Inadequate Surgical Coverage In The ER

Wed, 11/24/2010 - 3:45am

The majority of emergency department directors responding to a survey report inadequate on-call trauma coverage, and nearly one-quarter report a loss or downgrade of their hospitals' trauma center designations. The survey results are reported in a new study appearing online and in the December print edition of Academic Emergency Medicine. "Without adequate on-call surgical coverage, our health care system cannot provide for emergency and trauma patients," said lead study author Mitesh Rao, MD, MHS, of the department of emergency medicine at Yale University in New Haven, Connecticut and clinical scholar with the Robert Wood Johnson Foundation.

"Twenty-one percent of emergency department deaths and permanent injury can be linked to shortages in specialty physician care. Transferring patients significant distances to an available specialist is sometimes the only option, but it can create a dangerous delay in care." Sixty percent of respondents reported losing the ability to provide round-the-clock coverage for at least one medical specialty in the last four years. More than three-quarters of respondents reported that their emergency departments have inadequate coverage for plastic surgery, hand surgery and neurosurgery. Almost one-quarter of survey respondents reported an increase in patients leaving before being seen by a medically needed specialist, which is known to lead to worse outcomes and increased need for hospitalization.

"More than 70 percent of respondents noted difficulties with their neurosurgical coverage, and 80 percent reported inadequate hand surgery coverage," said Dr. Rao. "Patients with traumatic brain or hand injuries have a substantial risk of lifetime disability if they cannot get appropriate care in a timely fashion. We need to change the system to better handle the incentives and disincentives for surgeons who are willing to take call in the emergency department."

Teaching hospitals fare better than non-teaching hospitals, with inadequate coverage reported at 68 percent of the former and 78 percent of the latter. However, that may increase the burden on what the Institute of Medicine considers "core safety net providers" if non-teaching hospitals increasingly transfer patients who need surgical care to teaching hospitals.

"If you are in a car crash or even slice open your hand carving the holiday turkey, you need fast access to emergency surgery," said Sandra Schneider, MD, FACEP, the president of the American College of Emergency Physicians. "This study highlights one of the most critical threats to the emergency medical care system. As we implement health care reform, lawmakers must take steps to ensure that emergency surgery is available to anyone who needs it. Medical liability reform would be a great first step."


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