More than half of emergency nurses say they've been "spit on," "hit," "pushed or shoved," "scratched," and "kicked" while on the job, according to a national online survey by the Emergency Nurses Association.
It gets worse. One in four of the 3,465 emergency nurses surveyed for Violence Against Nurses Working in U.S. Emergency Departments say they've been assaulted more than 20 times in the past three years, and one in five nurses have been verbally abused more than 200 times during the same period.
"People who work in helping professions shouldn't have to put their physical and emotional well-being on hold to do their jobs," says ENA President Bill Briggs, RN. "Emergency nurses provide crucial healthcare services. Their departments and their hospitals depend on them being able to deliver high-quality care. They can't do that if they're in danger of being verbally or physically abused."
More than half of the nurses say one or more factors played a role in their abuse, including: patients and visitors who were drunk or using illicit drugs; psychiatric patients in the ED; crowding; long wait times; and staff shortages. More than two in three (67%) of emergency nurses rate their perception of safety in the ED at five or lower on a 10-point scale, and one in three say they had considered leaving their hospital or emergency nursing altogether because of the violence.
Reports of violence are lowest in pediatric emergency departments and highest during night shifts and on weekends. Male emergency nurses are more likely than female nurses to be assaulted. Workplace violence is lower in facilities that have strong policies for reporting and responding to the violence.
Conversely, violence is higher in facilities that have barriers to reporting violence, where nurses complain of: a perception that reporting violent incidents might have a negative effect on customer service reports; ambiguous policies for reporting incidents; fear of retaliation by superiors; perceptions that reporting incidents is a sign of incompetence; the attitude that violence is to be expected; and a lack of support from administration.
The ENA has several recommendations to reduce ED violence that include:
Ensuring that ED staff know that senior administration is aware of the issues and support efforts to prevent violence.
Establishing a culture of acceptance for reporting violence.
Developing clear procedures for reporting violence.
Providing access to medical care and follow-up counseling for ED staff who are assaulted.
Appointing an interdisciplinary task force to identify ED vulnerabilities and develop a plan for preventing, mitigating, responding to, and reporting violence.
The report's authors also recommend federal and state laws to protect ED nurses from violence. Laws protecting emergency nurses vary widely by state, and several states have no such laws.
The 69-question survey was published today in the July/August issue of the Journal of Nursing Administration, and was based on the results of an online survey that was conducted in April and May 2007. Nearly 84% of the respondents were women.
Adults who are dually eligible for both Medicaid and Medicare coverage are among the most chronically ill and costly patients—accounting for close to nearly half of all spending within Medicaid and a fourth of spending within Medicare. However, most of these eight million "duals," as they are often called, frequently are receiving fragmented, uncoordinated, and ultimately high-cost care, according to a new Center for Health Care Strategies (CHCS) policy brief, Supporting Integrated Care for Dual Eligibles.
Dual eligibles represent just 18% of Medicaid enrollees and 16% of Medicare enrollees. But, in spite of recent efforts to try to integrate care Special Needs Plans (SNPs) that would better coordinate their care, more than 80% of dual eligibles remain in fee for service plans, the researchers noted.
Duals often find themselves in "treatment silos" that prevent them from interacting with more than one healthcare provider at a time—even when they already have several physicians. They also may end up getting one prescription at a time--even when they take 15 different prescriptions in any one day, they noted.
By definition, dual eligibles are low income: 60% live below the poverty level, and as many as 94% live below 200% of the poverty level. Compared to the general Medicare population, dual eligibles are three times more likely to be disabled and have higher rates of diabetes, pulmonary disease, stroke, and Alzheimer’s disease. In 2005, the total cost to Medicare and Medicaid for care provided to dual eligibles was roughly $215 billion.
But despite the potential of SNPs for integrating care, only a handful of states operate fully integrated programs. Of the roughly 1.5 million dual eligibles receiving care via Medicare Advantage plans (including SNPs), only about 120,000 are in programs that are fully integrated Medicare and Medicaid services, the study said.
This may be partly due to "a lack of administrative support or to competing state priorities," said the researchers. It may also be linked to questions regarding what "makes SNPs uniquely qualified to care for a high needs population—particularly since many of these organizations have no prior experience caring for dual eligibles."
Integrated programs, the report noted, should include the following elements:
Strong patient centered primary care base, such as an accountable care home.
Multidisciplinary care team that is structured to address the full range of a beneficiary’s needs (medical, behavioral, and social).
Comprehensive provider network that meets the needs of the target population and supports the care coordination model.
Robust data sharing and communications systems that guarantee continuous access to services and promote coordination of care across settings.
Consumer protections that ensure access to longstanding community providers.
Financial alignment that addresses fragmented systems of care through blended funding and/or shared gains and risks of providing services.
While there have been a number of attempts to promote more widespread and "scaleable" integration for dual eligibles, progress has been limited in improving the coordination and cost effectiveness of care. To move forward, the researchers suggested that:
Congress and the Centers for Medicare and Medicaid Services provide greater authority for testing innovative alternatives in states where SNPs are not active and duals are served by the Medicare fee for service system.
Medicare and Medicaid stakeholders be enabled to share savings generated from the integration of services for dual eligibles.
Congress and CMS should support mechanisms that would enable states, plans, and the federal government to share savings, such as that realized from reduced emergency department and inpatient use, and from integrating primary, acute, behavioral, and long term supports and provider services.
The number of operational community-based HIEs sharing data electronically among hospitals, physicians, health plans, and patients increased by nearly 40% since last year, according to the Washington DC-based nonprofit eHealth Initiative's sixth annual survey. There are roughly 193 active programs involved in health information exchanges, 57 of which reported being operational in 2009, the survey found.
I'm certainly coming across more examples of health information exchanges. Here are two HIEs that I read about in just the past couple of weeks.
New York Clinical Information Exchange. Comprised of nine hospitals and two other health institutions in New York this exchange has started sharing data for emergency patients. The EDs use a Web portal to access information on patients, including demographics, lab and pathology test results, discharge summaries, and medication histories. The exchange also feeds data to a project sponsored by the New York State Department of Health Centers for Disease Control that is studying the role of HIEs in biosurveillance.
Transforming Healthcare in Connecticut Communities. A coalition of hospitals, physician practices, federally qualified health centers, insurers and employers in Connecticut aim to build a statewide health information exchange; support small physicians efforts to implement electronic health records, develop training and deployment tools for physicians and healthcare workers; and develop quality measures and performance improvement targets. The THICC initiative will initially be funded solely by THICC members and will work in conjunction with the Connecticut Department of Public Health. The exchange will rely on Web-based components and community systems that hospitals and doctors can use to share patient health summaries and clinical data like x-rays.
The American Recovery and Reinvestment Act of 2009 has definitely helped to, as the report says, "energize this field." Not surprisingly, since the care goals for the "meaningful use" requirement that providers must attain to receive stimulus funding include communicating with public health agencies and exchanging meaningful clinical information among the professional healthcare team. According to the HIT Policy committee's "meaningful use" recommendations for 2011, providers should:
Have the capability to electronically exchange key clinical information, such as problem lists, medication lists, allergies, and test results among healthcare providers and patient-authorized entities.
Perform medication reconciliation at relevant encounters and each transition of care, i.e. implement the ability to exchange health information with external clinical entities.
Be able to submit electronic data to immunization registries and provide actual submissions where required and accepted, i.e. report up-to-date status for childhood immunizations.
Last week, HIT Standards Committee recommended that providers implement the 12 HITSP endorsed standard capabilities, including being able to transmit in-hospital and out-patient prescriptions, structured health data for discharge summary and continuity of care documents, and lab test results. Having an initial set of standards and "meaningful use" definitions to work from is a good first step, but there is still a long way to go before the health industry reaches "meaningful interoperability."
Troyen A. Brennan, MD, executive vice president and chief medical officer for CVS Caremark, is not sure how quickly the industry can achieve interoperability. The biggest barrier is "deciding exactly what that interoperability is going to look like," says Brennan, who has had experience in various sectors of the industry. He served as chief medical officer for Aetna Inc., president and CEO of Boston's Brigham and Women's Physicians Organization and as a director of quality measurement and improvement in the hospital setting.
"If I have my patients on an EHR in an ambulatory setting how will that be informed by and inform people in the hospital who see my patients," says Brennan. "Exactly how that information gets shared is a tough part that we haven't exactly worked out."
Aspect Medical Systems, Inc., announced a five-year comparative effectiveness research collaboration with Cleveland Clinic focused on improving patient outcomes following surgery. The collaboration will utilize the Clinic's electronic medical record system to identify anesthetic management practices that are associated with optimum outcomes. These practices will then be tested prospectively utilizing real-time decision support methods. The company has also signed a licensing agreement with Cleveland Clinic that will cover the intellectual property that emerges from the collaboration.
Kettering Health Network will invest at least $50 million in electronic health records, network officials announced Thursday. The network, comprised of six area hospitals, has signed with Verona, WI-based Epic Systems Corp., an electronic medical record system company, to install the eHIS system at its hospitals. The multi-year project will cost more than $50 million.
Australian Prime Minister Kevin Rudd and Health Minister Nicola Roxon released a report by the National Health and Hospitals Reform Commission calling for all Australians to have electronic health records by 2012, ZDNet Australia reports. The report endorses Deloitte's 2008 recommendations for the national e-health strategy and calls for spending Australian $1.2 billion to Australian $1.9 billion, or about $983 million to $1.56 billion, on health IT.
Patients at Barrington Family Medicine know they can count on the doctors to answer a page at midnight or on a Sunday, and that living in town, they'll even go into the office at odd times. But with the help of technology, they often don't have to.
The HITECH Act offers a massive opportunity for providers to maximize the value of data and the promise of new automation. But the industry may not be equipped to capitalize on new automation, according to a Deloitte survey, "The Time is Now: 2009 Global Life Sciences & Health Care Security Study." Data leakage is a huge threat and as healthcare regulations continue to increase, security budgets may not be able to keep pace, the report says.
The HIT Standards Committee approved 27 quality measures and 12 standards capabilities that healthcare providers must put in place in 2011. The workgroup recommended that healthcare providers implement 12 HITSP endorsed standard capabilities to transmit discharge summaries; inpatient and outpatient prescriptions; and laboratory test results, for example.
A South Florida hospital that quietly chartered a plane and sent a seriously brain injured illegal immigrant back to Guatemala over the objections of his family and legal guardian did not act unreasonably, a jury ruled. Healthcare and immigration experts across the country have closely watched the court case. They say it underscores the dilemma facing hospitals with patients who require long-term care, are unable to pay and don't qualify for federal or state aid because of their immigration status.
