Almost Half of Hospitals Experience Crowded Emergency Departments

A report from the Centers for Disease Control:

Staffing, Capacity, and Ambulance Diversion in Emergency Departments: United States, 2003-04 (A summary, with a link to the report)

Between 40 percent and 50 percent of U.S. hospitals experience crowded conditions in the emergency department (ED) with almost two-thirds of metropolitan EDs experiencing crowding at times, according to a new report issued today by CDC’s National Center for Health Statistics.

The report, entitled "Staffing, Capacity, and Ambulance Diversion in Emergency Departments: United States, 2003-04," contains a number of findings, including:

An average of 4,500 EDs were in operation in the United States during 2003 and 2004.

Crowding in metropolitan EDs was associated with a higher percentage of nursing vacancies, higher patient volume, and longer patient waiting and treatment durations.

Over half the EDs saw fewer than 20,000 patients annually, but 1 out of 10 had an annual visit volume of more than 50,000 patients.

Most EDs used outside contractors to provide physicians (64.7 percent).

Half of EDs in metropolitan areas had more than 5 percent of their nursing positions vacant.

Approximately one-third of U.S. hospitals reported having to divert an ambulance to another emergency department due to overcrowding or staffing shortages at their ED.

Medication Error

From AOL News (AP wire):

Early last Saturday, nurses at an Indianapolis hospital went to the drug cabinet in the newborn intensive care unit to get blood-thinner for several premature babies.

The nurses didn't realize a pharmacy technician had mistakenly stocked the cabinet with vials containing a dose 1,000 times stronger than what the babies were supposed to receive. And they apparently didn't notice that the label said "heparin," not "hep-lock," and that it was dark blue instead of baby blue.

Those mistakes led to the deaths of three infants. Three others also suffered overdoses but survived.

Access to Emergency Care: Rural America

From an American College of Emergency Phyiscians (ACEP) press release (emphasis added):

Emergency Physicians' President Testifies in Salt Lake City at IOM Forum on Rural Emergency Medicine

Washington, DC - Rural areas deserve special consideration as the nation rethinks the way emergency medicine is organized and delivered in the United States, according to Dr. Frederick Blum, President of the American College of Emergency Physicians (ACEP) and a rural emergency physician from Morgantown, West Virginia. Dr. Blum testified today before the Institute of Medicine's (IOM's) first regional workshop on "The Future of Emergency Care in the United States Health System."

The IOM's three landmark reports on in-hospital care, Emergency Medical Services, and pediatric emergency medicine found the nation's emergency care system fragmented and stretched to the breaking point, as well as severely compromised in its ability to handle disasters.

"These forums are critical to our nation and to everyone who seeks emergency care," said Dr. Blum. "Emergency care in rural areas is hampered by a chronic shortage of emergency physicians and the long distances some patients have to travel to receive care. ACEP wants to make sure that as we move forward in reshaping emergency medicine in this country that we don't forget rural America."

The IOM held the first of four regional workshops to discuss the recommendations of the IOM reports today at the Primary Children's Medical Center in Salt Lake City, Utah. The day-long forum focused on the key issues of the reports and the top priorities for action. Among the key recommendations of the reports: an end to the practice of "boarding," where patients wait, sometimes for hours or days, for a hospital room to become available once they've been admitted; a significant increase in federal resources for emergency preparedness; and greater coordination among hospital emergency departments and the emergency medical services system.

The subsequent IOM workshops will be held in the next several weeks: October 27 in Chicago, IL, November 2 in New Orleans, LA, and December 11 in Washington, D.C.

"The IOM reports point out in great detail what emergency physicians have known for some time - that emergency departments, both rural and urban, are stretched to the breaking point on a daily basis and are ill-equipped to handle a natural or man-made disasters," said Dr. Blum. "ACEP is urging Congress to consider the IOM reports and enact the Emergency Medical Services Act as a first step toward preserving emergency care for everyone."

The IOM began this process in September 2003 by convening a committee on the "Future of Emergency Care in the United States Health System" to identify the most important issues facing emergency patients and make recommendations on how best to deal with those issues. Charged with creating a vision for the future of emergency care, the committee looked at hospital-based emergency care, pre-hospital services and the special challenge of providing emergency care for children.

Death in the Waiting Room: ACEP Responds

A press release from the American College of Emergency Physicians (ACEP):

The death of an Illinois woman in an emergency department waiting room has generated questions about what emergency patients should do if they are waiting and their medical conditions worsen. To address these concerns, the president of the American College of Emergency Physicians (ACEP) President Rick Blum, MD, FACEP, today issued the following statement:

"First, my heart also goes out to the family of Beatrice Vance. I know what it's like to lose a loved one. Emergency physicians and nurses are dedicated to saving lives, and we treat more than 110 million patients each year.

"Second, we don't know the facts about what happened in Illinois, so it's impossible to speculate about it. However, emergency physicians have been sounding an alarm for years about the growing crisis in our nation's emergency departments. We issued a national report card on the state of emergency medicine earlier this year, and the Institute of Medicine released three major reports in June about the fragmentation and lack of capacity to deal with day to day emergencies, let alone an act of terrorism. The biggest threats to the quality of care in emergency departments are the issues raised in these reports.

"All emergency departments use a triage process, which means the most critically ill or injured patients are seen first. So a person with chest pains, stroke symptoms, or any other symptoms of a life- or limb-threatening emergency will go to the front of the line.

"However, sometimes a patient will come in with mild symptoms, and while they are waiting, their medical condition worsens. It's very important for emergency patients in waiting rooms to notify the triage nurse if they are in pain or if they start to feel worse. If they are still concerned, they should ask to speak to an emergency physician or a patient advocate. People should not leave the emergency department without being seen.

"Having health insurance does not mean you will be seen quicker. All emergency patients are equal, regardless of whether or not they have health insurance or can pay. This is mandated by a federal law. People with less urgent medical conditions must wait in the waiting room until all the critical patients have been stabilized and admitted to the hospital.

"The lack of capacity in our emergency departments affects us all. The gridlock stems from the closure of nearly two hundred thousand inpatient hospital beds, as well as the shortages of on-call specialists and nurses.

"Finally, emergency physicians and nurses go into emergency medicine to save lives. To criminalize their efforts would be a terrible mistake and have a severe chilling effect on people going into the medical field."

"ACEP also is advocating for passage of the Access to Emergency Medical Services Act (HR 3875 and S. 2750), and we have asked the public to show their support for having emergency care available when they need it by sending messages to their political leaders, which they can do at our Web site www.acep.org.

Novel Call to Action

From Medgadget:

On behalf of O'Canadian Red Cross, an ad agency Downtown Partners has placed life-size realistic decals of collapsed men and women at the bottom of stairwells at two Cineplex Odeon Theatres in Toronto. The campaign's goal was to mark World First Aid Day.

The company explains:

At first glance, the decal generates the impression that someone is lying unconscious and needs help, but as bystanders get closer to the decal they'll realize it's just a picture on the floor and read the accompanying copy, "Know what to do. www.redcross.ca." To reinforce the message, a first-aid instructor will be on location to demonstrate CPR and provide information about CPR and first aid classes, which were recently revamped to make the life-saving skill even easier to learn and administer.

"The creative is a very simple but impactful idea to help the Red Cross build greater awareness of their CPR and first aid training courses. The power of this idea lies in the visceral reaction it generates within people and how it forces many of us to reflect on our inability to react correctly in the situation," says Dan Pawych, creative director, Downtown Partners.

"A person is three times as likely to survive when a bystander performs CPR instead of waiting for paramedics to arrive," says Tracey Braun, national first aid advisor, Canadian Red Cross. "While many people learn CPR and first aid training in the workplace to meet safety standards, statistics show you are most likely to use those skills to save the life of a friend or family member and that's why we want to encourage all Canadians to get trained."

Intruder strangled by nurse: a hit man?

From the Oregonian, an update on an earlier post:

Michael James Kuhnhausen Sr. first hired Edward Dalton Haffey to mop up the mess at Fantasy Adult Video.

Police say he then hired Haffey, a convicted felon with a long criminal history, to kill his wife.

Kuhnhausen, the estranged husband of the emergency room nurse who strangled an intruder in her Southeast Portland home last week, was charged early Thursday with criminal conspiracy to commit murder and attempted murder.

Detectives say Michael Kuhnhausen, 58, helped disarm the security alarm at the Southeast Alder Street home earlier in the day and let Haffey in. Haffey waited with yellow rubber gloves and a claw hammer for at least four hours until Susan Kuhnhausen arrived home from work.

A court affidavit released Thursday describes what Susan Kuhnhausen called the "fight of her life" -- the violent struggle she had with her attacker, and how what first looked like a bizarre burglary turned into a tangled, domestic-related murder plot.

One of the first clues left behind was the dead intruder's backpack. Inside was a day planner, with "Call Mike, Get letter," scribbled on the week of Sept. 4, and Michael Kuhnhausen's cell phone number jotted down on the inside of a folder.

Death after two-hour ER wait ruled homicide

From the Chicago Tribune
Death after two-hour ER wait ruled homicide

WAUKEGAN, Illinois (AP) -- A coroner's jury has declared the death of a heart attack victim who spent almost two hours in a hospital waiting room to be a homicide.

Beatrice Vance, 49, died of a heart attack, but the jury at a coroner's inquest ruled Thursday that her death also was "a result of gross deviations from the standard of care that a reasonable person would have exercised in this situation."

A spokeswoman for Vista Medical Center in Waukegan, where Vance died July 29, declined to comment on the ruling.

Vance had waited almost two hours for a doctor to see her after complaining of classic heart attack symptoms -- nausea, shortness of breath and chest pains, Deputy Coroner Robert Barrett testified.

She was seen by a triage nurse about 15 minutes after she arrived, and the nurse classified her condition as "semi-emergent," Barrett said. He said Vance's daughter twice asked nurses after that when her mother would see a doctor.

When her name was finally called, a nurse found Vance slumped unconscious in a waiting room chair without a pulse. Barrett said. She was pronounced dead shortly afterward.

Barrett said he subpoenaed records after finding discrepancies in the hospital's version of events.

It wasn't immediately clear if the ruling would lead to criminal charges. Dan Shanes, a chief of felony review for the state attorney's office, said his division needed to review the case.

Vista Medical Center spokeswoman Cheryl Maynen said the hospital, just north of Chicago, cooperated with the coroner's investigation and had also investigated the incident. She declined to comment on the homicide ruling.

Police: Nurse, 51, kills intruder with bare hands

From CNN.com

PORTLAND, Oregon (AP) -- A nurse returning from work discovered an intruder armed with a hammer in her home and strangled him with her bare hands, police said.

Susan Kuhnhausen, 51, ran to a neighbor's house after the confrontation Wednesday night. Police found the body of Edward Dalton Haffey 59, a convicted felon with a long police record.

Police said there was no obvious sign of forced entry at the house when Kuhnhausen, an emergency room nurse at Providence Portland Medical Center, got home from work shortly after 6 p.m.

Under Oregon law people can use reasonable deadly force when defending themselves against an intruder or burglar in their homes. Kuhnhausen was treated and released for minor injuries at Providence.

Haffey, about 5-foot-9 and 180 pounds, had convictions including conspiracy to commit aggravated murder, robbery, drug charges and possession of burglary tools. Neighbors said Kuhnhausen's size -- 5-foot-7 and 260 pounds -- may have given her an advantage.

"Everyone that I've talked to says 'Hurray for Susan,' said neighbor Annie Warnock, who called 911.

"You didn't need to calm her. She's an emergency room nurse. She's used to dealing with crisis."

Overuse of Over-The-Counter Analgesics Significant In Emergency Patients

From ACEP, via Press Release:

Many people coming to emergency departments overuse over-the- counter pain medications, including acetaminophen, ibuprofen, or naproxen, which can lead to serious medical problems, such as peptic ulcer, gastritis, and liver injury, as reported in the September issue of the Annals of Emergency Medicine ("Overuse of Over-the-Counter Analgesics by Emergency Department Patients").

"Pain is the most common complaint among patients seeking care in an emergency department," said lead study author Kennon Heard, MD, of the University of Colorado at Denver and Health Sciences Center. "Because many emergency patients have limited access to health care, they may have no alternatives to over-the-counter medications for treatment of pain, and therefore are at risk of overusing these products."

The study surveyed 546 patients, 307 of whom reported using a pain or cold medication containing ibuprofen, acetaminophen, naproxen or aspirin in the 72 hours before coming to the emergency department. Principal reasons patients gave for using over-the-counter medications were musculoskeletal pain, headache, and cold symptoms. More than half (53 percent) reported taking acetaminophen, 34 percent reported taking ibuprofen, 17 percent reported taking aspirin, and 7.8 percent reported taking naproxen.

Of the surveyed patients, 37 (6 percent) reported exceeding the manufacturer's recommended daily dose at some point in the three days preceding their visit.
The majority of overusers (23) exceeded the recommended dosages of ibuprofen, followed by acetaminophen (nine) and naproxen (five).

Pharmacist Review of Medication Orders

From the American College of Emergency Physicians (ACEP):

FAQs in Practice Management

Question: I have been told that JCAHO requires pharmacist review of medication orders prior to medication administration in the ED unless it is an emergency. Is this correct?

Answer: Yes. JCAHO standard MM.4.10 (Medication Management) states,

…a pharmacist reviews all prescription or medication orders unless a licensed independent practitioner (LIP) controls the ordering, preparation, and administration of the medication; or in urgent situations when the resulting delay would harm the patient, including situations in which the patient experiences a sudden change in clinical status.

When queried by ACEP, the Joint Commission indicated that “the physician’s presence in the ED when medication is given is not viewed as control of the administration of medication.” Therefore any medication, including first dose, requires pharmacy oversight.

ACEP is currently working with JCAHO to resolve the problems that this standard is causing in many emergency departments.

ED Team Video

From the Canberra (Australia) ED, posted to ImpactEDNurse, via GruntDoc.

People often ask me why I continue to work in the Emergency Department despite the ongoing hazards of overcrowding, access block and the high stress levels. Its a difficult question to answer in words. A while ago I tried to answer it in a video clip….

Large file (15.5 MB), but worth the download.