Hospital-based Emergency Care Research Articles

A Conceptual Framework for Optimizing the Equity of Hospital-Based Emergency Care: The Structure of Hospital Transfer Networks.

Emergency care includes two key components: initial stabilization and transfer to a higher level of care. Significant work has focused on ensuring that local facilities can stabilize patients. However, less is understood about transfers for definitive care. To better understand how transfer network structure impacts population health and equity in emergency care, we proposea conceptual framework, the hospital transfer network equity-quality model (NET-EQUITY). NET-EQUITY can help optimize population outcomes, decrease disparities, and enhance planning by supporting a framework for understanding emergency department transfers. To develop the NET-EQUITY framework, we synthesized work on health systems and quality of health care (Donabedian, the Institute of Medicine, Ferlie, and Shortell) and the research framework of the National Institute on Minority Health and Health Disparities with legal and empirical research. The central thesis of our framework is that the structure of hospital transfer networks influences patient outcomes, as defined by the Institute of Medicine, which includes equity. The structure of hospital transfer networks is shaped by internal and external factors. The four main external factors are the regulatory, economic environment, provider, and sociocultural and physical/built environment. These environments all implicate issues of equity that are important to understand to foster an equitable population-based system of emergency care. The framework highlights external and internal factors that determine the structure of hospital transfer networks, including structural racism and inequity. The NET-EQUITY framework provides a patient-centered, equity-focused framework for understanding the health of populations and how the structure of hospital transfer networks can influence the quality of care that patients receive.

Medical Coordination Rescue Members' and Ambulance Nurses' Perspectives on a New Model for Mass Casualty and Disaster Management and a Novel Terror Attack Mitigation Approach in the Netherlands: A Qualitative Study.

Mass-casualty incidents (MCIs), specifically incidents with chemical, biological, radiological, and nuclear agents (CBRN) or terrorist attacks, challenge medical coordination, rescue, availability, and adequate provision of prehospital and hospital-based emergency care. In the Netherlands, a new model for Mass Casualty and Disaster Management (MCDM) along with a Terror Attack Mitigation Approach (TAMA) was introduced in 2016. The objective of this study was to provide insight in the first experiences of health policy advisors and managers with a medical rescue coordinator and ambulance nursing background regarding the new MCDM and TAMA in order to identify strengths and pitfalls in emergency preparedness and to provide recommendations for improvement. The study had a qualitative design and was performed from January 2017 through June 2018. Purposeful sampling was used and the inclusion comprehended health policy advisors and managers with a medical rescue coordinator and ambulance nursing background involved in emergency preparedness. The respondents were interviewed semi-structured and the researchers used a topic list that was based on the literature and content of the newly introduced model and approach. All interviews were typed out verbatim and qualitative content analyzing was used in order to identify relevant themes. Respondents based their perceptions on large-scale training exercises, as MCDM and TAMA were not yet used during MCIs. Perceived issues of MCDM were the two-tiered triage system, the change in focus from "stay and play" towards "scoop and run," difficulties with new tasks and roles of professionals, and improvement in material provision. Regarding TAMA, all respondents supported the principles (do the most for the most; scoop and run; acceptable personal risk; never walk alone; and standard operational procedure); however, the definitions were lacking clarity while the awareness of optimal personal safety of professionals was absent.As there are currently regional differences in the level of implementation of MCDM and TAMA, this may pose a risk for an optimal inter-regional collaboration. The conclusions refer to experiences of professionals in the Netherlands. Elements of the MCDM and TAMA were highly appreciated and seemed to improve emergency preparedness, while other aspects needed further attention, training, and integration in daily routine. The Netherlands' MCDM model and TAMA will need continuous systematic evaluation based on (inter)national performance criteria in order to underpin the useful and effective elements and to improve the observed pitfalls in emergency preparedness.

Healthcare in transition in the Republic of Armenia: the evolution of emergency medical systems and directions forward

Armenia, an ex-Soviet Republic in transition since independence in 1991, has made remarkable strides in development. The crisis of prioritization that has plagued many post-Soviet republics in transition has meant differential growth in varied sectors in Armenia. Emergency systems is one of the sectors which is neglected in the current drive to modernize. The legacy of the Soviet Semashko system has left a void in specialized care including emergency care. This manuscript is a descriptive overview of the current state of emergency care in Armenia using in-depth key informant interviews and review of published and unpublished internal United States Agency for International Development (USAID) and Ministry of Health (MOH) documents as well as data from the Yerevan Municipal Ambulance Service and international agencies. The Republic of Artsakh is briefly discussed.The development of emergency care systems is an extremely efficient way to provide care across many different conditions in many age groups. Conditions such as traumatic injuries, heart attacks, cardiac arrest, stroke, and respiratory failure are very time-dependent. Armenia has a decent emergency infrastructure in place and has the benefit of an educated and skilled physician workforce. The missing piece of the puzzle appears to be investment in graduate and post-graduate education in emergency care and development of hospital-based emergency care for stabilization of stroke, myocardial infarction, trauma, and sepsis as well as other acute conditions.

Abstract WP303: Laying the Groundwork for Stroke Care in Armenia. Assessment of Ambulance Services in the Republic of Armenia: Current State of Care, Public Perception and Opportunities for Strengthening the Emergency Medical System

Background: The recent creation of the Armenian National Stroke Program has stipulated that all links in the Stroke Chain of Survival are examined and remediated including Emergency Medical Systems (EMS). EMS forms the second link in the chain of survival after early recognition of stroke symptoms by the general public. This study describes the perception of and performance of EMS in Armenia’s capital, Yerevan, and provides the groundwork for nascent stroke care in Armenia. Methods: We used mixed methods to derive a comprehensive picture of the state of Emergency Medical Systems. We administered a survey using random digit telephone number generator to 384 households at three intervals over a 5 year period in 2005, 2009 and 2010. A trend analysis was performed for six questions regarding EMS. We queried knowledge of the 911-equivalent access number, perception of accessibility of emergency services, perception of anticipated care, and financial concerns. The surveys had a 96% response rate. We also performed key stakeholder interviews and focus groups to describe the state and evolution of emergency care in Armenia. Results and Discussion: Appropriate and timely stroke care relies on activation of EMS. EMS in Armenia remains an ambulance-based service following the Franco-German model where ambulances are staffed by a physician, nurse and driver. Utilization of EMS in Armenia is one of the highest in the world. Eighty percent of calls are treated on scene and 20% are transported to surrounding hospitals. There is currently minimal hospital-based emergency care. Over the three survey periods there was a trend towards increased trust in the EMS system. The idea that the ambulance will respond in a timely manner and not request payment before accepting the call (p=0.04) gained traction. Increased trust means more people will wait for the ambulance than drive the patient to the hospital themselves (p=0.01), a key factor for prompt stroke care. Since February of 2019, stroke patients are transferred to two stroke referral centers in Yerevan. EMS systems strengthening starting with public education and trust-building, emergency medicine residency, ambulance and helicopter protocols and tele-stroke development is key in providing timely and quality stroke care.

Variation in resource allocation in urgent and emergency Care Systems in Ireland

BackgroundA key challenge for most systems is how to provide effective access to urgent and emergency care across rural and urban populations. Tensions about the placement and scope of hospital emergency services are longstanding in Irish political life and there has been recent reform to centralise hospital services in some regions. The focus of this paper is a system approach to examine the geographic variation in resourcing and utilisation of such care across GP practices, out-of-hours care, ambulance services, Emergency Departments and Local Injury Units in Ireland.MethodsWe used a cross-sectional study design to evaluate variation in resource allocation by aggregating geographic funding to various elements of the urgent and emergency care system and assessing patterns in hospital resource utilisation across the population. Expenditure, staffing, access and activity data were gathered from government sources, individual facilities and service providers, health professional bodies, private firms and central statistics. Data on costs and activity in 2014 are collated and presented at both county and regional levels. Analyses focus on resources spent on urgent and emergency care across geographic areas, the role of population concentration in allocation, the relationship between pre-hospital spending and in-hospital spending, and the utilisation of hospital-based emergency care resources by residents of each county.ResultsAn array of funding mechanisms exists, resulting in a fragmented approach to the resourcing of urgent and emergency care. There are large differences in spending per capita at the county-level, ranging from between €50 and €200 per capita; however, these are less pronounced regionally. Distribution of hospital emergency care resources is highly skewed to the North East of the country, and away from the recently reconfigured South and Mid-West regions.ConclusionsThis analysis advances the traditional approach of evaluating individual services or hospital resourcing. There are notable differences in utilisation of hospital-based emergency care resources at the regional level, indicating that populations within those regions which have been reconfigured have lower utilisation of hospital resources. There is a clear case for more integration in decision-making around funding and consideration of key principles, such as equity, to guide that process.

Emergency Care Utilization Among Pregnant Medicaid Recipients in North Carolina: An Analysis Using Linked Claims and Birth Records.

Objectives To estimate the rate of pregnancy-associated emergency care visits and identify maternal and pregnancy characteristics associated with high utilization of emergency care among pregnant Medicaid recipients in North Carolina. Methods A retrospective cohort study using linked Medicaid hospital claims and birth records of 107,207 pregnant Medicaid recipients who delivered a live-born infant in North Carolina between January 1, 2008 and December 31, 2009. Rates were estimated per 1000 member months of Medicaid coverage. High utilization was defined as ≥ 4 visits. Emergency care visits included encounters in the emergency department or obstetric triage unit during pregnancy that did not result in hospital admission. Results During the study period, 57.5% of pregnant Medicaid recipients sought emergency care at least once during pregnancy. There were 171,909 emergency care visits with an overall rate of 202.3 visits per 1000 member months. Among the subset of pregnant women with Medicaid coverage for the majority of their pregnancy (n = 75,157), 18.1% were high utilizers. High emergency care utilization was associated with young age, black race, lower education, tobacco use, late preterm delivery, multifetal gestation, and having ≥ 1 comorbidity. Threatened labor and abdominal pain were the leading indications for visits. Conclusion Utilization of hospital-based emergency care services was common in this cohort of pregnant Medicaid recipients. Additional research is needed to assess the drivers for accessing care through the emergency department, and to examine differences in pregnancy outcomes and health care costs between high and low utilizers.

Selection of quality indicators for hospital-based emergency care in Denmark, informed by a modified-Delphi process.

BackgroundIn 2013, Danish policy-makers on a nationwide level decided to set up a national quality of care database for hospital-based emergency care in Denmark including the selection of quality indicators. The aim of the study was to describe the Delphi process that contributed to the selection of quality indicators for a new national database of hospital-based emergency care in Denmark.MethodsThe process comprised a literature review followed by a modified-Delphi survey process, involving a panel of 54 experts (senior clinicians, researchers and administrators from the emergency area and collaborating specialties). Based on the literature review, we identified 43 potential indicators, of which eight were time-critical conditions. We then consulted the Expert panel in two consecutive rounds. The Expert panel was asked to what extent each indicator would be a good measure of hospital-based emergency care in Denmark. In each round, the Expert panel participants scored each indicator on a Likert scale ranging from one (=disagree completely) through to six (=agree completely). Consensus for a quality indicator was reached if the median was greater than or equal to five (=agree). The Delphi process was followed by final selection by the steering group for the new database.ResultsFollowing round two of the Expert panel, consensus was reached on 32 quality indicators, including three time-critical conditions. Subsequently, the database steering group chose a set of nine quality indicators for the initial version of the national database for hospital-based emergency care.ConclusionsThe two-round modified Delphi process contributed to the selection of an initial set of nine quality indicators for a new a national database for hospital-based emergency care in Denmark. Final selection was made by the database steering group informed by the Delphi process.Electronic supplementary materialThe online version of this article (doi:10.1186/s13049-016-0203-x) contains supplementary material, which is available to authorized users.

Impact of the Patient Protection and Affordable Care Act on Emergency Psychiatry.

Emergency psychiatry (EP) is an integral component of comprehensive hospital-based emergency care. EP developed and grew into a medical subspecialty in response to deinstitutionalization and other large-scale forces, resulting in large numbers of psychiatric patients presenting to emergency departments. The Affordable Care Act (ACA) of 2010 contains several features and provisions that are likely to impact the practice of EP. This article reviews and examines the impact of the ACA on psychiatric emergency care to date and anticipated in the near future.

What we have learned from a decade of ED crowding research.

What we have learned from a decade of ED crowding research.

Hospital-based emergency care in the Russian Federation: a historical analysis of statutory regulations

The ongoing changes the system of emergency care (EC) in the Russian Federation (RF), especially its in-hospital component, require modifications of applicable laws. This paper analyzes past development and evaluates the current state of regulations pertinent to hospital-based EC in RF. We have reviewed and analyzed the regulatory statutes that governed hospital-based emergency care in Russia between 1735 and 2013. The study traces the development of past regulations (legal and normative acts) applicable to EC in RF. Main regulations currently in effect are characterized. At present, there already exists a body of laws supporting further modernization of hospital-based EC in Russia. Most recently, the legal foundation has been laid for previously novel concepts such as short-term observation, and for the creation of hospitalbased centers of EC. Work in progress involves active steps towards clinical recommendations and protocols for the envisioned new structure of EC in the RF. The paper will be of interest to professionals studying global emergency medicine development. It will help researchers and clinical practitioners in the fields of emergency medical care and healthcare management by understanding the link between regulatory deficiencies and barriers to improving emergency department operations.

Pain management in trauma patients in (pre)hospital based emergency care: Current practice versus new guideline

IntroductionAcute pain in trauma patients in emergency care is still undertreated. Early pain treatment is assumed to effectively reduce pain in patients and improve long-term outcomes. In order to improve pain management in the chain of emergency care, a national evidence-based guideline was developed. The aim of this study was to assess whether current practice is in compliance with the guideline ‘Pain management for trauma patients in the chain of emergency care’ from the Netherlands Association for Emergency Nurses (in Dutch NVSHV), and to evaluate early and initial pain management for adult trauma patients in emergency care. MethodsChart reviews were conducted in three regions of the Netherlands using electronic patient files of trauma patients from the chain of emergency care. We included one after-hours General Practitioner Co-operation (GPC), one ambulance Emergency Medical Services (EMS), two Helicopter Emergency Medical Services (HEMS), and three Emergency Departments (EDs). Organisation of pain management, pain assessment, and pain treatment was examined and compared with national guideline recommendations, including quality indicators. ResultsWe assessed a random sample of 1066 electronic patient files. The use of standardised tools to assess pain was registered in zero to 52% of the electronic patient files per organisation. Registration of (non-)pharmacological pain treatment was found in less than half of the files. According to the files, pharmacological pain treatment deviated from the guideline in 73–99% of the files. Time of administration of medication was missing in 73–100%. Reassessment of pain following pain medication was recorded in half of the files by the HEMS, but not in files of the other organisations. ConclusionsThe (registration of) current pain management in trauma patients in the chain of emergency care varies widely between healthcare organisation, and deviates from national guideline recommendations. Although guideline compliance differs across groups of healthcare professionals, maximum compliance rate with indicators registered is 52%. In order to improve pain management and evaluate its effectiveness, we recommend to improve pain registration in patient files. Furthermore, we advise to identify barriers and facilitators related to the implementation of the national guideline in all emergency care organisations.

Potential use of amiodarone to treat new-onset AF in the pre-hospital setting

Incidence of atrial fibrillation (AF) is high, it is the most prevalent arrhythmia in the UK, Europe and the USA ( Naccarelli et al, 2009 ; Davis et al, 2012 ; Dagres et al, 2013 ) and is associated with significant morbidity, high risk of stroke and mortality ( Cottrell, 2012 ). Clinical guidance from the National Collaborating Centre for Chronic Conditions (NCCCC) (2006) and the National Institute for Health and Care Excellence (NICE) (2006) supports clinicians working in primary and hospital-based emergency care, but not those working in pre-hospital care. Updated guidance from NICE (2014) highlights the importance of providing rapid, personalised, evidence-based care, yet does not provide any guidance for pre-hospital clinicians responding to emergency presentations of AF. Paramedics have knowledge and experience of identifying AF, possess antiarrhythmic, anticoagulant and anti-platelet medications as part of their formulary and possess the necessary skills for obtaining intravenous access. This article reviews the national guidance and available best-evidence to provide safe treatment to patients presenting with new-onset AF and considers areas that merit further research.

Addressing World Health Assembly Resolution 60.22: A Pilot Project to Create Access to Acute Care Services in Uganda

The World Health Assembly 2007 Resolution 60.22 tasked the global health community to address the lack of emergency care in low- and middle-income countries. Little progress has yet been made in integrating emergency care into most low- and middle-income-country health systems. At a rural Ugandan district hospital, however, a collaborative between a nongovernmental organization and local and national stakeholders has implemented an innovative emergency care training program. To our knowledge, this is the first description of using task shifting in general hospital-based emergency care through creation of a new nonphysician clinician cadre, the emergency care practitioner. The program provides an example of how emergency care can be practically implemented in low-resource settings in which physician numbers are limited. The Ministry of Health is directing its integration into the national health care system as a component of a larger ongoing effort to develop a tiered emergency care system (out-of-hospital, clinic- and hospital-based provider and physician trainings) in Uganda. This tiered emergency care system is an example of a horizontal health system advancement that offers a potentially attractive solution to meet the mandate of World Health Assembly 60.22 by providing inexpensive educational interventions that can make emergency care truly accessible to the rural and urban communities of low- and middle-income countries.

Emergency medicine in the United Arab Emirates

It has been a decade since emergency medicine was recognized as a specialty in the United Arab Emirates (UAE). In this short time, emergency medicine has established itself and developed rapidly in the UAE. Large, well-equipped emergency departments (EDs) are usually located in government hospitals, some of which function as regional trauma centers. Most of the larger EDs are staffed with medically or surgically trained physicians, with board-certified emergency medicine physicians serving as consultants overseeing care.Prehospital care and emergency medical services (EMS) operate under the auspices of the police department. Standardized protocols have been established for paramedic certification, triage, and destination decisions. The majority of ambulances offer basic life support (BLS/Type 2) with a growing minority offering advanced life support (ALS/Type 3).Medicine residency programs were established 5 years ago and form the foundation for training emergency medicine specialists for UAE.This article describes the full spectrum of emergency medicine in the UAE: prehospital care, EMS, hospital-based emergency care, training in emergency medicine, and disaster preparedness. We hope that our experience, our understanding of the challenges faced by the specialty, and the anticipated future directions will be of importance to others advancing emergency medicine in their region and across the globe.

Diagnostic laparoscopy after anterior abdominal stab wounds

The National Institute of Medicine's report Hospital-Based Emergency Care: At the Breaking Point highlighted the critical issue of emergency department overcrowding. At our institution, patients with anterior abdominal stab wounds (AASW) have been managed with a protocol that uses diagnostic laparoscopy (DL) after positive result on local wound exploration. Patients with negative DL result are eligible for discharge directly from the recovery room. The purpose of this study was to evaluate the use of DL for AASWs in light of the recommendations that suggested serial abdominal examination (SAE) is preferred to determine the need for laparotomy. Patients admitted to a Level 1 trauma center from January 2010 through August 2012 with AASWs were included (contemporary period to Western Trauma Association study). Information regarding baseline characteristics, diagnostic workup, injury management, and outcomes were retrospectively reviewed and compared with the SAE AASW algorithm. A total of 158 patients with AASWs were evaluated using our institutional algorithm. Thirty-eight patients (24%) went directly to the operating room for peritonitis, shock, or evisceration; 120 underwent local wound exploration; 99 had positive result (82%). Twenty-eight patients had immediate laparotomy owing to worsening clinical examination findings. Seventy had DL, and 19 of these patients were discharged home from the recovery room, with a mean length of stay of 6.4 hours. When comparing patients managed using the DL algorithm to those managed using the SAE-based algorithm, the nontherapeutic laparotomy rate was lower, although not statistically significant. However, the DL algorithm produced a significantly higher percentage of patients discharged directly home following local wound exploration. With some trauma centers suffering from emergency department overcrowding and constrained resources, DL may offer an alternative to SAE to efficiently use available resources. Both SAE and DL are safe and offer similar therapeutic laparotomy rates. The method used to evaluate patients after AASW should be tailored to institutional needs and resources. Therapeutic/care management, level IV.

Transforming Psychiatric Care Delivery in the Emergency Department: One Hospital’s Journey

Transforming Psychiatric Care Delivery in the Emergency Department: One Hospital’s Journey

Emergency Medicine Rural Rotations: A Program Director's Guide

The Institute of Medicine's 2006 report titled "Hospital-Based Emergency Care: At the Breaking Point" called national attention to the lack of specialty-trained emergency care practitioners, particularly in rural America. One suggested strategy for narrowing the gap between the prevalence of residency-trained, board-certified emergency physicians practicing in rural and urban emergency departments is the development of rural clinical experiences for emergency medicine residents during the course of their training. This article addresses promotion of a rural emergency medicine rotation to hospital leadership and resident recruits, examines funding sources, discusses medical liability and disability insurance options, provides suggestions for meeting faculty and planned educational activity residency review committee requirements, and offers guidance about site selection to direct emergency medicine academic leaders considering or planning a new rural emergency medicine rotation.

A Profile of Freestanding Emergency Departments in the United States, 2007

BackgroundFreestanding Emergency Departments (FSEDs) have emerged as an alternative to traditional hospital-based emergency care. Study ObjectiveWe sought to determine the number, basic types, distribution, and characteristics of United States (US) FSEDs in 2007. MethodsCombining data from the 2007 National Emergency Department Inventory-USA database, the 2007 American Hospital Association Annual Survey of Hospitals, Internet searches, and telephone calls, we established an inventory of FSEDs. We define FSEDs as emergency care facilities physically distinct from a hospital. FSEDs include “satellite” Emergency Departments (EDs), which are owned by a parent hospital, and “autonomous” EDs, which lack such an affiliation. ResultsWe identified 80 FSEDs operating in 2007, representing 1.6% of all US EDs; 73 (91%) in 20 states were satellite EDs, and seven (9%) in three states were autonomous EDs. Most FSEDs (92%; 95% confidence interval 83–97%) were located in urban areas, which is considerably higher than the proportion for hospital-based EDs (58%). The median distance from a satellite ED to a parent hospital ED was 10.6 miles. In 2007, FSED annual visit volumes ranged from 700 to 56,545 visits. The 2007 median visit volume was 18,769 (interquartile range 11,106–23,504; n = 52). This value did not vary by geographic region and is almost identical to the 2007 median visit volume for hospital-based EDs (18,776 visits). ConclusionsFSEDs represent <2% of US EDs, with satellite EDs comprising a majority of all FSEDs. Most (92%) FSEDs are located in urban areas.

What's in a Name?

In the previous issue of Advanced Emergency Nursing Journal, the inappropriateness of the terms “mid-level provider” and “physician extender” was discussed (Hoyt, 2012). Prior to that, we explored the difference between the terms “evidence-based practice,” “standard of care,” and “best practice” (Proehl & Hoyt, 2012). Some readers probably think, So what, it's just semantics. So what? Do semantics matter? Some minor points may not be worth quibbling about, but the fact remains that words are powerful and can create or reinforce an inaccurate image or misunderstanding. As editors we are very sensitive to the subtle nuances of language that can lead to misunderstanding. As advanced practice nurses, it is incumbent upon us to set a good example and help educate others. One of the ways we can promote the dissemination of accurate information is by using accurate and precise language. Here are a few more terms that deserve consideration. First, the name “emergency room” or “ER.” Does anyone still have one room where all emergency patients are seen? Perhaps, in a clinic setting this is true, but hospital-based emergency care is invariably carried out in a multiroom department. On the hospital's organizational chart, emergency care certainly deserves departmental status. Judy Kelleher famously made this point when she and Anita Dorr merged their two organizations, the Emergency Department Nurses Association and the Emergency Room Nurses Association; the resulting organization was named the Emergency Department Nurses Association. The name was changed in 1985 to the Emergency Nurses Association in recognition of the fact that emergency nurses do not just practice in emergency departments (EDs). To be inclusive of all nurses who practice our specialty, the words matter. What is our specialty? If you said “emergency medicine,” do you have a medical license? You are not a physician, you are a nurse. Therefore, your specialty is emergency nursing or emergency care. What do you do if someone calls you “doctor” (and you are not a doctorally prepared nurse)? If you don't correct them, you are misleading the patient and that is unethical. You may also be promoting the stereotype that only physicians, not nurses, are highly intelligent. Many of you have undoubtedly been told by well-meaning physicians and others that you are so smart you should have gone to medical school. To this we respond, “Thank you. I'm sure you meant that as a compliment. But don't you think that the nurse, who spends the most time at the bedside, who makes life-saving decisions and performs complex interventions, and who advocates for patients and helps to protect them from harm, should be smart?” Of course, nurses need to be smart; patients' lives depend on them. You should be proud to be a nurse and ready to gently correct and educate your patients and the public. The term “medicine” is often used as a synonym for “health care.” While the distinction between the two terms may seem picky, inappropriate use of the term “medicine” may also serve to obscure the contribution of nursing and other disciplines to health care. For example, consider the term “medical records.” What about the nurses' notes and the notes from physical therapy, respiratory therapy, nutrition services, so forth? Why not call it the patient record or the health care record? A glaring example is the Institute of Medicine (IOM), which recently produced a ground-breaking document, The Future of Nursing: Leading Change, Advancing Health. This report fully recognizes the value of nursing. In fact, two of the major recommendations in the report are that nurses be (1) allowed to practice to the full scope of their education and training and (2) full partners in redesigning health care (IOM, 2010). The IOM report has been applauded by nurses and nursing organizations across the country. It is ironic, but not surprising, that the report came from the Institute of Medicine but was not well received by all medical groups because some perceive this as a threat to their status as “captain of the ship.” That the report is from the Institute of Medicine may reinforce the idea that nursing is subservient to medicine on a grand scale. We have previously suggested that the IOM be renamed the Institute of Health Care in recognition of the fact that medicine is a component of health care; it is not all of health care (Proehl & Hoyt, 2011). Tilting at windmills? Perhaps, perhaps not. —Jean A. Proehl, RN, MN, CEN, CPEN, FAEN Emergency Clinical Nurse Specialist Proehl PRN, LLC Cornish, NH —K. Sue Hoyt, PhD, RN, FNP-BC, CEN, FAEN, FAANP Emergency Nurse Practitioner St. Mary Medical Center Long Beach, CA

Development of Consensus Statement on Definitions for Consistent Emergency Department Metrics

One of the Emergency Nurses Association's (ENA) top three clinical priorities is crowding in the emergency department (ED). Crowding, which is defined as an excessive number of patients, was brought to the forefront of health care discussion via the 2006 Institute of Medicine report The Future of Emergency Care. 1 Institute of Medicine Committee on the Future of Emergency Care in the United States Health System. Hospital Based Emergency Care: At the Breaking Point. Institute of Medicine, National Academies Press, Washington, DC2007 Google Scholar Crowding is becoming progressively worse as the current recession creates additional pressure on our already strained health care system. Whether it is state funding cuts that result in closing psychiatric care facilities, individuals losing health care coverage, or individuals not being able to afford the medications that they or their families need, all of these situations result in more people coming to the emergency department for their health care of last resort. Response to: “Development of Consensus Statement on Definitions for Consistent Emergency Department Metrics”Journal of Emergency NursingVol. 38Issue 6PreviewI am writing with regard to the article “Development of Consensus Statement on Definitions for Consistent Emergency Department Metrics.”1 I work in a 28-bed, Level III trauma center north of Houston. Our department sees 90 to 120 patients daily, and we continue to have patients leaving without medical screening examinations as we remain saturated. Most of our beds remain occupied with patients holding for admission or with psychiatric patients boarding in the emergency department for 12 to 48 hours awaiting psychiatric placement. Full-Text PDF