Th Shortage
The
Sh t
off OnOn
O -Call
C ll
Specialist Physicians: A
National Survey
y of ED
Directors
Mitesh B. Rao,
Rao, MD, MHS
June 28th, 2009
AcademyHealth
EM ERG EN CY DEPARTM
Se rv ices Availa ble
Frac tu re s
D slo ca tio ns
Di
Is ch em ic Stro ke
Ca rd ia c Arre st
1 st Trim es te r Bleed
An te rio r No se Blee d
ENT
Serv ic es NO T Availa ble
Frac tu rere Dislo ca
c tio
ti ns
Te nd on La ce ra tio ns
He m orrh ag ic Stro ke
GI Blee d
3 rd Trim es te r Prob le m s
Po sterio r No
ossee Blee d
An estimated 21% of
Emergency Department
patient death and permanent
injury can be attributed to
delays in treatment linked to
shortages in specialist
physicians
physicians*
*Sentinel Event Alert, No. 26, The Joint Commission (June 17th, 2002)
Objectives
To report the experiences of Emergency
Department (ED) directors regarding:
 The degree of difficulty in providing
specialist coverage
 The impact
p
of onon-call coverage
g shortages
g
on emergency patient care
 The shortage of onon-call coverage for
specific specialties
 The difference in impact of onon-call
shortages to teaching and nonnon-teach
institutions
Study Design
 Cross sectional self
self--administered survey of a
sample of all ED directors in the 48
contiguous United States.
 Survey design based on prior studies and
further developed based on:
 Review of the literature
 Input from leaders from the American
g of Emergency
g
y Physicians
y
and
College
the American College of Surgeons
Population
 750 hospitals
p
drawn from all institutions
across the 48 contiguous states
 Sample
S
l stratified
t tifi d b
by even di
distribution
t ib ti across
all states, in proportion to variation in
numbers of facilities per state.
 Names of hospitals
p
and their ED directors
along with addresses and phone numbers
were obtained from a vendor of hospital
marketing data
Exclusion Criteria
 Excluded facilities that do not offer fullfullservice emergency medical care to the
general p
g
public
 Federally owned hospitals
 Pediatric and women’s
women s hospitals
 Specialty longlong-term hospitals
 Final sample consisted of 715 hospitals
Instrument
 Survey addressed presence of onon-call
specialist shortages overall as well as by
specialty
 Surgical specialties specifically identified:
 General Surgery
 Trauma Surgery
 Neurosurgery
 Plastic Surgery
g y
 Hand Surgery
 Orthopedics
Instrument
Examined potential effects of onon-call surgical
shortages:
 Whether onon-call shortages affected the
hospital’s
h
i l’ trauma llevell
 Changes in number of patients leaving
b f
before
b
being
i seen b
by a medicallymedically
di ll -needed
d d
specialist
 Reliability of current onon-call specialists
 Recent losses in 24/7 coverage for a
specialty
 Changes in ED transfer rates
Administration
 Mailed to ED Directors in winter of 2008
 Employed modified fivefive-wave contact
strategy to ensure acceptable response rate
 Final survey response rate of 62%
 Respondents representative
representati e of ac
acute
acutete-care
U.S. hospitals
Analysis
 Analyzed using SAS 9.1
9 1 Statistical Software
 Demographic information on participating
hospitals collected via the American
Hospitals Directory website
 Bivariate analyses between reported
measures of the onon-call problem and hospital
(trauma level
level, ownership
ownership, teaching status)
and geographic variables (geographic region,
rural/urban))
P-Values:
Trauma: 0.03
Teaching: 0.03
MSA 0
MSA:
0.9
9
Reported On-Call Problem
80%
70%
60%
50%
40%
72%
30%
60%
55%
T rauma
Level I
T rauma
Level II
74%
66%
LLevell III o r
less
T eaching
hi
Hosp it al
76%
72%
N o nT eaching
Ho spit al
U rbb an
72%
20%
10%
0%
Overallll
O
Sample
R urall
Effect of On-Call Shortages on Emergency Care
70%
60%
50%
40%
30%
61%
20%
10%
0%
23%
Lost Trauma
Designation
Suspended/Lost
24%
26%
Increase in Patients Unreliability of Current
Loss of Ability to
Leaving Before Being On-Call
On Call Specialists Provide 24/7 Coverage
Seen
for a Specialty
Problems With On-Call Coverage by Specialty
Specialty Not
Represented
Dfficulty Maintaining
On-Call Services
90%
80%
70%
60%
25%
25%
55%
57%
34%
50%
10%
37%
40%
30%
7%
20%
41%
40%
30%
28%
10%
0%
General
Surgery
Orthopedic
Surgery
Trauma Surgery Neurosurgery
Hand Surgery Plastic Surgery
Teaching vs. Non-Teaching Hospitals
60%
%
50%
40%
57%
30%
Teaching
Non-Teaching
42%
20%
37%
28%
10%
14%
17%
0%
Traum a Level
Affected
Increasing
Transfers To ED
Increasing
Transfers From ED
P-Values all <0.01
Conclusions
 More critical
critical--need patients leaving
before being seen for higherhigher-level care
 Increasing attrition of specialist
coverage
 Unreliability and inadequacy in current
call coverage
Conclusions
 Non
Non--teaching and lower trauma
trauma--level
hospitals:
 Suffer more from onon-call shortages
g
 Face traumatrauma-level
downgrades/suspensions
g
p
 Teaching hospitals:
 Overburdened with increasing numbers
of incoming patient transfers
Next Steps…
Additional analysis on:
 Current and future management of onon-call
coverage
 Efficacy of current solutions
 Perspectives
Perspecti es on potential ffuture
t re sol
solutions
tions
 “Roadblocks” to change
A Special Thanks To…
 The U.S. Department of Veteran Affairs
 The Robert Wood Johnson Clinical Scholars
Program and Foundation
 Our Funders:
 Connecticut Chapter
p of the American
College of Surgeons
 Connecticut College of Emergency
Physicians
 American College of Emergency
Physicians
Appendix
Responders versus NonNon-Responders
Variable
Responders (%)
Non
Non--Responders (%)
Level 1
30 (6.8)
7 (2.6)
Level 2
30 ((6.8))
21 ((7.7))
381 (86.4)
246 (89.8)
Yes
150 (34.3)
66 (24.7)
No
287 (65.7)
201 (75.3)
Northeast
75 (17.0)
13 (4.7)
South
186 (42.2)
93 (33.9)
Midwest
112 (25.4)
95 (34.7)
West
68 (15.4)
73 (26.6)
Yes
283 (64.5)
142 (52.0)
No
156 (35.5)
131 (48.0)
T
Trauma
Level
L
l
Level 3 or less
Teaching
Geography
MSA
Variable
(N)
On
On--Call Problem (N), (%)
Overall Sample
437
315 (72.1)
Trauma Level
P-Value
0.02
I
30
18 (60.0
II
29
16 (55.2)
III or less
380
282 (74.2)
Teaching Hospital
0.03
Yes
149
98 (65.8)
No
286
217 (75.9)
(75 9)
Geographic Region
<0.01
Northeast
73
56 (76.9)
South
186
147 (79.0)
(79 0)
Midwest
112
67 (59.8)
West
68
46 (67.7)
Metropolitan Statistical Area
0.90
0 90
Urban
281
202 (71.9)
Rural
156
113 (72.4)
H
Hospital
it l Ownership
O
hi
0.72
0 72
Voluntary Nonprofit
260
184 (70.8)
Governmental
99
73 (73.7)
72
54 (75 0)
P
i t
Variable
Inadequate On
On--call
Coverage
Adequate OnOn-Call
Coverage
Affected trauma designation
P-Value
<0.01
Yes
87 (27
(27.9)
9)
13 (10
(10.9)
9)
No/Does not apply
225 (72.1)
106 (89.1)
Patients leave after initial evaluation
<0.01
Increase
84 (28.7)
11 (10.1)
Decrease
14 (4.8)
8 (7.3)
195 (66.6)
90 (82.6)
Stay the same
Number of transfers to ED
0.01
Increase
67 (21.8)
38 (35.9)
Decrease
7 (2.3)
1 (0.9)
233 (75.9)
67 (63.2)
Stay the same
Number of transfers from ED
<0.01
Increase
178 (58.4)
33 (28.0)
Decrease
8 (2.6)
8 (6.8)
119 (39.0)
77 (65.3)
Stay the same
Reliable onon-call specialists?
<0.01
All/most of the time
214 (68.8)
105 (89.7)
Some of the time/rarely
97 (31
(31.2)
2)
12 (10
(10.3)
3)
Lost ability to provide 24/7 coverage
<0.01
Yes
221 (72.2)
37 (32.2)
No
85 (27.8)
78 (67.8)
Variable
Overall (%)
Teaching (%)
NonNon-Teaching (%)
Affected trauma designation
<0.01
Yes
101 (23.3)
21 (14.2)
79 (28.1)
No/Does not apply
332 (76.7)
127 (85.8)
202 (71.9)
Patients leave after initial evaluation
0.81
Increase
95 (23.5)
32 (23.7)
63 (23.7)
Decrease
22 (5.5)
6 (4.4)
16 (6.0)
287 (71.0)
95 (71.9)
187 (70.3)
Stay the same
Number of transfers to ED
<0.01
Increase
105 (25
(25.3)
3)
59 (41
(41.6)
6)
46 (17
(17.0)
0)
Decrease
8 (1.9)
3 (2.1)
5 (1.9)
302 (72.8)
80 (56.3)
219 (81.1)
Stay the same
Number of transfers from ED
<0 01
<0.01
Increase
212 (49.9)
53 (36.8)
159 (57.4)
Decrease
16 (3.8)
9 (6.3)
6 (2.2)
196 (46.4)
82 (56.9)
112 (40.4)
Stay the same
P-Value
Reliable onon-call specialists?
0.72
All/most of the time
319 (74.2)
111 (75.0)
204 (73.4)
Some of the time/rarely
111 (25.8)
37 (25.0)
74 (26.6)
Lost ability to provide 24/7 coverage
0.51
Yes
259 (61.2)
93 (63.7)
165 (60.4)
No
164 (38.8)
53 (36.3)
108 (39.6)