are mixed. Patient contact with primary health care appears to reduce the recurrence. In addition to the diagnoses of cardiac failure, training level of admitting physicians in emergency departments was an independent risk factor for early readmission. Our conclusion is that it is cost-effective to have all decisions on admission to hospital care confirmed by senior doctors. Inappropriate selection of patients to inpatient care contributes to poor patient outcomes and reduces cost-effectiveness and quality of care.