status of clinical and academic emergency medicine at 111 veterans affairs medical centers

ORIGINAL CONTRIBUTION Veterans Affairs medical centers

Status of Clinical and Academic Emergency

Medicine at 111 Veterans Affairs Medical Centers

From the Emergency Medicine Service, Portland Veterans Affairs Medical Centel, Portland, Oregon; and Department of Emergency Medicine, Highland General Hospital, Oakland, California.

Received for publication April I3, I992. Revision received March 17, I993. Accepted for publication March i8, I993.

Gary P Young, MD, FACEP, FACP Study objectives: To assess the current state of clinical and academic emergency medicine at Veterans Affairs medical centers in the nation's largest health care system.

Design and interventions: Written survey mailed to 111 Veterans Affairs medical centers.

Setting: One hundred eleven Veterans Affairs medical centers affiliated with medical schools and designated as providing acute medical care.

Participants: Veterans Affairs physicians and administrative managers responsible for Veterans Affairs medical center emergency departments•

Measurements and main results: All 111 Veterans Affairs medical centers surveyed were included in the results. All provide emergency patient care; all but one of these Veterans Affairs EDs (99%) are open 24 hours a day, seven days a week• The mean ED census is 55 patients per day (or slightly more than 20,000 patients annually). The mean percentage of admitted patients is 26%, 31% of whom are admitted to ICUs. Acute, unscheduled ambulance patients are transported from home to 106 (96%)Veterans Affairs medicar centers, and 105 (95%) accept patient transfers directly from other hospitals' EDs. House staff rotate through 60 (55%) of these EDs as part of their training; emergency medicine house staff rotate through four (7%) of these EDs. There are emergency medicine residency- trained and/or emergency medicine board-certified physicians in 21 (19%) of these Veterans Affairs EDs: At the time of the survey, 29 (26%) of the respondents were either actively recruiting (12) or planning to recruit (17) emergency medicine staff physicians, including 13 seeking an ED director. In five cases, an inde- pendent emergency medicine service/section is responsibl e for their ED, three of which are affiliated with a division/department of emergency medicine at their medical school•

Conclusion: In many EDs at Veterans Affairs medical centers, nonemergency medicine staff physicians and house

AUGUST 1993 22:8 ANNALS OF EMERGENCY MEDICINE 1 3 0 4 / 7 5

VETERANS MEDICAL CENTERS Young

staff unsupervised by emergency physicians care for patients seeking emergency medical care. In addition, there is a growing need for more emergency medicine staff physicians and emergency medicine house staff in the Veterans Affairs system. Organized emergency medicine should initiate efforts to inform administrators and legislators responsible for Veterans Affairs policy making and funding.

[Young GP: Status of clinical and academic emergency medicine at 111 Veterans Affairs medical centers. Ann Emerg MedAugust 1993;22:1304-1309.]

INTRODUOTION

In 1989, the American College of Emergency Physicians' Task Force on Military Emergency Medicine published a position statement in Annals of Emergency Medicine entitled "Military Emergency Medical Systems. ''1 Thus was emergency medicine in our national military health care system documented with regard to scope of services, cate- gorization of emergency departments, physician staffing and contracting, provider mix including nursing and other providers, prehospital care and patient transfers, education and training of house staff and undergraduates, and "organizational and personnel considerations. "1 This document ended with a "summary of major recommendations," which concluded that "where a legitimate need for ongoing emergency medical services is demonstrated, the ultimate goal would be to staff such EDs with a full com- plement of board-certified and board-prepared emergency physicians and all other resources recommended.., consis- tent with the evolving standard in the civilian sector, q The task force's recommendations were thorough and comprehensive regarding the need for the national health care system of the uniformed services within the Department of Defense to commit itself promptly to meet- ing the civilian standard of care in emergency medicine, both clinically and academically.2, 3

The nation's largest health care system, the national health care system of the Department of Veterans Affairs (VA), now finds itself at a similar crossroads with regard to providing emergency medical care to veterans. 4-6 Governing bodies, such as the Joint Commission on Accreditation of Healthcare Organizations, the Residency Review Committee for Emergency Medicine, and the Residency Review Committee for Internal Medicine, stipulate that the-VA system must meet the community and teaching hospital standards of practice in emergency medicine, incIuding the supervision and work hours of house staff.r, 8 Thus, there is a need to assess the status of

clinical and academic emergency medicine in the VA system. The objectives of this survey of those 111 medical school-affiliated VA medical centers designated as providing acute medical care were to delineate current clinical and academic emergency medicine in the Veterans Affairs system; to serve as a baseline from which io measure progress as the VA's emergency medicine capabilities improve; and to provide vital information to, and to make recommendations for, policy makers in the Central Office of the VA in Washington, DC, as well as VA medical center directors and chiefs of staff throughout the country.

MATERIALS AND METHODS

A three-page survey (Figure 1) was sent to the chief of staff's offices of 111 (65%) of the 172 VA medical centers. These VA medical centers were chosen for two reasons: They are among the 134 VA medical centers that are academically affiliated with 102 of the nation's medical schools, and they are a further subset of VA medical

Figure 1. Key survey items

VA medical center demographics Population of city ED patient census ED patient admissions

VA medical center relationships VA position of respondent Official name of ED Organizational model of ED Section, service, or program responsible for ED Division or department affiliations at medical school

Emergency medical services system relationships Ambulance patient traffic Ambulance "divert" mechanism Transfers from other EDs

ED staffing Number of health care personnel Type of health care personnel Number and type of house staff Supervision of house staff

ED staff physicians Number of VA staff physicians Specialties of VA staff physicians Academic rank and position at medical school Use of monnlighting physicians

ED medical directors Medical school academic rank, position, and compensation Time and effort distribution Title of supervisor of ED medical director

Emergency medicine-trained and/or board-certified staff Present VA staff Recruitment plans

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centers that are clinically designated as providing acute medical care (ie, care for emergency and urgent patient conditions). The general categories and specific items were chosen and developed initially by the author to fulfill the goals and objectives mentioned above (Figure 1). The format and specific questions were validated by feed- back provided by our VA medical center's chief of staff and from our university hospital's director of emergency medicine research programs. This survey was exempted from institutional review board review.

The survey was undertaken and completed within a six-month period in 1991. All 111 VA medical centers voluntarily responded in writing, either initially or with follow-up mail contacts, and completed every section of the survey instrument. Data analysis of the survey responses involved standard descriptive statistics for mean values and standard deviations. Statistical analyses included the Z 2 test for categorical variables (P < .05). Analytical comparisons (correlations and frequency analyses) were made using the Kruskall-Wallis nonparametric test (P _< .05; two-sided analysis).

RESULTS

The respondents included 32 (29%) medical directors of their respective EDs, 51 (46%) physicians responsible for outpatient ambulatory care in their VA medical centers, 11 chiefs of staff, and 17 nonphysician administrative officers. VA administrative officers function like ED managers in each VA medical center and serve as a reliable source of ED data. The 111 VA medical centers are located in cities of various sizes, ranging from less than 50,000 (19%) to more than 500,000 (36%) (Figure 2). The most common name for the locations where veterans receive

Figure 2. Populations of 111 study cities with VA medical center EDs

50-100,000 (15.3%)

< 50,000 (19.0%)

00-500,000 (29.7%)

> 500 ,000 (36.0%)

i

acute outpatient care on an unscheduled basis is the emergency "room" or "department" in 50 (45%), whereas 24 are titled "evaluations and admissions" and 23, the "admitting office." Of the remaining 14, about half refer to acute or urgent care and the other half to ambulatory care. The organizational structure of the study EDs significantly more often involves separate lines of responsibility and authority for physicians, nursing, and administrative functions within the VA medical center (97, 87%; P < .05, g2). The remainder of the EDs are wholly integrated patient care areas in which the medical director oversees all three functions (14, 13%).

All 111 VA medical centers provide emergency patient care; all but one of these VA EDs (more than 99%) are open 24 hours a day, seven days a week. ED census data, including ambulance and admitted patients, are shown (Table 1). The mean census is 55 + 35 patients per day, or slightly more than 20,000 annual patient visits. The mean percentage of admitted patients is 26 + 19%, 31 + 15% of whom are admitted to ICU settings. Acute, unscheduled ambulance patients are transported from home to 106 (96%) VA medical centers. Also, 105 (95%) accept patient transfers directly from other hospitals' EDs. Almost half of these VA medical centers (50, 47%) do not divert ambulance patients at any time; the remaining 56 (53%) have a mechanism for diverting ambulance traffic from the ED. Among those VA medical centers that divert ambulance traffic, it was estimated that 11 _+ 12% of the

Figure 3. Physician coverage in 11 ] VA medical center EDs (unsupervised and supervised house staff*)

No. of VA Medical Center EDs • VA Staff 120 1 [] Moonlighters

[ ] Supervised House Staff Unsupervised House Staff

1OO

80

60

40

20

0 Weekdays Weekday Evenings Weekday Nights Weekends/Holidays

Different shifts during the day or week *The columns do not add up to 111 ; the remaining ED clinical coverage is provided by e combination of VA staff and moonlighting physicians•

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time is spent on divert. Although none of the VA medical centers are trauma centers, almost all (106, 96%) are capable of providing care to minor trauma patients, inc!uding any trauma patients brought by ambulance at 76 (69%) VA medical Centers (ie, within the parameters established by the local emergency medical services system).

Data concerning the health care workers providing ED care are shown (Table 2). VA-employed staff physicians provide a mean of 52 _+ 3 hours of clinical coverage per week (or 32% of the total number of hours in a week). The mean number of full-time and part-time VA staff physicians providing clinical patient care or supervision of house staff in the ED is 3.6 + 3.3 and 3.3 _ 3.% respec- tively However, because of other responsibilities within the medical centers, not all of which are related to ED functions, the mean full-time equivalent physician positions staffing each ED is actually 3.5 + 2.5 (Table 2). VA staff physicians work significantly more often during weekday day shifts (P < .05, Kruskall-Wallis) (Figure 3). The remainder of the week (mean, 114 hours) of total ED patient care time is provided by either non-VA staff physicians and/or house staff, who often are not supervised by either VA staff or non-VA staff physicians. Eighty- four VA medical center EDs (76%) employ "moonlighting" physicians, who provide a mean of 91 patient care hours per week. The moonlighting physicians are either non-VA physicians (in 37, 44%, of the 84 EDs) and/or house staff (59, 70%) who are not performing this service during their regular VA medical center house staff hours. Other than the requirement that they have state medical licenses, each VA medical center sets its own standards with regard to the qualifications of moonlighting physicians. Figure 3 also reveals that moonlighting physicians are used signifi-

Table 1. Daily ED census data for 111 VA medical center's

Daily Group %Ambulance % Census %ICU Census Census t Patients* Admitted § Admits ~ Groups*(No.) (Mean_+SD) (Mean_+SD) (Mean_+SD) (Mean+SD)

1-25 (26) 12 -+8 3 -+3 40 +-24 35 +_15 26-50 (27) 39 -+8 5 +3 27 +-15 33 +-15 51-75 (25) 65 +-7 5 +-3 21 +-17 38 _+14 76-10O {25) 88 +-8 5 +-4 15 +-7 27 +_ 13 > 100 (8) 130+-21 10+11 21 _+20 24-+14 Mean=111 55+-35 5+-4 26+-19 31+-15

*Number of VA medical centers with average daily ED patient census within five groupings at intervals of 25 patients per day. tMean daily ED patient censt~s in five groupings. *Percentage of total number of ED patients brought by ambulance. UPercentage of total number of ED patients admitted to hospital. ~Percentage of total admissions to an ICU setting.

cantly more often during nonweekday shifts (in about half of the VA medical centers; P < .05, Kruskall-Wallis).

House staff have primary responsibility for patient care as part of a residency training rotation in 61 (55%) of these EDs. The mean number of house staff per rotation is 2.5 _+ 1.9 (Table 2) with a range from one td ten at any time. The house staff care for patients an average of approximately 67 hours per week. Figure 3 reveals that house staff are significantly more likely to be supervised 0nly during weekday shifts, and they are more likely to provide unsupervised ED patient care during evenings, nights, and weekends or holidays (P < .05, Kruskall- Wallis). The house staff specialties include emergency medicine in only four of these 61 VA medical center EDs (7%) and internal medicine in almost all instances. Psychiatry, surgery, neurology, and family practice also provide house staff for VA medical center ED rotations.

There are emergency medicine residency-trained and/or board-certified VA staff physicians in 21 (19%) of these 111 VA medical center EDs. Nine (8%) of the EDs have emergency medicine residency-trained staff, and 17 (15%) have staff who are board certified in emergency medicine. Twenty-nine (26%) Of the VA medical centers reported plans to recruit staff physicians trained and/or board certified in the specialty of emergency medicine; 12 (41%) of these respondents were actively recruiting at the time of the surve)~ Among these planned recruitments are the position of ED medical director in 13 and staff emergency physicians in 16 EDs.

The academic rankings of the ED medical directors include seven (6%) professors, 26 (23%) associate professors, and 50 (45%) assistant professors. These academic

Table 2. ED personnel at 211 VA medical centers

No. of FTEs* Hr]Day Days/Week Hr/Week

Positions (Mean_+SD) (Mean_+SD) (Mean+SD) (Mean+SD)

IJhysician staff {111 EDs) 3.5+2.5 10.0+4.6 5.2+_0.6 52_+3

Moonlighting physicianst (84 EDs) NA 14.4+3.8 6.3_+1.7 91_+7

House staff (61 EDs) 2.5_+1.9 12.1 _+6.3 5.5_+1.1 67__7 Nursing staff (111 EDs) 10.6 +_6.9 23.9_+1.1 7_+0 167_+8 Nurse practitioner {29 EDs) 2.1 +2.0 8.6_+3.1 5.1 _+0.4 44+_1

Physician assistant (37 EDs) 1.9+-1.0 8.4-+2.8 5.1 +-0.5 43+-1

*FIE, salaried full-time equivalent positions. tMoonlighting physicians are non-VA, nonsalaried physicians; they may be house staff moonlighting during off-duty hours (see text).

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titles are held in the department or division of emergency medicine of the affiliated medical school or university in only four instances (3.6%); most of the remainder are in the department of medicine. The ED medical director receives some form of compensation from the medical school or university at 18 (16%) VA medical centers. The reported time and effort distribution for the ED medical directors are as follows: administrative, 43 _+ 26%; patient care, 38 + 24%; teaching, 15 + 17%; and research, 4 -+ 8%.

A service or section of emergency medicine is responsible for medical direction and patient care in the ED in only five (4.5%) of the 111 VA medical centers. Most often, either the ambulatory care program (80) or the general medicine section (25) is directly responsible for ED functions. Family practice provides medical direction for one VA medical center ED. On a functional chart, 18 (16%) of the ED medical directors report directly to their medical center's chief of staff, whereas most first report either to the directors of the ambulatory care program (62) or to the chiefs of the medicine service (31). Only three (3%) of the EDs are organizationally linked to an academic department or division of emergency medicine at their medical school or university hospital, whereas most (89%) fall under the auspices of the department of medicine. There are seven affiliations with surgery and two with family practice.

Comparison of survey results between those 50 (45%) VA medical centers using the label "emergency room" or "department" with the 61 (55%) VA medical centers not doing so reveals the following statistically significant differences. Five of the former and none of the latter VA medical centers have emergency medicine services or sections; three of these are linked with emergency medicine departments or divisions at their affiliated medical schools or university hospitals. Most (34, 68%) of the former VA medical centers rotate house staff through their EDs compared with only a few of the latter (27, 44%; P = .03, %2). As a consequence, at the VA medical centers not using the emergency label, VA staff physicians more often provide direct patient care (54 versus 39 hours per week; P = .03, t-test). Both groups of VA medical centers rely heavily on moonlighting physicians; often these physicians are moonlighting house staff. Although VA medical centers using the emergency label have more plans to recruit emergency medicine-trained and/or emergency medicine board-certified staff physicians (18 versus 11; P = .043), at the time of the suryey there was only a statistical trend between the two groups of VA medical centers with regard to emergency medicine specialists already on staff. There are no other statistically significant differences between

VA medical centers using the label "emergency room" or "department" compared with the VA medical centers not yet doing so.

DISCUSSION

The survey results indicate that the specialty of emergency medicine has only a small presence in the 111 VA medical centers that are affiliated with medical schools and that also provide acute patient care. Although house staff rotate through most (61) of these VA medical center EDs, in only four (7%) do they include emergency medicine house staff. There are emergency medicine residency- trained and/or board-certified VA staff physicians in only 21 (19%) of the 111 surveyed VA medical centers. These latter numbers should increase based on the intent of about one-fourth of these VA medical centers to recruit emergency physician staff, including ED medical directors. Academic appointments for VA staff within (four), and ED organizational links to (three), a department or division of emergency medicine at the affiliated medical school or university hospital are uncommon, as are actual emergency medicine services or sections within VA medical centers (five).

Other important survey results include: 1) almost all the VA medical center EDs provide continuous patient care and accept ambulance patients and interfacility transfers; but 2) VA staff physicians provide much less than half of the clinical hours of coverage in these EDs, in part because of insufficient numbers of such staff; and 3) as a consequence, either moonlighting physicians or house staff unsupervised by attending physicians provide most of the hours of clinical coverage for veteran patients seeking emergency medical care. Yet, compared with the community and academic standard of practice outside of the VA system, the VA has an inconsistent approach to emergency patient care. This is exemplified by the titles different VA medical centers give to their EDs, including emergency "room" or "department," "evaluations and admissions," and "admitting office." A more important example is the lack of compliance on the part of individual VA medical centers to meet Residency Review Committee requirements for house staff supervision in the ED,8 including the relative understaffing of full-time equivalent ED attending physician positions by most VA medical centers. 9 VA medical centers are being motivated by outside forces, including the Joint Commission on Accreditation of Heahhcare Organizations standards and individual Residency Review Committee decisions, to move toward compliance.r, s

AUGUST 1993 22:8 ANNALS OF EMERGENCY MEDICINE 1 3 O 8 / 7 9


Given the will to do so, the VA system can find a way to meet the community and academic standard of practice in emergency medicine. The external review pressures exerted by bodies such as the the Joint Commission on Accreditation of Healthcare Organizations and the Residency Review Committees are having an impact on individual VA medical centers whose concerns are being heard in the VA Central Office in Washington, DC. Specific measures to be used to evaluate future policy or interventions to address issues raised by these findings could include many of the measurements documented by this survey instrument: increasing numbers of emergency medicine residency-trained and/or emergency medicine board-certified staff physicians within the VA system; more house staff from emergency medicine residencies rotating through the EDs at VA medical centers; more on-line supervision of house staff caring for veterans in these EDs by well-trained attending staff; the use of fewer moonlighting physicians or unsupervised house staff; and an increase in the numbers of emergency medicine services or sections within VA medical centers, including their organizational links to departments or divisions of emergency medicine at affiliated medical schools or university hospitals.

More than just a symbolic statement, a change from the traditional titles that VA medical centers label their acute care areas to the more appropriate "emergency department" would better reflect the true needs of veterans seeking unscheduled, episodic acute care for their urgent and emergency medical problems. The VA Central Office has always shown a willingness to listen and respond to organized medicine, either directly or indirectly Organized emergency medicine should initiate efforts to inform administrators and legislators responsible for VA policy making and funding that veterans deserve quality emergency care.

C O N C L U S I O N

Reported is a survey of the current status of clinical and academic emergency medicine in the VA, the nation's largest health care system. In many EDs at VA medical centers, non-emergency medicine staff physicians and house staff unsupervised by emergency physicians care for patients in need of emergency medical care. There is a growing need for more emergency medicine staff physicians and emergency medicine house staff in the VA system. OrganiZed emergencymedicine (eg, the American Board of Emergency Medicine, the American College of Emergency Physicians, the Residency Review

Committee--Emergency Medicine, and the Society for Academic Emergency Medicine) can have a positive effect on these developments by informing deans of medical schools, university hospital directors, VA Central Office administrators, and legislators in Congress of the necessity for the VA to train and recruit emergency medicine specialists to provide quality emergency care for acutely ill and injured veterans.

R E F E R E N C E S

1. American College of Emergency Physicians: Military emergency medical systems. Ann Emerg Mad 1989;18:214-221.

2. Hamilton GC: Military sponsorship of resident training in civilian programs. Academic News and Views, Newsletter of the Academic Affairs Committee, American ColIege of Emergency Physicians, September 1989.

3. Ocrant I, Mallory D, Moore R: The relationship between ER patient diagnoses and medical officer of the day training in a small military hospital, Milit Med1984;149:366-368.

4. Schneider KC, Dove HG: High users of Veterans Administration ER facilities: Are outpatients abusing the system or is the system abusing them? Inquiry 1983;20:57-64.

5. Kerr HD, Byrd JC: Nursing home patients transferred by ambulance to a VA ED. JAm Geriatr Soc1991;39:132-136.

6. Walsh JW: Role of VA medical centers in emergency preparedness (editorial). MilitMed 1979;144:547.

7. Joint Commission on Accreditation of Healthcare Organizations, Chicago, Illinois.

8. Residency Review Committee for Emergency Medicine, Chicago, Illinois.

9. American College of Emergency Physicians: Emergency care guidelines (revised). Ann Emerg Med 1986;15:486490.

The author acknowledges the contributions of Drs Ted Galey, Jerris Hedges, and Bill Oirnikowski and of Ms Teresa Sanchez to the performance of this survey and prepa- ration of this manuscript.

Address for reprints: 6ary P Young, MD, FACEP, FACP

Department of Emergency Medicine

Highland General Hospital

1411 East 31 st Street

Oakland, Oalifornia 94602

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status of clinical and academic emergency medicine at 111 veterans affairs medical centers

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