The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions.
The emergency department (ED) is quite possibly the most vulnerable area in our healthcare system when it comes to harm from avoidable errors. On almost every shift, emergency physician and nurses cope with high production pressures, unknown patients, ritualized multitasking, noise, frequent interruptions, suboptimal teaming and uncontrolled flow. Some of their patients may be unstable and in highly dynamic phases of illness. What's more, these providers often find themselves attempting to cover the entire spectrum of specialty care (which spans 24 specialties and nearly 100 subspecialties).
In other words, if one were to develop a test lab for medical error, it would quite possibly look like today's ED. But given these realities, is safety our top priority in emergency care?
Physicians Worried About the Future of Healthcare
A survey of 1,200 providers has revealed that many physicians are increasingly skeptical about the current state and future of healthcare. Over 60 percent of those surveyed believe "the current healthcare climate is 'somewhat to very' detrimental to care," with the same number of providers believing that the quality of medicine will decline over the next few years. Additionally, around three-quarters of physicians are unfamiliar with the Accountable Care Organization (ACO) model that has been touted as the future of healthcare delivery.
Recently I heard Dr. Sanjay Gupta give a talk at the Marin Speaker Series. He covered a lot of ground (he is CNN's most traveled correspondent), and one of the issues he discussed was altruism. He cited a study linking altruism to neural activation of a pleasure center in the brain. This study substantiated his belief that altruism was a fundamental attribute of human nature, something he has seen consistently and repeatedly on every continent. This observation segued into the role of altruism in the practice of medicine, and this in turn led me to consider the particular role of altruism in the practice of emergency medicine. Although I am not inclined to believe that altruism is a universal human trait, I do think altruistic tendencies play a role in the personal choices we make and the walks of life we tend to follow. Medicine is obviously just one of many professions that offer opportunities to exercise the altruistic muscle; and unfortunately opportunities to satisfy our baser instincts as well. Certainly, emergency physicians (EPs) do not have a corner on the altruism market, but there is no question in my mind that altruism plays a major role in the practice of emergency medicine.
As a physician assistant working in the emergency department, one of my greatest frustrations is sending my patients out the door and into the great unknown of post-discharge care. On
every shift, I encounter several who lack a "medical home" that they can rely on for follow-up care. I do my best to arm them with a few basic resources — the phone numbers and addresses for the county hospital, local clinics or their insurance carrier. But without a more comprehensive plan, I worry that in a few days or weeks, these patients will land back in the emergency room (or worse, a different emergency room where they will undergo repetitive exams and testing leading to the same diagnostic conclusion they had weeks or even days before).
Proper coding of emergency department (ED) services is crucial to hospital reimbursement. And with expanded coverage under Obamacare expected to drive increased patient volumes, compliant but appropriate patient acuity coding will be more important that ever. However, documentation and coding reviews conducted by our team at Healthcare Administrative Partners suggests that providers at pediatric EDs have a tendency to undervalue some of the services they provide.
The guidelines of emergency department charting and coding (which include History/Physical and Medical Decision Making) are governed by CMS and CPT requirements that span all ED settings. However, pediatric EDs differ significantly from their generalist counterparts in terms of acuity metrics, type of care rendered and documentation challenges. For example, an injury that might result in prescription medication for an adult usually results in an over-the-counter medication for a child, because many prescription-strength painkillers are not suitable for children. And in terms of documenting key elements of the patient history, any pediatrician can attest that three-year olds simply aren't very good historians.
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Great article Seth! As a non-clinician, I know that a call-back would mean the
Great article and really a good 'how to do it' in a way that makes sense and
Thanks, Seth, for highlighting the personal gratification that comes from
Rachel, thank you for sharing your unique method of coping that allows you to