Survey: ERs Lack On-Call Specialists

Two-thirds of emergency department directors report problems

TUESDAY, Sept. 28, 2004 (HealthDayNews) -- On the television show ER, beleaguered emergency room physicians often stand in exasperation by the phone, waiting for a psychiatrist, ophthalmologist or other specialist to call back or come in to confer on a case.

Such scripts reflect real life, according to a survey of 1,427 emergency department medical directors released Tuesday by the American College of Emergency Physicians.

Two-thirds of the emergency department physicians surveyed reported problems with on-call specialist coverage, the survey found. When they need someone to consult on a patient or come in, the specialists are often in short supply.

"The data we have doesn't address whether patients are being harmed, but that is what we worry about," said Dr. Ben Vanlandingham, the principal investigator of the survey team and a Robert Wood Johnson Clinical Scholar at Johns Hopkins University in Baltimore.

The survey was spurred by recent regulatory changes that are widely seen as a relaxation of the requirements for physician specialists taking on-call duty at hospital emergency departments.

Asked to describe the most significant consequence of the shortage, 27 percent of respondents said "risk or harm to patients who need specialist care," 21 percent said a "delay in patient care," and 18 percent said "more transfers of patients between emergency departments."

The team sent out questionnaires to 4,444 emergency department medical directors between April 2004 and August 2004; 1,427, or 32 percent, responded. Most were from non-teaching community hospitals, while the rest were from academic teaching hospitals.

Larger hospitals were more likely to report problems with specialty coverage than smaller ones, the survey found.

"The study reflects what is really going on," said Dr. Wally Ghurabi, the emergency department director of the Santa Monica-UCLA Medical Center near Los Angeles, where recent hospital closings have put a heavy burden on nearby hospital emergency departments.

The ACEP survey was undertaken to assess the effects of current regulations and the practice climate on the availability of medical specialists who can provide care in the nation's emergency departments, according to Vanlandingham.

Under the Emergency Medical Treatment and Labor Act (EMTALA), passed in 1986, hospitals are required to medically screen every person who comes to an ER to decide whether an emergency medical condition is present and, if it is, to stabilize the patient.

But since the passage of EMTALA, it has been subject to judicial and regulatory interpretations.

Last November, Vanlandingham said, "the Centers for Medicare and Medicaid Services released an updated clarification of EMTALA, [which was] interpreted as a relaxation of the on-call responsibilities."

Under these revised regulations, hospital must continue to maintain a list of on-call physician specialists, but the specialists are permitted to be on call at more than one hospital at the same time and may limit the amounts of call time they are willing to take.

Before last year's clarification, Vanlandingham said, "the common interpretation that had grown over these years was the thought that any specialist who is on staff at a hospital should probably be reasonably expected to take [a] call every third night."

With the relaxation in rules, "a lot of this puts more pressure on emergency department doctors," Vanlandingham said. "Emergency departments have less and less coverage, that was the feeling. But no one had really studied it."

The survey confirms the suspicions, he added.

To remedy the shortage, the survey found, some hospitals are providing incentives to specialists to take emergency department call duty by paying stipends, guaranteeing certain levels of payment for service, and providing some measure of medical liability coverage for doing so.

Ghurabi, a veteran emergency department director, sees another solution: to require on-call commitments to be part of the responsibility of all physicians on a hospital staff. That is the policy, he believes, at well-run hospitals.

The medical staff's view, he added, is that "if you are going to be on staff here, you are going to take [emergency department] calls."

Another arrangement, he said, is to require doctors who don't want to take emergency calls to "pay for your pleasure," to contribute a specified amount to the hospital for the right to be left alone.

Traditionally, Ghurabi said, specialists who are trying to build their practice are eager for on-call duty, but as their practice grows, their desire to take emergency department calls often declines or disappears.

More information

To learn about what to do in a medical emergency, visit the American College of Emergency Physicians.

SOURCES: Benjamin Vanlandingham, M.D., Robert Wood Johnson Clinical Scholar, Johns Hopkins University, Baltimore; Wally Ghurabi, D.O., emergency department director, Santa Monica-UCLA Medical Center, Santa Monica, Calif.; September 2004 American College of Emergency Physicians Survey of Emergency Department Directors
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