On-call Specialists Research Articles

Emergency management of traumatic dental injuries in 42 countries.

Availability and quality of emergency services for traumatic dental injuries (TDI) are important as the prognosis of TDI is decided at the place of accident or during the first hours after the injury has occurred. To report how emergency services for TDI are provided in some places around the world. This is a preliminary observational study of descriptive character. One-hundred and three participants from 83 cities in 42 countries described the emergency services in their city by answering a questionnaire related to: (1) availability of advice per telephone at the place of the accident; (2) availability of emergency treatment resources at different times of the day; and; (3) assessment of competence level of the person carrying out the service. Answers and comments were scored with regard to availability and level of competence. 62% of the participants were not satisfied with their current emergency services. 50% reported organized emergency telephone service always available. 43% of the advice given by phone was from professionals with dental training. An organized on-call 24/7 service was available in 33%. Treatment of TDI within the first hour was available in 53%. A competent dentist was available in 40%. 56% reported compromised competency outside office hours. Places with a well-organized system built on a well-developed first-line care managed by trauma-trained general dentists, ideally on a 24/7 basis, supported by on-call specialists outside office working hours, achieved the highest scores. With all the limitations of a preliminary questionnaire study, we can conclude that there is a need to perform more comprehensive well-designed studies in this field to understand more of the varying quality of emergency services worldwide. The major problem today seems to be related to limited availability and competence, especially outside office working hours.

Cost analysis of miniaturized ECMO in H1N1-related ARDS managed by a single caregiver

Dear Editor, Extracorporeal membrane oxygenation (ECMO) has a significant impact on intensive care unit (ICU) patient costs. Human resources are a major cost driver for ECMO in severe acute respiratory distress syndrome (ARDS) [1]. However, recent developments in ECMO technology has allowed safe patient management by a single caregiver [2–4]. In the present report, we analyze the direct ICU costs of patients with influenza A (H1N1)-related ARDS supported with miniaturized ECMO systems and managed by a single caregiver. We performed an observational study of all patients (n = 10) with H1N1-associated ARDS treated with ECMO in Hospital S. Joao (Porto, Portugal), between November 2009 and April 2011. The clinical data and ECMO treatment details of this ICU patient cohort have been described in a previous report [5]. Patients were admitted in medical ICUs and managed by a single caregiver using miniaturized ECMO circuits (Rotaflow Centrifugal Pump plus Quadrox PLS and CARDIOHELP; Maquet Cardiopulmonary AG). In our single caregiver model, the ICU nurse primarily managed the ECMO patient under the coordination of 24/7 inhouse ICU physicians, with the backup of an on-call ECMO specialist. Our multidisciplinary ECMO specialist team (ICU physicians, ICU nurses, and cardiovascular perfusionists) is responsible for managing equipment and supplies, circuit preparation, patient transportation, troubleshooting, daily rounds, education, and service administration. Per patient ICU direct costs were analyzed retrospectively from clinical records and hospital databases using both top-down and bottom-up approaches. Bottom-up analysis was performed for all drugs, transfusion requirements, laboratory and imagiology exams. Regarding disposable items, bottom-up analysis was possible for ECMO-specific disposables and for renal replacement therapies. Costs with human resources were assessed using the top-down approach. Specific ECMO costs were also individualized for each ICU episode: (1) disposables devices; (2) laboratory tests; (3) transfusion requirements; and (4) drugs. The Ethics Committee of the Hospital S. Joao approved this study and waived the need for patients’ informed consent. Variables are reported as median and interquartile ranges, if not otherwise indicated. The cost drivers of H1N1-related ARDS patients treated with miniaturized ECMO are presented in Table 1. ECMO support corresponded to 63.6 (62.5–88.5) % of the ICU length of stay (LOS). The ICU LOS positively correlated (r = 0.97; p \ 0.001) with ICU patient costs [42,721 (33,358–56,801) €], but not with specific ECMO costs [r = 0.17; p = 0.63; 7,516 (5,599–7,736) €]. ECMO-specific costs represented 17.6 (13.1–18.1) % of the total ICU direct costs, mostly ECMO disposable devices [94.8 (87.1–96.1) %]. Daily ICU costs with antibiotics, sedation, analgesia and neuromuscular blockade, fluids and nutrition, vasoactive drugs, anticoagulation medications, and other unspecific drugs were higher during the period of ECMO support compared with the period without ECMO support. In conclusion, the use of miniaturized ECMO had a small impact on direct ICU costs in our cohort of H1N1-related severe ARDS patients managed by a single caregiver and did not correlate with the ICU LOS. Knowledge of the incremental costs associated with miniaturized ECMO will contribute to the clarification of its cost-effectiveness in severe ARDS.

Frostbite: a practical approach to hospital management.

Frostbite presentation to hospital is relatively infrequent, and the optimal management of the more severely injured patient requires a multidisciplinary integration of specialist care. Clinicians with an interest in wilderness medicine/freezing cold injury have the awareness of specific potential interventions but may lack the skill or experience to implement the knowledge. The on-call specialist clinician (vascular, general surgery, orthopaedic, plastic surgeon or interventional radiologist), who is likely to receive these patients, may have the skill and knowledge to administer potentially limb-saving intervention but may be unaware of the available treatment options for frostbite. Over the last 10 years, frostbite management has improved with clear guidelines and management protocols available for both the medically trained and winter sports enthusiasts. Many specialist surgeons are unaware that patients with severe frostbite injuries presenting within 24 h of the injury may be good candidates for treatment with either TPA or iloprost. In this review, we aim to give a brief overview of field frostbite care and a practical guide to the hospital management of frostbite with a stepwise approach to thrombolysis and prostacyclin administration for clinicians.

The Enduring Role Of The Emergency Medical Treatment And Active Labor Act

The Emergency Medical Treatment and Active Labor Act (EMTALA) is a seminal law that imposes screening, stabilization, and transfer duties on all Medicare-participating hospitals that have emergency departments. More than twenty-five years after its enactment, EMTALA continues to generate controversy over the scope and depth of its obligations on issues ranging from the nature of the screening obligation and rules regarding on-call specialists to whether EMTALA's stabilization protections exclude emergency inpatients. Despite ongoing questions that flow from its detailed provisions, EMTALA is an enduring testament to society's evolving views that hospitals must provide emergency care not only to their established patients but to the broader communities they serve.

Emergency Physicians Accurately Interpret Video Capsule Endoscopy Findings in Suspected Upper Gastrointestinal Hemorrhage: A Video Survey

Acute upper gastrointestinal (GI) hemorrhage is a common emergency department (ED) presentation whose severity ranges from benign to life-threatening and the best tool to risk stratify the disease is an upper endoscopy, either by scope or by capsule, a procedure performed almost exclusively by gastroenterologists. Unfortunately, on-call gastroenterology specialists are often unavailable, and emergency physicians (EPs) currently lack an alternative method to endoscopically visualize a suspected acute upper GI hemorrhage. Recent reports have shown that video capsule endoscopy is well tolerated by ED patients and has similar sensitivity and specificity to endoscopy for upper GI hemorrhage. The study objective was to determine if EPs can detect upper GI bleeding on capsule endoscopy after a brief training session. A survey study was designed to demonstrate video examples of capsule endoscopy to EPs and determine if they could detect upper GI bleeding after a brief training session. All videos were generated from a prior ED-based study on patients with suspected acute upper GI hemorrhage. The training session consisted of less than 10 minutes of background information and capsule endoscopy video examples. EPs were recruited at the American College of Emergency Physicians Scientific Assembly in Denver, Colorado, from October 8, 2012, to October 10, 2012. Inclusion criteria included being an ED resident or attending physician and the exclusion criteria included any formal endoscopy training. The authors analyzed the agreement between the EPs and expert adjudicated capsule endoscopy readings for each capsule endoscopy video. For the outcome categories of blood (fresh or coffee grounds type) or no blood detected, the sensitivity and specificity were calculated. A total of 126 EPs were enrolled. Compared to expert gastroenterology-adjudicated interpretation, the sensitivity to detect blood was 0.94 (95% confidence interval [CI] = 0.91 to 0.96) and specificity was 0.87 (95% CI = 0.80 to 0.92). After brief training, EPs can accurately interpret video capsule endoscopy findings of presence of gross blood or no blood with high sensitivity and specificity.

Consequences of Federal Patient Transfer Regulations: Effect of the 2003 EMTALA Revision on a Tertiary Referral Center and Evidence of Possible Misuse

To the Editor: Emergency department (ED) utilization has risen steadily over the past 20 years, in part because patients are guaranteed medical attention under the Emergency Medical Treatment and Active Labor Act (EMTALA). EMTALA requires EDs to evaluate and stabilize all patients regardless of ability to pay, and hospitals must provide specialist care or arrange transfer to a tertiary care center when specialist care is unavailable.1,2 Community hospitals have reported difficulty providing specialist coverage since the enactment of EMTALA, and the Centers for Medicare and Medicaid Services (CMS) published its “Final Rule” regarding EMTALA in September, 2003, stating that hospitals with EDs are not required to guarantee specialist coverage at all times.3 It has been suggested that elimination of coverage requirements permits selective transfer of underinsured patients to centers with mandatory on-call specialists.4,5 This concern has not been validated, in part because data regarding EMTALA referrals are limited. Our institution has kept a log of transfer requests since 2000 that provides a unique opportunity to analyze trends in EMTALA transfer patterns.

Emergency obstetric care in a rural hospital: On-call specialists can manage C-sections

Background:Institutional birth and Emergency Obstetric Care (EmOC) are important strategies of the National Rural Health Mission (NRHM). While the Community Health Center (CHC) is expected to serve EmOC needs in NRHM, the CHCs are hamstrung due to chronic shortage of specialist doctors. Alternative strategies are therefore needed for ensuring EmOC.Objectives:This study aims to estimate the EmOC needs in a private rural hospital from case records and find some useful predictors for caesarian section (C-section) and to assess C-section needs in the context of on-call specialist support.Materials and Methods:We analyzed a two-decade series of 2587 obstetric cases in a private rural hospital for normal deliveries and EmOC including C-section.Results:About 80% of the obstetric cases were normal deliveries. Of the remaining 20% cases that required EmOC, nearly one-third required C-section. In the series, two maternal deaths occurred due to hemorrhage. About 13% case records showed past abortion, which adds to EmOC workload. Primipararous mothers with higher age had a greater incidence (23%) of C-section. The C-section rate shows a steady rise from 3% to above 10% in the series.Conclusions:This rural hospital required C-section in 6.4% cases. This C-section workload was managed with the help of on-call specialists. The local hospital team could manage 93.6% of the cases and abortions with only two maternal deaths. This strategy of an on-call specialist team can be an option for CHCs till resident specialists are adequately available.

Out of Hours Multidetector Computed Tomography Pulmonary Angiography: Are Specialist Resident Reports Reliable?

The purposes of this study were to assess the accuracy of trainee radiologists' reports for computed tomographic pulmonary angiographic (CTPA) imaging and to determine agreement or discrepancy with final verified consultant reports. A total of 100 consecutive out-of-hours CTPA examinations were prospectively analyzed. Fifty-one male and 49 female subjects were included in the study. The mean age of patients scanned was 63.7 years (range, 17-98 years). Eighteen of the 100 subjects (18%) had findings positive for pulmonary embolism. The interobserver agreement for pulmonary embolism between on-call radiology residents and consultant radiologists was almost perfect (κ = 0.932; 95% confidence interval, 0.84-1.0; P < .0001). There was one false-negative CTPA report. Eighty-two CTPA scans (82%) were reported as negative for pulmonary embolism by consultant radiologists. In this group, there was a single false-positive interpretation by the on-call specialist resident. The interobserver agreement for all findings between resident and consultant reports was almost perfect (weighted κ = 0.87; 95% confidence interval, 0.79-0.96; P < .0001). The overall discrepancy rate, including both false-positive and false-negative findings, between the on-call radiology resident and consultant radiologist was 8% (eight of 100). CTPA reports by radiology residents can be relied and acted upon without any major discrepancies. There is a relatively much higher proportion of patients with alternative diagnoses, mainly infective consolidation and heart failure presenting with similar symptoms and signs as pulmonary emboli. It is imperative for trainees to be systematic and review all images if observational omissions are to be reduced.

273 Emergent Availability of On-call Consultants in New York State

Study Objectives: National studies reveal a concerning shortage of timely availability of specialists to treat patients with emergent conditions. How hospitals are addressing this issue and the extent of this issue in specific states remain unclear, but are of interest to lawmakers. Here we seek to assess how often New York emergency departments (EDs) experience delays in obtaining emergent consultations, and to determine what measures hospitals have adopted in response. Email addresses were obtained and validated for New York ED directors. An anonymous electronic survey was sent to directors using an online survey tool. The survey asked how often (5-point Likert scale) various types of specialists were on-call and were available in under 2 hours. The survey also asked about specialist availability within 12 hours, times when availability was worse, knowledge of resulting adverse patient outcomes, and whether specific measures had been taken by hospitals to address the problem. Specified specialties included general surgery, trauma surgery, orthopedic surgery, cardiovascular surgery, neurosurgery, hand surgery, cardiology, gastroenterology, ophthalmology, and obstetrics and gynecology. Descriptive statistics were calculated overall and by hospital size. Significance of differences among size groups was determined by the Fisher Exact Test. Contact information was validated for 128 of 176 New York ED directors (72%). 60 responded (47%): 45% from EDs with under 50,000 annual patient visits and 17% with over 100,000; 46% from academic EDs (80% of large, 68% of medium and 15% of small EDs). 64.8% of directors reported witnessing adverse clinical outcomes due to lack of timely specialist availability. 80% of large, 61% of medium and 15% of small EDs always have specialists on-call for each specialty (P < 0.022). 89% of large, 61% of medium and 15% of small EDs can always access specialists who are on-call within 2h (P < 0.095). Of those who cannot 22% reported more difficulty on weekdays, 63% on weekends and 63% overnight. Over 25% of all respondents “never” or “rarely” obtained consultations in under 2 hours from cardiovascular surgery, neurosurgery, hand surgery and ophthalmology. Overall, 90% reported consulting specialists who are not on-call at times when on-call specialists were not available. At least 1 quarter of small EDs are not always able to get on-call specialists to consult within 12 hours for trauma surgery, cardiovascular surgery, neurosurgery, hand surgery and gastroenterology. Only 3 hospitals (5%) have attempted to make legislative or regulatory changes at a city, county or state level. 36% share consultants among hospitals (a “community share plan”). Hospital-based solutions were implemented by 75%, most commonly: allowing specialists to perform elective or other procedures while on call (70%), allowing specialists to take call at more than1 hospital (68%), hiring hospitalists or surgicalists (60%), compensating on-call specialists for time on call (60%), allowing consultation by phone or internet (47%). Emergent specialist availability is a significant problem in New York, especially at smaller hospitals. Many hospitals are attempting to address it. Further research is needed to identify the effectiveness of the attempted solutions.

The Shortage of On‐call Surgical Specialist Coverage: A National Survey of Emergency Department Directors

problems with on-call specialist physician coverage have been identified as a significant issue for our nation's health care system. Despite this, little is known about the full extent of these coverage deficiencies in emergency departments (EDs), their effect on emergency care provision, or the subsequent effect on patient flow should specialist-requiring patients need to be transferred to centers of higher-level care. The objective was to report the experiences of a national sample of ED directors regarding the degree of difficulty in providing specialist coverage and the effect of on-call coverage problems on emergency patient care. the authors conducted a cross-sectional self-administered survey of a national sample of ED directors. How frequently ED directors reported on-call coverage problems, whether they recently lost on-call coverage, whether their current on-call coverage was reliable, and the potential effect on emergency care provision were all assessed. the overall response rate was 62% (442 of 715). Seventy-four percent of respondents reported on-call coverage problems with specialist physicians. Sixty percent reported having lost 24/7 coverage for at least one specialty in the past 4 years. Twenty-six percent reported unreliability in their current on-call coverage. Twenty-three percent noted that their trauma center designation level had been affected by on-call coverage, and 22% noted an increase in patients leaving before being seen by a medically needed specialist. difficulties in obtaining specialty on-call coverage are a pervasive issue for EDs at the national level. Emergency care provision appears to have been affected, and this issue is further impacted by a perceived unreliability in current on-call coverage provision as well as the attrition of coverage for individual specialties.

A systematic review of economic analyses of telehealth services using real time video communication

BackgroundTelehealth is the delivery of health care at a distance, using information and communication technology. The major rationales for its introduction have been to decrease costs, improve efficiency and increase access in health care delivery. This systematic review assesses the economic value of one type of telehealth delivery - synchronous or real time video communication - rather than examining a heterogeneous range of delivery modes as has been the case with previous reviews in this area.MethodsA systematic search was undertaken for economic analyses of the clinical use of telehealth, ending in June 2009. Studies with patient outcome data and a non-telehealth comparator were included. Cost analyses, non-comparative studies and those where patient satisfaction was the only health outcome were excluded.Results36 articles met the inclusion criteria. 22(61%) of the studies found telehealth to be less costly than the non-telehealth alternative, 11(31%) found greater costs and 3 (9%) gave the same or mixed results. 23 of the studies took the perspective of the health services, 12 were societal, and one was from the patient perspective. In three studies of telehealth to rural areas, the health services paid more for telehealth, but due to savings in patient travel, the societal perspective demonstrated cost savings. In regard to health outcomes, 12 (33%) of studies found improved health outcomes, 21 (58%) found outcomes were not significantly different, 2(6%) found that telehealth was less effective, and 1 (3%) found outcomes differed according to patient group. The organisational model of care was more important in determining the value of the service than the clinical discipline, the type of technology, or the date of the study.ConclusionDelivery of health services by real time video communication was cost-effective for home care and access to on-call hospital specialists, showed mixed results for rural service delivery, and was not cost-effective for local delivery of services between hospitals and primary care.

Emergency department utilization and capacity.

Americans rely on emergency departments (EDs) to play a critical role in the health care safety net. But while the number of ED visits climbed significantly, the number of EDs dropped from 5,000 to 4,000 from 1991 to 2006. This synthesis examines the evidence on who uses EDs, the causes and consequences of overcrowding, and the cost of providing care in the ED. Key findings include: privately insured patients account for the largest and fastest growing segment of ED users. Low income and poor health are strong predictors on ED use. After adjusting for health status and other demographic and market factors, the uninsured use the ED at the same rate as the privately insured, while patients with Medicaid/SCHIP or Medicare had much higher utilization rates. The use of EDs for non-urgent, preventable conditions is growing due to limited access to primary care providers, although the identification of these conditions is imprecise. Patient boarding, or the inability to move patients from the ED to the appropriate inpatient unit, and a shortage of on-call specialists are major causes of ED overcrowding. The true cost of providing care in the ED is complex and not well understood. Finally, expansion of health insurance coverage is likely to increase rather than decrease stress on overcrowded EDs because the insured represent the fastest growing subpopulation of ED users.

On-Call Specialists and Risks to EPs

On-Call Specialists and Risks to EPs

Study: Shortage of On-Call Specialists Spreads Nationally

Study: Shortage of On-Call Specialists Spreads Nationally

On‐call Specialists and Higher Level of Care Transfers in California Emergency Departments

To survey California emergency department (ED) medical directors' impressions of on-call specialist availability and higher level of care (HLOC) transfer needs and difficulties and changes since the passage of the Emergency Medicine Treatment and Active Labor Act (EMTALA) final rule in 2003. The authors conducted a survey of all California ED medical directors from February to June 2006 with regard to the composition of the ED on-call panel and need for HLOC transfer. ED demographic data were obtained from the California Office of Statewide Health Planning and Development. Overall response rate was 243 of 347 (70%). More than 80% of respondent EDs reported having internal medicine, obstetrics/gynecology (OB/GYN), and pediatrics on call. However, fewer than 60% of EDs reported cardiac surgery, otolaryngology, neurosurgery, plastic surgery, or vascular surgery on call. Specialists were less likely to be on call in rural EDs. On-call coverage was rated worse than 3 years ago for 10 of 16 specialties. Rural EDs were more likely, and trauma centers and teaching hospitals were less likely to transfer at least one patient daily for HLOC. ED medical directors reported that the ability to transfer for HLOC has worsened over the past 3 years for all specialties. Respondents indicated that more than 40% of ear, nose, and throat (ENT), orthopedics, plastic surgery, and mental health HLOC transfers take more than 3 hours. This survey of California ED medical directors suggests ED on-call specialist availability and the ability to transfer for HLOC have worsened since the passage of the EMTALA final rule in 2003.

Study Highlights Dire Lack of Emergency On-Call Specialists

Study Highlights Dire Lack of Emergency On-Call Specialists

Executive Summary: The Institute of Medicine Report and the Future of Academic Emergency Medicine: The Society for Academic Emergency Medicine and Association of Academic Chairs in Emergency Medicine Panel: Association of American Medical Colleges Annual Meeting, October 28, 2006

The findings in the Institute of Medicine's Future of Emergency Care reports, released in June 2006, emphasize that emergency physicians work in a fragmented system of emergency care with limited interhospital and out-of-hospital care coordination, too few on-call specialists, minimal disaster readiness, strained inpatient resources, and inadequate pediatric emergency services. Areas warranting special attention at academic medical centers (AMCs), both those included within the report and others warranting further attention, were reviewed by a distinguished panel and include the following: 1) opportunities to strengthen and leverage the educational environment within the AMC emergency department; 2) research opportunities created by emergency medicine (EM) serving as an interdisciplinary bridge in the area of clinical and translational research; 3) enhancement of federal guidelines for observational and interventional emergency care research; 4) recognition of the importance of EM residency training, the role of academic departments of EM, and EM subspecialty development in critical care medicine and out-of-hospital and disaster medicine; 5) further assessment of the impact of a regional emergency care model on patient outcomes and exploration of the role of AMCs in the development of such a model (e.g., geriatric and pediatric centers of EM excellence); 6) the opportunity to use educational loan forgiveness to encourage rural EM practice and the development of innovative EM educational programs linked to rural hospitals; and 7) the need to address AMC emergency department crowding and its adverse effect on quality of care and patient safety. Strategic plans should be developed on a local level in conjunction with support from national EM organizations, allied health care, specialty organizations, and consumer groups to help implement the recommendations of the Institute of Medicine report. The report recommendations and other related recommendations brought forward during the panel discussions should be addressed through innovative programs and policy development at the regional and federal levels.

The On-Call Crisis: A Statewide Assessment of the Costs of Providing On-Call Specialist Coverage

A recent change in the delivery of emergency care is a growing reluctance of specialists to take call. The objective of this study is to survey Oregon hospitals about the prevalence and magnitude of stipends for taking emergency call and to assess the ways in which hospitals are limiting services. This was a cross-sectional, standardized survey of chief executive officers from all hospitals with emergency departments in Oregon (N=56). This e-mail-based survey asked about payments made to specialists to take call and examined changes in hospitals' trauma designation and ability to provide continuous coverage for certain specialties. We received responses from 54 of 56 hospitals, representing a 96% response rate (100% of trauma centers). Twenty-three of 54 (43%) Oregon hospitals pay a stipend to at least 1 specialty, and 17 (31%) hospitals guarantee pay for uninsured patients treated on call. Stipends ranged from $300 per month to more than $3,000 per night, with a median stipend of $1,000 per night to take call. Trauma surgeons, neurosurgeons, and orthopedists were the specialists most likely to receive stipends. Seven of 54 (13%) hospitals have had their trauma designation affected by on-call issues. Twenty-six hospitals (48%) have lost the ability to provide continuous coverage for at least 1 specialty. Problems with on-call coverage are prevalent in Oregon and affect hospital financing and delivery of services. A continuation of the current situation could degrade the effectiveness of the trauma system and adversely affect the quality of emergency care.

CT pulmonary angiography for the detection of pulmonary embolism: interobserver agreement between on-call radiology residents and specialists (CTPA interobserver agreement)

The aim of this study was to prospectively determine interobserver agreement between on-call radiology residents and specialists in the interpretation of computed tomographic pulmonary angiography (CTPA). CTPA examinations obtained between January 2002 and March 2003 were interpreted by a radiology resident on call and by two radiology specialists. Agreement was assessed using percentage of agreement between interpreters and by the kappa coefficient. Sensitivity of residents' interpretations was calculated by relating them to the interpretation of Specialist 1, which served as the gold standard. Of the 81 CTPA examinations evaluated, there was agreement of 93% and 91% for the diagnosis of pulmonary embolism (PE) and of 97% and 85% for the exclusion of PE with Specialist 1 and 2, respectively. The concordance between residents' interpretations and those of Specialist 1 was very high (kappa=.8), and with those of Specialist 2 was high (kappa=.7). In all cases of agreement between the two specialists, there was complete agreement between the specialists' and the residents' intepretations. Our study showed good to very good agreement of residents' interpretations with each of the radiology specialists. Therefore, relying on the residents' preliminary interpretations during after-hour calls is reasonable.

Predictors of On‐call Specialist Response Times in California Emergency Departments

To assess waiting times in emergency departments (EDs) for on-call specialist response and how these might vary by facility or neighborhood characteristics. Limited availability of on-call specialists is thought to contribute to ED overcrowding. Direct observational data from a random sample of 1,798 patients visiting 30 California EDs during a six-month period provided specialist waiting times. The authors used multivariate logistic regression and survival analysis to analyze predictors of time to on-call specialists' telephone response. Eighty-six percent of on-call specialists who were paged responded by telephone within 30 minutes. Ten percent of specialists did not respond at all. After controlling for the annual percentage of nonurgent ED patients at each facility, near closure status, and hospital ownership status, for every 10,000 dollars increase in hospital zip code income, the odds of on-call specialist response within 30 minutes increased by 123% (adjusted odds ratio = 2.23; 95% confidence interval = 1.24 to 4.02; p = 0.01). Although the majority of on-call specialists met the federal recommendation of a 30-minute response, those in poor neighborhoods were less likely to do so. One in ten on-call specialists did not respond at all. State and federal policies should focus on making more funding available for on-call specialist panels in poor areas.