Brief Report

State of affairs of emergency medicine in the Veterans Health Administration^?,??

Chad Kessler MD^a, Jennifer Chen MD, MPH^b,?, Curt Dill MD^c,

Gary Tyndall MD^d,e, Mark D. Olszyk MD^f

^aDepartments of Internal Medicine and Emergency Medicine, University of Illinois-Chicago, Jesse Brown VA Hospital,

Chicago, IL 60612, USA

^bDepartment of Medicine, David Geffen-UCLA School of Medicine, West Los Angeles VA Medical Center, Los Angeles,

CA 90073, USA

^cDepartment of Emergency Services, NYU School of Medicine, VA New York Harbor Healthcare Center, Brooklyn,

NY 11209, USA

^dEmergency Services, Syracuse VAMC, Syracuse, NY 13210, USA

^eNational Director for VA Emergency Medicine

^fEmergency Services, VA Maryland Healthcare System, Baltimore, MD 21201, USA

Received 1 May 2009; revised 3 August 2009

Abstract

Background: The Veterans Health Administration has reformed its emergency medical services.

Objectives: This study updates an overview of emergency medicine within VHA.

Methods: This is a cross-sectional survey of VHA medical facilities offering Emergency medical care. Results: Sixty-eight percent (95/140) of facilities had emergency departments (EDs) only, 12% (16/140) had both ED and urgent care centers (UCCs), and 16% (23/140) had only UCCs. The mean (SD) ED/UCC census was 13 371 (7664). A mean (SD) of 53% (27%) of facility admissions were admitted through ED/UCCs. The median of all ED/UCC admissions admitted to intensive care unit level care was 11% (interquartile range, 7-16). Of physicians with any board certification, 16% (209/1331) of physicians had emergency medicine board certification.

Conclusions: Emergency medical care is now available at most VHA facilities. The specialty of emergency medicine has an important but minority presence within clinical emergency medical care at VHA.

Introduction

The Veterans Health Administration (VHA) is the nation’s largest integrated health care system. Although several

^? No external funding.

^?? No other previous presentations.

* Corresponding author.

E-mail address: [email protected] (J. Chen).

studies recently demonstrated VHA’s superiority in preven- tive care, care of chronic medical conditions, and surgical care as compared with national samples, emergency medical care within the VHA is a relative newcomer as a specialty in the VHA [1,2].

In 1993, Young [3] issued the only published analysis of emergency medicine (EM) in VHA, calling upon VHA to increase recruitment of emergency physicians and upon organized EM to engage VHA and help develop patient

0735-6757/$ – see front matter. doi:10.1016/j.ajem.2009.08.008

access to proper EM specialists. The issue of quality emergency medical care gained visibility when an analysis of patients with acute myocardial infarction suggested that care in VHA emergency departments (ED) was a weak point in the care delivery model [4]. Greiner et al [5] confirmed that emergency care was not delivered in a consistent fashion throughout VHA.

In the past, VHA emergency care lagged behind community standards, with only 19% of VHA medical centers having any EM residency-trained or board- certified staff physicians [3]. In comparison, a national study of EDs conducted 6 years later found that approximately 58% of surveyed EDs employed board- certified or residency-trained emergency physicians [6]. Young also illustrated that even nomenclature was a problem–only 45% of VHA sites surveyed were titled an “emergency department.”

Veterans Health Administration has tried to improve and to meet the community and teaching hospital standards of practice in EM [7]. In fall 2006, VHA Directive 2006-051, Standards for Nomenclature and Operations in VHA Facility Emergency Departments, mandated that “in facilities having medical-surgical beds and an intensive care unit, unscheduled access to an Emergency Department (ED) must be available 24 hours a day, seven days a week.” A 2008 American College of Emergency Physicians report on emergency care in military medical systems was favorable to VHA in various domains, including access to emergency care, public health and injury prevention, quality and patient safety environment, and Disaster preparedness [8].

The purpose of this study is to provide a current overview of EM in VHA, focusing on the findings related to unit characteristics, patient census, acuity, staffing patterns, and the footprint of organized and academic EM within the VHA.

Methods

This is a cross-sectional survey of VHA medical facilities offering emergency and urgent medical care. A 99-item online survey was sent to the chief of staff’s office at every VHA medical center. All VHA medical facilities completed an initial portion of the questionnaire to ascertain the presence or absence of emergency medical care. Those sites that affirmed the presence of “a dedicated unit for unscheduled patients needing Emergent medical care” completed the entire survey (see Appendix A).

Veterans Health Administration’s Emergency Medicine Field Advisory Committee, in collaboration with VHA’s National Director of Emergency Medicine, chose and developed the general categories and specific items of the survey, to capture the status of EM capabilities within VHA. The survey used some questions adapted from a previously conducted internal VHA intensive care unit (ICU) survey. Six sites across the country piloted the format and specific questions. After subsequent revision and editing, the survey was sent out nationally, including the 6 pilot sites. This survey was granted exemption status by the institutional review board. Respondents filled out the closed-answer Web-based survey online. Participation was mandated by the Central Office, and ultimately, there was a 100% response rate. The data were collected and processed by the Office of Healthcare Analysis and Information Group of VHA. survey results were compiled and catalogued. Tables were generated using Microsoft Excel and standard descriptive statistics calculated

using SAS 9.1 statistical software (SAS, Cary, NC).

Results

The survey of fiscal year 2006 practice characteristics was undertaken and completed within a 30-day period in

Fig. 1 Number of Emergency Departments and Urgent Care Centers.

2007. A total of 153 total facilities received the survey, with 140 facilities with EDs or urgent care centers (UCCs; 92%) completing the full survey, either initially or with follow-up e-mail/telephone/mail contacts.

Unit characteristics

Of the 140 facilities that self-identified as having an acute care area, 95 (68%) identified as having EDs only, 16 (12%) identified as having both an ED and an UCC, 23 (16%) identified as having only UCCs, and 6 (4%) identified as “other” (Fig. 1). Outside the formal survey, additional communication reclassified 5 of the 6 facilities self-identifying as “other,” to 4 EDs, and 1 UCC. Most EDs do not provide trauma, obstetric, or pediatric care. There are 2 VHA EDs designated as level 2 trauma centers, and 4 VHA EDs designated as level 3 trauma centers. Four VHA facilities reported providing pediatric care, and 11 VHA facilities provide obstetric care. Ninety-three percent of facilities conduct psychiatric evaluations in the ED or UCC, and 69% admit involuntary psychiatry patients. The median annual number of inpatient medical-surgical admissions per facility was 3140 (interquartile range [IQR], 1710-5247). The median annual number of inPatient psychiatric admissions per facility was 653 (IQR, 412-1003). Forty- seven percent (64/135) of facilities use the 5-level Emergency Severity Index triage system, 22% (30/135) use a 3-tier triage system, 19% (26/135) use “other,” 7% (9/ 135) use the Canadian 5-tier triage system, and 4% (6/135) use “other 5-level triage system.” Eighty-two percent (114/ 140) have the capacity to receive patients from the Local emergency medical services (EMS) system.

Facilities reported a total of 1253 acute care beds, with 925 ED, 167 combined ED/UCC, 111 UCC, and 50 “other” staffed beds. Beds identified as “other” included fast track, screening areas, and other urgent care beds (Table 1). The combined census of these 140 facilities for FY 2006 was 1 884 331, with 1 392 559 ED, 260 722 ED/UCC, 168 547

UCC, and 62 503 “other” visits. Fifty-eight percent of those visits occurred during day-shift hours. Sixteen percent (22/ 140) of EDs have boarding or Observation status protocols, but only 4 facilities have a separate area for these short stays. The mean (SD) ED/UCC census was 13 371 (7664).

Emergency departments and UCCs were an important means of entry to the hospital, with a mean (SD) of 53% (27%) of admissions by facility evaluated and admitted through these

Table 1 Available ED/UCC beds

physician staffing/organization”>Type of bed	Beds per facility	Total no. of beds in VHA	% of total
ED	Mean +- SD, 10 +- 5	925	74
UCC	Mean +- SD, 3 +- 3	111	9
ED/UCC	Median, 7; IQR, 3-13	167	34
Other	Median, 7; IQR, 3-12	50	4

Attending physician coverage in-house VHA physician

Contract physician

Attending physician coverage from pager/home VHA physician

Contract physician Fellow coverage in-house

Fellow coverage from pager/home resident coverage in-house Resident coverage from pager/home medical officer on duty

Coverage by attending physicians off site or located at another facility

Total responses

96

66

67

10

9

1

16

2

9

2

40

2

197

Table 2 Staffing patterns

sites. The median of all ED/UCC admissions admitted to ICU level care was 11% (IQR, 7-16).

Academics

A total of 121 facilities (83%) self-identified an academic affiliation with either a medical school or university. One hundred twenty-five facilities (86%) had academic affilia- tions with a degree program in a nursing college. Fifteen (11%) facilities participate in EM residencies and have EM residents rotating through the department.

In 2006, 16% of VHA EDs had active research projects conducted in the department. Twelve EDs reported that physicians conducted clinical trials, 11 reported quality improvement research, 5 reported patient safety research, 2 reported other research, and 1 reported conduct of basic science/bench research. No information about the number of individuals at each facility actually participating in research activities is available.

Crowding

Of 140 facilities, 100 diverted patients to another hospital in FY 2006. Only 18 of the 100 facilities that went on diversion tracked diversion status/hours through the regional EMS prehospital system. Like many EDs in the community, crowding is often due to a shortage of inpatient beds, with 52% of facilities reporting ED/UCC stays prolonged on a daily or weekly basis by a shortage of inpatient beds.

Physician staffing/organization

board certified EM physicians fill 33 (24%) of 140 of ED/UCC medical directorships. Thirty-four (24%) of the ED/UCC medical directors report directly to their medical center’s chief of staff, whereas most first report either to the chiefs of the medicine service (44) or to the directors of the ambulatory care program (24).

The median number of full-time ED/UCC physicians per facility was 3 (IQR, 1-5). The median number of part-time ED/UCC physicians per facility was 1 (IQR, 0-8). Use of midlevel practitioners (nurse practitioners [NPs], physician assistants [PAs]) is very limited, with median NP staff of 0 (IQR, 0-1) and median PA staff of 0 (IQR, 0-0). Facilities were asked about the number of VHA-employed attending physicians in their EDs and UCCs with board certification. Of physicians with any board certification, 209 (16%) physicians had board certification from either the American Board of Emergency Medicine or Board Certification of Emergency Medicine. Most remaining full-time physicians had internal medicine board certification (934/1122, 83%). There was no information collected about the total number of full-time attending physicians at surveyed facilities. Twenty- two percent of VHA attending physicians (301/1402) moonlight outside VHA.

Sixty-one percent (86/140) of facilities had physician double coverage for at least some part of the day. The mean (SD) number of double coverage hours was 11 (5) hours. Thirty-seven percent (52/140) of facilities had double- provider coverage, with an NP or PA as the second provider. Times of day where there is double coverage with either 2 doctors of medicine or a doctor of medicine plus midlevel vary widely. Coverage systems were variable “Off hours,” that is, weekends, evenings, federal holidays, and nights. Facilities were asked to check all that apply. Of 197 checked responses, 96 facilities had in-house coverage by an attending physician, either VHA employed (66) or contract physicians

(67). Ten facilities had attending physician coverage on home/pager call. Forty facilities indicated coverage by the medical officer on duty; 16 facilities used in-house moonlighting fellows for off-hours staffing (Table 2).

Seventy-six percent of facilities responded that it was “somewhat difficult” or “extremely difficult” to recruit and hire qualified physicians for the ED or UCC. This question explicitly did not imply that any particular board certification status was needed to be a qualified physician. Inadequate salary (40%) and geography (18%) were the 2 strongest identified barriers to recruitment. Median starting salary for physicians with EM board certification was $160 000 for those with less than 3 years’ experience and $171 448 for those with more than 3 years’ experience.

Clinical time requirements for physicians to meet the “full-time” designation vary between facilities. The leading model at 64% (90/140) of facilities requires 40 hours of clinical time, with the next most popular model at 20% (28/ 140) requiring 40 hours of combined clinical, academic, and administrative duties. Sites varied in their use of 8-, 10-, or 12-hour shifts for physicians.

Nursing and other staff

Veterans Health Administration ED/UCCs employ a mean (SD) of 14 (8) full-time nurses (registered nurses, or RN) and a median of 0 part-time RNs (IQR, 0-2). Day shifts

at VHA ED/UCCs are staffed with 4 +- 2 RNs. The median number of RNs for evening shifts is 3 (IQR, 2-4), and for night shifts, it is 1.5 (IQR, 1-2). Eighty-five percent of facilities have less than 5% of nurse staffing provided by contract nurses. Sixty percent of facilities responded that it was “somewhat difficult” or “extremely difficult” to recruit and hire qualified nurses for the ED or UCC.

Eighty-nine percent of ED/UCC nurse managers have a bachelor’s or master’s degree in nursing. Use of licensed vocational nurses and medical technicians is limited. Veterans Health Administration ED/UCCs employ a median of 0 medical technicians per facility (IQR, 0-2).

Ancillary services/environment

Having departments such as radiology and laboratory services physically nearby can facilitate ED functioning. In 50% (70/140) of VHA facilities, the radiology department is located on another floor separate from the ED. Sixty-nine percent (96/140) of VHA facilities have laboratory services located on another floor separate from the ED, remarkable as only 29% (41/140) of settings use tube transport systems, the rest using a variety of manual transport schemes. Point-of- care diagnostic testing is available at 78% (109/140) of VHA Acute care facilities, with troponin as the most commonly available point of care test (34%).

Most VHA ED/UCCs do not have a dedicated on-site pharmacist (96%) or dedicated respiratory therapist (97%). Moreover, only a minority of VHA ED/UCCs have any medications stocked in the unit, predominantly medications for acute cardiac care.

In regard to physical environment, 31% (43/140) of VHA facilities were built or renovated in the 3 years before the survey.

Informatics

Most facilities do not track waiting room times or repeat visits. Eighty-nine (64%) of 140 facilities track if patients leave without being seen. Of these, the median leave- without-being-seen volume was 8 per month (IQR, 2-20). Sixty-five percent (91/140) of facilities track if patients leave against medical advice, with a median of 5 patients per month (IQR, 2-11).

Despite VHA’s experience with computerized patient records and physician Order entry, use of electronic patient Tracking systems in the ED is extremely limited. Forty-five (32%) of 140 facilities perform any electronic patient tracking, with 37 facilities using a VHA-developed clinical information system.

Discussion

Although naming of patient care areas does not absolutely indicate level of service available, it does suggest that

between 1991 [3] and 2006, accessibility and availability of 24/7 Acute medical care within VHA increased from 45% of facilities self-identifying as EDs to 80% of facilities self- identifying as EDs or combination ED/UCCs. A follow-up survey further out from the 2006 directive mandating emergency care at all VHA facilities with an intensive care unit and medical-surgical inpatient beds is warranted to see if access increases even more.

The previous published survey by Young indicated that the specialty of EM “has only a small presence” within VHA. The 1991 survey and this survey are not directly comparable, but some thematic comparisons can be made. Young found that only 21 of 111 surveyed medical centers (19%) had EM residency-trained and/or board-certified VA staff physicians. An unpublished internal VHA EM survey done in 2003 found that only 11% of ED coverage time was provided by EM board-certified physicians, and each center had a mean of 1.1 EM board-eligible/board-certified physicians on its staff [9]. This survey asked about the total number of EM board- certified physicians and found that in FY 2006, VHA employed 209 EM board-certified physicians, amounting to 15% (209/1401) of all board-certified physicians working in VHA EDs, with a mean of 1.5 EM board-certified physicians per facility (median, 0; IQR, 0-1). Previously, 7% of surveyed centers had EM residents rotating through their EDs [3]. This survey found that 15% of centers had EM residents.

Few EDs housed ongoing research. More efforts should be made to extend VHA’s research focus on quality to the ED [10]. In general, some improvements in the frequency of EM specialists have been made, but the profession of EM still remains a minority presence.

Limitations include self-report of survey responses, lack of independent verification of responses, and that persons other than the ED director may have completed the survey. Many of the facilities either could not provide information or only provided estimates in response to questions, that is, diversion activities. Additional limitations include lack of transparency and lack of standardization of who completed the survey at each facility.

Future surveys may want to collect data that are more directly comparable to measures in the American College of Emergency Physicians (ACEP) National Report Card on EM. Currently, comparison with non-VHA emergency services by ACEP is based more on expert interviews than on objective data. Other areas of potential benefit from increased data collection include accurate numbers of overall ED inpatient admissions rates and triage severity distribution of patients, to facilitate better assessment of Acuity level and patient mix. Like community EDs, VHA EDs face increasing patient censuses and other over- crowding issues. Improved information collection about diversion activities, better standardization of diversion status protocols, and improved communication with

regional EMS systems about diversion activities are called for. Currently, usage of clinical informatics systems is low, but many survey respondents indicated imminent plans for implementation of clinical informatics systems. Prospec- tive data streams on patient flow, length of stay, missed opportunity rates, and other metrics will be of interest.

Conclusion

This survey reports on the current status of clinical emergency medical care within VHA. Emergency medical care is now available at a majority of VHA facilities. The specialty of EM has an important but minority presence within clinical emergency medical care at the VHA. Veterans Health Administration emergency medical care compares favorably with community emergency medical care as measured by ACEP, but more detailed information for comparison is needed.

Appendix A. Supplementary data

Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ajem.2009.08.008.

References

1. Asch S, McGlynn EA, Hogan MM, et al. Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Ann Intern Med 2004;141(12):938-45.
2. Jha AK, Perlin JB, Kizer KW, et al. Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med 2003;348(22):2218-27.
3. Young GP. Status of clinical and academic emergency medicine at 111 Veterans Affairs medical centers. Ann Emerg Med 1993;22(8):1304-9.
4. Landrum MB, Guadagnoli E, Zummo R, et al. Care following acute myocardial infarction in the Veterans Administration Medical Centers: a comparison with Medicare. Health Serv Res 2004;39(6 Pt 1): 1773-92.
5. Greiner GT, Jesse R, Sales AE. The state of emergency medicine in VHA: results of the 2003 VHA Emergency Department Survey. VA HSRD National Meeting 2005; 2005.
6. Moorhead JC, Gallery ME, Mannle T, et al. A study of the workforce in emergency medicine. Ann Emerg Med 1998;31(5):595-607.
7. Millard WB. Emergency medicine in the VA: the battleship is turning. Ann Emerg Med 2008;51(5):632-5.
8. Epstein SK, Burstein JL, Case RB, et al. The National Report Card on the State of Emergency Medicine: evaluating the emergency care environ- ment state by state 2009 edition. Ann Emerg Med 2009;53(1):4-148.
9. Jesse RL. The state of emergency medicine in VHA: results of the 2003 VHA Emergency Department Survey; 2003 [VA internally published report].
10. Kizer KW, Fonseca ML, Long LM. The Veterans Healthcare System: preparing for the twenty-first century. Hosp Health Serv Adm 1999;42 (3):283-98.