Trauma care in the United States is so fragmented and underfunded that the survival of people who suffer major injuries often depends on where they are when they're hurt, says Brent Eastman, MD, chairman of the Board of Regents of the American College of Surgeons.
Writing in the current issue of the Journal of the American College of Surgeons, Eastman said high death rates in rural areas, a growing shortage of trauma surgeons and a disconnect between existing trauma systems and regional disaster preparedness plans add to a bleak picture of trauma care in the nation.
Eastman is a general, vascular and trauma surgeon and CMO of Scripps Health and N. Paul Whittier Chair of Trauma at Scripps Memorial Hospital La Jolla, CA. His article in the journal's August edition—Wherever the Dart Lands: Toward the Ideal Trauma System—is the first time his findings have been published for public review. Eastman initially voiced his findings during his "Scudder Oration on Trauma" at the 2009 Clinical Congress of the ACS in Chicago.
"Coordinated, regionalized and accountable trauma systems are proven to get the right patients to the right hospital at the right time," Eastman wrote. "For victims of major trauma, access to timely, optimal care during the first "golden" hour has been proven to save lives, restore function and prevent disability."
Eastman is a co-founder of San Diego County's trauma system, which has reduced preventable deaths in San Diego from 22% when it was deployed in 1984 to approximately 2% today.
Eastman wrote that many parts of the country, especially rural areas, are not served by trauma systems.
He compiled a map of the United States showing death rates due to trauma per 100,000 population, travel times to the nearest trauma center and populations of surgeons. It shows a shortage of surgeons and gaps in regional trauma systems, which Eastman says has stymied access to timely, appropriate trauma care in many areas of the country.
As a result, Eastman wrote, death rates due to trauma are unnecessarily high in those areas, contributing to the fact that trauma is the leading cause of death for people 45 and younger in the United States and in developing countries.
His survey of trauma surgeons in each state shows that 38% of states reported having no statewide trauma system. Of the 62% of states that have a statewide trauma system, for most, funding to sustain these systems is in jeopardy.
"Everyone living or traveling in the U.S. should be able to expect prompt transport to the appropriate level of care proportionate with their injuries," Eastman wrote. "That's the vision when I say that wherever the dart lands on a map of the U.S., there should be a system to take care of your traumatic injury."
Eastman wrote that the sophisticated military trauma systems in Iraq and Afghanistan are an ideal trauma model, and he called on surgeons to advocate for trauma systems in states or regions where developed systems are still lacking.
Lengthy contract talks between the California Nurses Association and Sutter Health's California Pacific Medical Center, and St. Luke's Hospital in San Francisco turned toxic last week when the union filed a grievance with the city claiming that Sutter had imposed a hiring ban on Filipino nurses.
At a press conference, CNA and Filipino community and church groups have asked the San Francisco Human Rights Commission to investigate their allegations of "systematic" employment discrimination on the basis of race, ethnicity, and national origin.
"St. Luke's and CPMC RNs, many of them Filipino, have been outspoken in defense of their patients, and in opposition to Sutter and CPMC's plans to reduce services to the largely lower income, minority community depending on St. Luke's from SOMA to the Excelsior," said CNA Co-president Zenei Cortez, RN.
"Rather than respond to the concerns of the community, CPMC and Sutter have chosen instead to retaliate by carrying out a punitive, illegal, and immoral campaign of discrimination," said Cortez. "There can be no excuse for racial or ethnic discrimination. A hospital should be a center of therapeutic healing for patients, not a model of bigotry."
CPMC CEO Warren Browner, MD, called the accusations "false and designed to cover up the union's own failure to win a contract despite three years of negotiations."
"We pride ourselves on our diverse hiring policies and our longstanding commitment to promoting equal opportunity employment," Browner said. "The allegations of discrimination made by the California Nurses Association are dishonest and without merit."
CNA said the hospitals' hiring data supports the discrimination complaint, and details a major demographic shift among the nurses being hired at St Luke's that began in early 2008. Before February 2008, 65% of St Luke's RNs were Filipino. After February 2008, only 10% of RNs hired were Filipino.
Browner said the hospital's data tells a different story. "In 2007, 63% of our nurses at St. Luke's were Asian. Today that number is 66%," he said. "We do not have any way of identifying what percentage of our nurses are Filipino because we don't break down these categories by ethnicity or country of origin. In fact, the only data we have on ethnicity are self-reported by our employees using categories approved by the Federal government such as Asian, Hispanic or Latino, Black or African American or White (non-Hispanic)."
More than two dozen Filipino and other community leaders joined with CNA and sent a letter to CPMC this week demanding a meeting with Browner and Diana Karner, the Sutter West Bay vice president of nursing, and that CPMC publicly renounce its discriminatory practices.
At the press conference, CNA offered testimony by former nursing supervisors at CPMC and nurses who have faced the discriminatory practices. Chris Hanks, a former director of Critical Care Services at CPMC, said Karner told him on a number of occasions, "you are not to hire any Filipinos."
Former nurse supervisor Ronald Villanueva said that he heard Karner tell another supervisor, "do not hire foreign graduate nurses"—an unambiguous reference to Filipinos.
Sutter brought forward several Filipino nurses who called the CNA complaints groundless. Emilia Maninang RN, Clinical Nurse Manager in the Skilled Nursing Facility/Sub-Acute care unit at St. Luke's, said she has worked at the hospital nearly 20 years and was never told not to hire Filipinos. "I'm Filipino and if I had heard anyone say that I would've been appalled. I think the claims are part of CNA's agenda to try and make CPMC look bad," she said.
Rose Duya RN, who has been at St. Luke's for 12 years said the allegations are false and demonstrate that the union is "desperate."
"I'm Filipino, most of my colleagues here at St. Luke's are Filipino and I have been to many of the other CPMC campuses and have seen many other Filipinos there as well, so I don't see how the union can make those claims," she said.
Federal data showing increasing demand and cost for emergency department visits for often non-emergency medical issues demonstrates the value of urgent care centers, a trade group for urgent care centers claims.
The Centers for Disease Control and Prevention's National Health Statistics Reports shows that of the 116.8 million visits covered by the 2007 Emergency Department Summary, only 16.4% were admitted to a hospital or kept for observation, while 62% were referred to their primary care provider or a specialist for follow up.
Another 35% were referred back to the ED "as needed," presumably because they did not have a regular doctor. More than one third of the patients categorized their pain levels as "none" or "mild" the chief complaints continue to be—as they were in 2006— upper respiratory issues, earache, abdominal pain, wounds, and obstetrics complications.
While in the ED, the CDC data showed that 45.5% of the patients had a procedure, the majority of which were common procedures such as administration of IV fluids, splinting or wrapping, repair of a laceration, or a nebulizer treatment.
The Urgent Care Association of America says its member clinics can treat the vast majority of issues that don't require an inpatient stay and are not life or limb-threatening emergencies—at a lower cost and usually with a shorter wait time than a hospital emergency department.
A recent Press Ganey report detailed record-long waits at the nation's EDs. Emergency physicians say waits will lengthen as health coverage expands, EDs close, and hospitals fail to improve admitting processes.
North Carolina hospital and physician leaders have announced plans to create a statewide healthcare information network to facilitate the adoption of meaningful use.
When operational, the North Carolina Healthcare Information Exchange will allow physicians to create a continuity of care record for each patient, including clinical information from all of the providers in the exchange. NCHEX will launch in seven hospitals, three freestanding emergency departments and 57 physician practices, as the first step towards a statewide health information exchange that meets the criteria for an HIE outlined in the HITECH Act for Meaningful Use.
NCHEX backers include:
The North Carolina Hospital Association; 135 members
The North Carolina Medical Society, more than 11,000 physician members;
Moses Cone Health System, in Greensboro;
WakeMed Health & Hospitals in Raleigh;
Consultants Thomson Reuters;
HIT vendor CareEvolution.
The exchange will be open to all North Carolina healthcare providers and will connect with regional health information organizations, exchanges, and technology systems using the Nationwide Health Information Network Connect and other HIE standards.
To save time and money, NCHEX will be built on the infrastructure developed for the North Carolina Hospital Emergency Surveillance System, which was created by the state in 2004 to capture real-time clinical data from 114 hospital information systems.
Compensation for practice management administrators held steady or saw only modest gains in 2009, according to Medical Group Management Association’s Management Compensation Survey: 2010 Report based on 2009 data.
Administrators with seven to 25 full-time-equivalent physicians earned 0.3% less, while their counterparts with 26 or more FTE physicians reported a 2.3% increase in compensation, the survey found.
Though compensation was generally static for most practice management professionals, some positions made gains in 2009 by taking on more responsibility, including:
Assistant administrator
COO
Office manager
Human resources director
Nursing services director
“Clinical integration and greater complexity in healthcare appeared to drive salary increases for certain medical practice management professionals,” says William F. Jessee, MD, MGMA president/CEO. “These professionals likely took on a broader scope of responsibility in their positions as a result of continued economic pressures and changes in the healthcare environment.”
MGMA executive members reported greater median compensation than nonmember executives, as did senior managers and office managers who held MGMA memberships, MGMA says. Office managers with an MGMA membership earned $13,272 more per year than their nonmember counterparts, and finance directors with MGMA memberships earned $942 more per year than finance directors without memberships.
When affiliated with the American College of Medical Practice Executives, the certification and standards-setting body of MGMA, several managerial positions enjoyed increased compensation as well. ACMPE-affiliated administrators in practices with seven to 25 FTE physicians, and 26 or more FTE physicians earned 21.2% and 24.6% more, respectively, than their counterparts who were not affiliated with ACMPE. CFOs experienced the greatest compensation boost based on ACMPE affiliation, earning $59,328 more than their unaffiliated counterparts.
MGMA has 21,500 members leading 13,700 organizations nationwide in which some 275,000 physicians provide more than 40% of the healthcare services delivered in the United States.
After months of bargaining with no agreement, the Minnesota Nurses Association has asked more than 900 members to turn out Wednesday to reject a contract offer from SMDC Medical Center in Duluth, and vote for a one-day walkout instead.
A key sticking point appears to be nurse staffing ratios.
"The bottom line is, the executives at the bargaining table have made it clear to us that management does not trust its nurses with the well-being and safety of our patients," said Steve Strand, an RN at SMDC. "It's ironic considering nurses are the most trusted professionals in the United States. And we are not asking for anything costly, outrageous or unusual."
Thomas Patnoe, MD, president of SMDC Health System, issued a brief statement in response to the MNA comments: "We feel we have bargained in good faith and have proposed a very good offer, which reflects our commitment to our nurses, to safe care and to the patients and families we serve. My sincere hope is that we will ultimately reach a respectful resolution and avoid a strike."
In addition to the SMDC vote, 420 RNs at St. Luke's Hospital in Duluth are bargaining for a new contract, but haven't reached an agreement. SMDC nurses have no more negotiating sessions scheduled, but St. Luke's RNs met with management Monday to try to work out an agreement.
Both groups of nurses will vote on Wednesday to either ratify their contract offers or authorize a one-day strike at each hospital.
MNA said Duluth RNs are seeking the same contractual rights to advocate for their patients that Twin Cities nurses already have: First, to be allowed to temporarily close a hospital unit when it is no longer safe to admit additional patients. Second, to be able to refuse additional patient assignments when a nurse's patient load has reached an unsafe level, MNA said in a media release.
"Business executives at SMDC are refusing to allow nurses to do our duty—as dictated by the Minnesota Board of Nursing and our profession itself—of advocating for our patients," Strand says. "What Duluth nurses are asking for is reasonable, and in our negotiations we attempted to bargain in good faith to implement some concessions that would allow the cost to be minimized for the changes necessary. Should nurses in the Northland be treated differently than our counterparts in the Twin Cities when it comes to safety issues? Should our patients, for that matter?"
Strand says SMDC nurses already dealing with staffing shortages need some kind of protection in their contract when it comes to caring and advocating for patients.
"As nurses, we live this every day," he says. "We know better than anyone when it is or isn't safe on our unit. As the people directly responsible for your well-being when you come into our hospital, we want to make sure you get the safest care possible. Doesn't that seem like a rational, reasonable thing to ask of the executives who employ us and expect us to guarantee your safety as our patients? Why can't they see that they will be patients too?"
St. Luke's RN Cindy Prout says executives there have left nurses with no option other than recommending the vote to authorize a one-day strike.
"If you listen to the stories coming out of the hospital, you know that we don't have any other choice," she said. "Our first contract is with the public—to care for them, keep them safe and advocate for them."
Forty-five states and the District of Columbia will each get $1 million in federal funds to monitor proposed health insurance premium hikes in their jurisdictions, and take action against unreasonable increases, the Department of Health and Human Services has announced.
HHS Secretary Kathleen Sebelius said the funding is needed because health insurance companies in many states hike premiums with little oversight, transparency, or accountability. She says premiums have doubled in the past 10 years, much faster than wages and inflation, putting health coverage out of reach for millions of Americans and business owners.
Twenty-six states and the District of Columbia now have the authority to reject proposed increases that are excessive, but many can't afford to enforce the regulations, which Sebelius said has contributed to unjustified premium hikes in some states. The Affordable Care Act provides states with $250 million in Health Insurance Premium Review Grants over five years.
Sebelius said Affordable Care Act provisions will ultimately increase competition, lower insurance overhead, and provide for risk pooling in health insurance exchanges in 2014, which should cut premiums in the individual market by 14% to 20%. “Between now and then, we will continue to work with states to ensure consumers are receiving value for their premium dollars and to avoid the kind of double-digit premium increases seen recently. The state proposals approved today demonstrate the need and desire for new resources and tools to help them protect against unjustifiable premium increases,” she said.
Earlier this year, Sebelius asked insurance companies to justify large premium increases and encouraged state and local officials to obtain stronger health insurance premium review authorities under state laws. The increased scrutiny at the state and federal level led to the withdrawal or reduction of several proposed health insurance premium increases that in some cases turned out to be based on faulty assumptions and data.
States have proposed to use this funding in a variety of ways.
Additional Legislative Authority: 15 states and the District of Columbia want more legislative authority to review or requiring advanced approval of proposed health insurance premium increases;
Expand the Scope of Health Insurance Premium Review: 21 states and the District of Columbia will expand the scope of their health insurance review by reviewing and requiring pre-approval of rate increases for additional health insurance products.
Improve the Health Insurance Premium Review Process: All 46 states receiving grants will require insurance companies to provide more extensive information through a standardized process to better evaluate proposed premium increases and increase transparency.
Make More Information Publicly Available: 42 states and the District of Columbia will increase the transparency of the health insurance premium review process and provide easy-to-understand, consumer friendly information to the public about changes to their premiums; and
Develop and Upgrade Technology: All 46 states will streamline data sharing and put information in the hands of consumers more quickly.
“States will use these grant dollars in the way that makes the most sense for their insurance consumers,” says Jay Angoff, Director of the Office of Consumer Information and Insurance Oversight. “As we continue to implement the new health insurance reform law, we will continue to work with states to ensure they have the tools they need to ensure the stability of the marketplace, keep costs low and provide consumers with increased transparency, choice and quality they need to make the best health care decisions for their businesses and families.”
Under the Health Insurance Premium Review Grants, starting in 2011:
HHS will review justifications for unreasonable increases in premiums and make them public;
Insurers will be required to spend at least 80% of premium dollars on medical care services and quality-improvement activities and limit their spending on overhead, marketing, CEO salaries, and profits; and
In 2014, states will be empowered to exclude health plans that show a pattern of excessive or unjustified premium increases from the new health insurance exchanges.
By now—unless you've been prospecting for zinc in Siberia—you've probably read and heard about Steven Slater and his dramatic last day at work.
The JetBlue flight attendant literally pulled the chute on his career during a heated confrontation with a passenger who Slater says was acting rudely. After Slater used the jet's PA system to curse the passenger, he grabbed a couple of beers, popped open the emergency exit, waved goodbye, and swooshed down the inflatable slide into unemployment and jail. His meltdown became the stuff of legend and created a throng of admirers for a man who—for many—has become the living embodiment of a Johnny Paycheck song.
Some scolds have noted that Slater's actions were unprofessional and irresponsible. In fact, the blow back for Slater—always predictable in the media saturation cycle—has already started with investigators questioning passengers on the flight and the flight attendants about their versions of the events.
Was he irresponsible? Of course! That's why his stunt reverberates with so many working and middle class Americans who've had their fill of being responsible and playing by the rules their whole lives, and who still find themselves living one paycheck off the street. Is Slater's version of events the truth? I don't know. It almost doesn't matter. The specifics of the stunt are not as important as the symbolism.
This recession is taking its toll on the psyche of the American worker, and the frayed edges are showing. About 14.6 million people are unemployed, and there is no indication that their prospects are going to improve any time soon.
Many people who've been fortunate enough to keep their jobs have seen their life's savings diminish or disappear, or their home values plummet. Many haven't received a pay raise of any size in years. Some employers have stopped their match on already-battered 401(k) plans, and are using the recession as a worker retention strategy. Health insurance premiums continue to increase at a rate well above inflation, along with co-pays and deductibles, even as health insurance companies post record profits and shower their top executives with what some would argue is obscene compensation.
This is the environment in which many working and middle class Americans find themselves. And many of these same people are either employees at your healthcare workplace, or they're walking through your doors as patients.
There are obvious comparisons between the job demands on a flight attendant, and those made on a frontline healthcare professional. Both occupations bring a heavy burden of responsibility—often incommensurate with the pay—and require dealing with an increasingly resentful and irritated public, often at their worst in stressful environments. The flight attendant and the healthcare professional are often scapegoats for problems far beyond their control. The public doesn't want to hear why the plane is delayed, or why they've been waiting in pain and in fear for two hours in your ER without seeing a physician. They have a problem, and it's your fault!
We're already seeing more instances of rowdy patient behavior and outright violence in the hospital setting. Can we expect to see a sequel, perhaps "Revenge of the Nurse?" Will some fed up, angry healthcare professional "Pull a Slater" on his or her way out the door?
For the most part, the healthcare sector has been spared much recession-related misery because skilled healthcare professionals remain in demand in most parts of the country. That doesn?t mean that healthcare workers are happy, or that they're not stressed out, or that they don't carry deep frustrations about their jobs. Add a potentially volatile patient mix—and the ingredients are prepped for a major meltdown.
I cringe at phrases like "teachable moment," but that may apply with the Steven Slater affair. His stunt is something that everybody who has ever held a job can relate to, regardless of whether or not they support his actions. Can the flight attendant's farewell gesture be used to engage your employees about their own concerns, fears, and frustrations at work? What ventilation systems—if any—does your healthcare workplace provide for stressed-out employees who want to blow off steam in an appropriate way? Have you asked? Do you know?
As for Slater, there are some indications that he is remorseful, if not overwhelmed by the reaction to his stunt. The flight attendant's attorney told a throng of reporters last week that Slater—now suspended by JetBlue—hopes to get his job back. It's hard to imagine he'll return to the unfriendly skies, unless he buys a ticket. Actions have consequences, and he's already pulled the chute.
The University of Texas System Board of Regents has approved an $800 million project that includes the construction of the 424-bed University Hospital at UT Southwestern Medical Center in Dallas. The project now goes to the Texas Higher Education Coordinating Board for final approval.
The 12-story hospital is a key component of UT Southwestern's commitment to become one of the nation's top 10 academic medical centers. It will replace the aging University Hospital St. Paul, which opened in 1963.
"With the necessity of constructing this new replacement hospital came the ability to create a design that will enable us to provide patient-centric care as well as integrate our education, research, and clinical missions," said Daniel K. Podolsky, MD, president of UT Southwestern. "It incorporates forward looking approaches to patient care and embeds appropriate space to support clinical and translational research as well as education and training."
The $800 million total project also includes a dedicated thermal energy plant and facilities to support the hospital. Construction of the 1.3 million-square-foot project will start in March 2011 with completion anticipated in late 2014. University Hospital—St. Paul will remain fully operational until the new facility opens. The new hospital will be located on a 32-acre site on UT Southwestern's West Campus.
North Shore-LIJ Health System member North Shore University Hospital will buy the bankrupt Saint Vincent’s Catholic Medical Center Certified Home Health Agency for $17 million, the Great Neck, NY-based health system announced this week.
The deal, which awaits approval from a federal bankruptcy judge, provides an eight-county Certified Home Health Aides (CHHA) license for North Shore University Hospital, which includes the five boroughs of New York City, Nassau, Suffolk, and Westchester counties. North Shore-LIJ Home Care now is licensed for Long Island and Queens.
The purchase includes $17 million in cash and assumption of some CHHA obligations. North Shore University Hospital will retain CHHA workers who meet its hiring standards and will work with the unions to transition the work force.
“The ability to provide post acute services such as home care, in counties where we have hospitals is strategically important as we continue to bundle and integrate chronic disease across the continuum of care,” said Michael Dowling, president/CEO of North Shore-LIJ Health System. “Many patients do best in their home environment. With this new acquisition we’re expanding our ability to reach the number of patients who can receive clinical services in the comfort of their own homes.”
When the deal is finalized, CHHA will be part of the North Shore-LIJ Health System’s Home Care Network, which conducts more than 800,000 home health visits annually for short-term health issues such as recovery from surgery, to longer-term chronic care management of conditions such as congestive heart failure, stroke, diabetes and other illnesses.
“When you look at providing service to a community—you look at how to best meet a need with quality care,” says Mark Solazzo, executive vice president/COO for North Shore-LIJ Health System. “We know that providing quality home healthcare is essential in our area. We believe this purchase makes sense for us and for the community from both a quality and access to care perspective.”
The 15-hospital North Shore-LIJ Health System is the nation's second-largest, non-profit, secular healthcare system, with a service area that extends into Long Island, Queens, Manhattan, and Staten Island, encompassing more than 7 million people.
