BBI Contributing Writer

BOSTON, Massachusetts The annual American College of Emergency Physicians (ACEP; Irving, Texas) conference, held here in mid-October, drew some 4,000 emergency doctors, nurses and others to learn what is new in the field of emergency medicine. The most striking theme at this year's conference was the continued overcrowding of emergency departments (EDs) in the U.S.

Both the General Accounting Office (GAO; Washington) and the Centers for Disease Control and Prevention (CDC; Atlanta, Georgia) have published reports this year relating to the overcrowding that is occurring across EDs. Both reports showed an upward trend in the use of EDs. The CDC found that patient volumes are increasing as EDs continue to close, and that patients are waiting longer and are sicker, contradicting the notion that overcrowding is caused by unnecessary use. The GAO report found that although overcrowding varied by the size of a hospital (larger, urban hospitals had much more serious overcrowding issues than EDs located in cities under 1 million), the common difficulty that cut across the issue was that of "boarding" patients in the ED. To reduce costs, hospitals cut the number of inpatient staffed beds by 103,000 and the number of med/surg ICU beds by 7,800 between 1990 and 1998. As a result, there are now fewer beds available to accommodate ED admissions, and patients are increasingly ending up with prolonged stays in the ED department as they wait for inpatient beds to become available.

Specifically, the CDC reported a 20% increase from 89.8 million in 1992 to 107.5 million in 2001 in the utilization of EDs. This latest figure represents a slight decrease from the 2000 number of 108 million visits. The number of EDs also decreased by 15% over the past decade, contributing to increased patient volume as well as wait times in the facilities that remained open. Interestingly, only 9.1% of the visits were classified as non-urgent in the 2001 data. On average, patients spent three hours in the ED from arrival to discharge, with more than half spending two to six hours. The report also cited that more than 400,000 patients spent 24 hours or more in the ED. Older Americans showed the highest rate of visits, with about 60 visits for every 100 persons 75 years or older, compared to 38 visits per 100 people of all ages.

ACEP held a special press conference at the convention to address the data. Dr. George Molzen, president of the organization, said, "The CDC report underscores the vital and growing role emergency departments play in safeguarding the public's health. It also recognizes the importance of emergency care for older Americans and the unique role of EDs as detectors of biologic agents." Molzen also stressed the role that the continued shortage of ED nurses, as well as the continued malpractice issue, the cutbacks in reimbursement from Medicare and Medicaid (and other payers), as well as denials of coverage, played major roles in the overcrowding issue.

Protracted patient stays in the ED also raise patient safety and quality-of-care issues, as these patients are sick enough to require admission to the hospital and may need continuous vital signs monitoring. Often, however, such patients are left totally unmonitored in the hallway on a stretcher or if monitored, may have only a non-networked monitor, both of which create serious patient safety and quality-of-care issues for an area already struggling with soaring malpractice insurance premiums. What happens if a patient gets into trouble? Unmonitored, the first noticed signs may be a collapse and subsequent second emergency. If monitored only locally, who is available to watch the monitor or even hear the alarm in a larger and very noise emergency department?

This creates a market for new patient monitoring systems, particularly the portable, wireless and patient-worn type that can be networked back to the ED staff charting area, where presumably someone can monitor any adverse trends that are developing. Welch Allyn Monitoring (Beaverton, Oregon) has identified and addressed this problem with its Mobile Acuity LT (light) system, which includes 12 monitors or Micropaqs and a portable, PC-based central station that can be set up and used without the normal installation usually required. These products also are intended for ad hoc disaster site use where no formal medical facility exists but patients must be cared for, such as after floods, tornados or in the event of chemical, nuclear or biological attacks. Other companies with networked portable monitors also are well positioned to capitalize on this need to retain ED patients awaiting admission for longer periods of time.

Stretcher manufacturers might also find a new market here as the normal ED stretcher is not designed to be laid on for many hours and can create pressure sores that can add days to patient stays. A thicker mattress, even some heated component could complement conventional stretchers found in EDs. Companies like Hill-Rom (Batesville, Indiana), Stryker (Kalamazoo, Michigan) and others that manufacture stretchers could see their business increase.

The ACEP conference also addressed the controversy over the use and expansion of chest pain centers (CPC). Some in the emergency medicine field are concerned that CPC's do not offer an improvement in patient care but are instead just a marketing tool. Some 5 million people come to an ED annually because of chest pain, with almost half of these people being admitted to the hospital for suspicion of acute coronary syndrome (ACS). About one in four of these patients will go on to be confirmed with a diagnosis of ACS, but not all of these patients can be admitted in order for a diagnosis to be established. However, the most common cause of malpractice litigation in emergency medicine is the failure to diagnose acute coronary syndrome. These are the patients that make the news headlines when they are rushed to an ED, sent home, and die or are severely disabled due to an acute myocardial infarction suffered just a few hours later. Chest pain clinics are effective at reducing such deaths without a formal admission to the hospital, because patients can be monitored in the CPC setting until the diagnosis can be confirmed or ruled out.

Chest pain centers the first was opened in 1981 at St. Agnes Hospital (Baltimore, Maryland) were established with the goal of early detection of ACS while minimizing unnecessary hospital admissions and inappropriate hospital charges. The savings touted for hospitals with chest pain centers is anywhere from $450 to $2,600 per patient. Currently, the number of chest pain centers is listed as between 1,800 and 3,000, but because there is no standard definition of exactly what a chest pain center is, the number varies depending upon the definition. Some hospitals have separate physical areas for their chest pain center, including separate physician and nursing staff, while other hospitals "dedicate" one or two beds in their existing ED and call it a chest pain center. In the first situation the CPC may be separately staffed, while in the latter case the same ED nursing staff that is attending to other patients is supposed to also "watch" the patients in the designated CPC beds.

According to Michael Bresler, MD, clinical professor at Stanford University School of Medicine (Palo Alto, California), some hospitals are looking to lower costs within their chest pain centers by increasingly using ED physicians to perform the tests and make the decisions associated with a stay in a chest pain center. These tests and decisions have historically come under the auspices of the much higher paid cardiologists and cardiology staff. Bresler noted that hospitals can bill at a higher rate for outpatient procedures and that outpatient services are usually not capitated. By using ED doctors in place of cardiologists, the hospital's bottom line improves.

Bresler cited numerous studies that supported the cost efficiency of chest pain centers, but he said that many of these studies did not take into account the initial capitalization costs of physically setting the unit up and training the staff to meet the different needs of chest pain center patients. He noted that it was up to the hospital administration, nursing, ED physicians and cardiologists to work together to determine if a chest pain center is a viable solution for their institution.

Bresler advocated a standard definition of what actually comprised a chest pain center and pointed the attendees toward the Society of Chest Pain Centers and Providers (SCPCP; Columbus, Ohio). That organization has initiated an accreditation standard within the past year and currently has accredited four hospitals and hopes to become the standard by which all chest pain centers will be measured. The SCPCP offers facilities an application and manual for $150, after which a task force would work with a hospital to measure that facility's performance against eight key criteria. Hospitals that meet all the main benchmarks receive accreditation status for three years.

The goal is to decrease the use of chest pain centers by hospitals as a marketing gimmick and have them become known for focusing on quality patient care. These facilities create a market for 12-lead or derived 12-lead ECG and vital signs monitoring systems, apart from the monitors already available in the hospital's ED. The typical size of a CPC can range from two to 12 beds, but the most common size is in the six- to eight-bed range.

Defibrillator vendors at ACEP

Medtronic PhysioControl (Redmond, Washington) introduced its new Lifenet EMS at ACEP. Lifenet EMS is a ruggedized tablet computer with touch screen capability for use in the pre-emergency department area (EMS personnel and paramedics). This unit electronically captures and analyzes all patient encounters and offers wireless transfer, web viewing of all data as well as data storage and retrieval. The unit is Windows-based, SQL server and uses a dual processor Intel Pentium 4 at 2.4 GHz and can fully integrate with Medtronic's Lifepak 12 defibrillator/monitor series. The basic cost of this unit is $10-15,000 with a number of add-on modules and features.

Laptop and pen-based tablet PC makers are waking up to the specialized needs of the medical vertical market. Acer (Temple, Texas) introduced a new tablet PC that weighs only 3.1 pounds, but has a 10-hour battery operating time, including a 30 gigabyte hard drive. A newer tablet with a 14" display is also in the works. Products like this, designed to exceed the normal eight-hour shift in EDs, will be quickly embraced by hospitals that have previously had to choose from a spectrum of portable computers and tablets optimized for speed rather than battery life. Recharging batteries every 2.5 to five hours in a busy emergency department seriously limits the use of such products in spite of the appeal of "portability" that they offer.

Zoll Medical (Chelmsford, Massachusetts) highlighted its 15% interest in Revivant (Sunnyvale, California), a move that allows Zoll to market Revivant's product, called the AutoPulse, while holding off on a deeper financial commitment until that product has proven its marketability and can support the acquisition cost. In a year, Zoll has the option to purchase the remainder of Revivant shares for an additional $15 million. The Revivant device is an automatic "belt" (called Lifeband) that is attached to a special board upon which a patient in need of resuscitation can be placed. With the push of a button, the belt automatically tightens around the patient's chest and begins to compress the heart. Revivant says that in an in-hospital human trial, "the AutoPulse product increased coronary perfusion pressure in arrest victims to above levels needed for a return to spontaneous circulation while manually performed CPR did not." Additional studies are currently in progress.

This product and Zoll's automated external defibrillator (AED) would be an obvious and perhaps interesting fit. The AutoPulse unit sells for $13,300 and the use-once disposable Lifeband sells for $125. The AutoPulse received FDA clearance in August of 2002 and has been qualified for adults up to 300 pounds with a nontraumatic chest diagnosis. This unit has a 3-horsepower, 60-amp battery made of nickel/metal hydride that runs continuously for 30 to 60 minutes and then simply needs a battery change to keep going.

Zoll also noted that the U.S. military awarded an $8.9 million contract to the company earlier this year for 660 transport defibrillators and that it had shipped most of those units as of ACEP meeting. Interestingly, Fred Gahab, a senior engineer from Siemens Medical (Danvers, Massachusetts) joined Zoll recently. Gahab is well-known for developing the Siemens arrhythmia algorithms and as being an expert in ECG alarm detection and processing, which leads one to wonder if there could be a monitoring product line in Zoll's future.

Welch Allyn Monitoring also was showing sensitivity to the military in a new product it has labeled Mobile Acuity LT which is a central monitoring system that is ready to deploy anytime and anyplace. The system includes a laptop "central station" and 12 of Welch Allyn's Propaq or Micropaq wireless monitors. The batteries last from 12 to 16 hours if monitoring ECG and Sp0₂ or 24 to 26 hours if only ECG is monitored. Up to 12 patients can be monitored on a single workstation with 24 hour full disclosure and remote control of patient monitors and alarms from the central station. Mobile Acuity LT also incorporates Mortara Instruments' (Milwaukee, Wisconsin) Veritas life-threatening arrhythmia algorithm.

The entire set-up comes in a ruggedized army footlocker type of carrying case that comes complete with set-up instructions. Welch Allyn says that the system can be set up in 20 minutes. The cost of the system is around $50,000 and did not require FDA clearance because it was spawned from the company's full Acuity System. Not only is the military interested in this system, but it would appear to be an ideal set-up for emergency preparedness and any natural disaster.

Philips Medical Systems (Andover, Massachusetts) was showing its new, FDA-cleared defibrillator unit. This is a basic 3-lead ECG configurable defibrillator with two five-hour lithium ion batteries. This basic unit (with added optional modules) can be configured to 12-leads and can include BP, SP0₂ and NC0₂. The basic unit starts at $9,250 and can increase in price depending upon options to more than $20,000 per unit.

Philips also was showing a work in progress that is pending FDA clearance its new NICCO (noninvasive continuous cardiac output) product, which it has integrated into its monitor, designed for Philips by Analogic (Wakefield, Massachusetts). NICCO includes modules for ECG, NIBP, temperature, respiration, C0₂ and impedance cardiography (ICG) and is intended for use in sub-acute care areas. Philips said the unit, which it hoped would be FDA-cleared by November, would cost $19,200 with the C0₂ module. Sensors will cost $15 for a set of four for use with the ICG module. NICCO has a "smart cable" connection that reads which cable is plugged in and then configures the monitor to that connection. Analogic, its OEM supplier, will piggy-back off the FDA clearance and market a non-Philips-branded version of the device in non-U.S. markets in competition with other smaller vendors such as Ivy Biomedical (Branford, Connecticut) and Criticare Systems (Milwaukee, Wisconsin). The unit features Nellcor (Pleasanton, California)-compatible pulse oximetry processing, rather than Masimo (Irvine, California) or Philips' own pulse oximetry processing.

ED information system markets get hot

The emergency department environment would seem to be an ideal setting for information systems; there is a need for keeping track of patients, documentation by physicians and nurses, billing needs, discharge instruction and more recently, the recognized need for risk management and the reduction of errors all often needed "stat." So why is it that only 2% of all emergency departments currently have a fully integrated information system installed? The answer lies somewhere between hospitals wanting a proven return on investment before they buy to the varied approach that the emergency department information system (EDIS) vendors take.

There are the original ED vendors that believe the emergency department is a unique environment and must be approached separately from other hospital information systems. Wellsoft (Somerset, New Jersey) believes this to be true and speaks to an overall vision of where they see the ED market going. While other companies are using more and more bells and whistles in their viewing screens, Wellsoft has eliminated icons and gone to communicating messages by color alone, simplifying the viewing screen. In addition to a clean view board, Wellsoft was the only vendor exhibiting at ACEP that has incorporated the patient's full list of vital signs shown across the top of every screen that the clinician chooses.

Wellsoft also is of the opinion that the best way for clinicians to utilize ED information systems is to have a monitor on a swivel arm in each ED patient room where clinicians spend most of their time. Wellsoft offers a high-speed Internet connection that enables them to quickly make changes desired by the ED staff to any of the installed software, or the ED staff can make the changes onsite, without Wellsoft's involvement. However, it is not the only player.

ibex (Rosemont, Illinois) is another original ED vendor and, like Wellsoft, was showing a full implementation design in its PulseCheck system. ibex believes that the answer to ED overcrowding is better management of the ED, and showed how PulseCheck enabled patient tracking, triage, ambulance tracking, administrative reporting, physician and nurse documentation and optional risk management for physician and nurse documentation, charge management, billing and biosurveillance and biometric authentication. At ACEP, ibex announced a new interface to Hewlett-Packard's (Palo Alto, California) iPac personal assistance device (PAD).

It is interesting to note that there was a divergence of opinions concerning the use of personal assistance devices (PADs) for information. The ibex interface allows all of the information available on their view board to be seen on the PAD. Other vendors integrated only some of the available information into PADS, believing that the amount of information could not be adequately displayed on a screen the size of most PAD screens. Some ED vendors believe that clinicians will use PADs for viewing only laboratory results and little else. Other vendors said that as the physicians and nurses that staff the ED continue to age, PADs will become less desirable and the more readily viewable tablet format will be the platform of choice.

The ibex PulseCheck also offered an optional Risk Management module that had pop-up screens associated with some diagnoses that prompted a doctor or nurse to address specifics associated with that diagnosis. For example, when the diagnosis of chest pain is chosen, a pop-up appears to prompt the clinician to specify location, intensity and other variables and then the system suggests a diagnosis and treatment plan to follow until that diagnosis is proven false.

T-system (Dallas, Texas), one of the wider application vendors, was showing its three-module solution of physician and nurse documentation and patient tracking. The T-system allows multiple nurses to chart on the same patient and access to prior records as well. The charting is accomplished by the clinician choosing to circle the descriptors to be included and to place a line through those to be negatively included, but in order to accomplish this the clinician sometimes had to use both the mouse and the keyboard. There appeared to be no checks or security built into the system if a clinician entered a higher-than-normal dose for a medication to be administered and little other risk management information. T-System is a very popular choice for its paper-forms based documentation, but has yet to succeed in converting any large percentage of that client base to its electronic charting solution.

Emergisoft (Arlington, Texas) also did not appear to have adequate risk management software installed. When the person demonstrating the system (a non-clinician) entered a blood pressure of 100 (systolic) over 128 (diastolic), the system readily took the number and continued to display it whenever the patient record board was viewed. These types of errors are potentially serious in the ED environment when the pace is hectic and clinicians have little time to determine if the data they are viewing has been accurately entered. This is particularly interesting because Emergisoft is one of the original ED vendors and at ACEP was publicizing the fact that the company had just invested $7 million to change from a DOS operating system to a Windows-based system. Emergisoft also interfaces to a hospital's formulary so that any medication updates are only as good as the hospital's updates. Other larger vendors have opted to run either First Data or Multim medication software in their systems, either of which includes medication updates. In spite of all this, Emergisoft's sales have tripled in the last year.

There is no excuse for computer charting systems to accept data that cannot be physiologically valid. This has been an issue for years and has not yet been fixed. Healthcare providers are looking for solutions to charting problems, not additional charting problems introduced by an automated system that is not properly designed.

A4 Health (Cary, North Carolina), which bought one of the original ED vendors (Nine Rivers), has added to the quality base that it started with by including First Data as its medical software program, adding an ad hoc query tool and including a charge nurse screen. The charge nurse screen includes current real-time departmental information so that the clinician can mange the department more efficiently and perhaps reduce ED overcrowding (at least for those variables that the ED has control over).

The larger vendors like Cerner (Kansas City, Missouri), GE Medical Systems (Waukesha, Wisconsin) and McKesson Information Systems (Alpharetta, Georgia) that have ED systems as part of their overall approach were at ACEP as well. These companies advocate the integration of all hospital systems as being an advantage that with little difficulty the ED system integrates to the rest of the hospital and allows communication to "flow." This approach could be an advantage in maintaining awareness of where empty beds are so that ED patients can be moved through the department more efficiently. However, movement of patients is but one of the problems that affect EDs, and in order for these larger vendors to be successful in this area, they need to develop an ED product, not just alter the information system they use in other areas of the hospital.

As is true for all information systems used in U.S. hospitals today, the EDIS is in transition. But with overcrowding, pressure for computer physician order entry to reduce medication errors and other problems that EDs are facing, it is time for ED clinicians to stop thinking in terms of a final solution and start to think in terms of joining the process of information technology. When more than a paltry 2% of EDs have an integrated solution in place, more clinicians will have the understanding necessary to communicate with vendors to truly improve the flow of information and safety of ED patients. The key to proliferation of these systems, apart from making them reflect clinical reality, is to show the independent physician groups that provide coverage to many hospital emergency departments that such systems can provide them with better charts, better patient care and measurable outcomes needed to drive down the ever escalating malpractice insurance premiums.

There will never be the data required until there are the electronic systems in place to capture and analyze it. This is something that anesthesiologists, prodded by the Anesthesia Patient Safety Foundation (APSF; Indianapolis, Indiana), have realized. They have laid the foundation by developing a data dictionary for every anesthesiology charting system to use, which has been accepted and included in SnoMed, and they accomplished it in one year.

Some collaboration by the emergency department vendors and ACEP could accomplish the same thing in the same time period. It's time for the emergency physicians and system vendors to quit complaining about adoption of electronic systems and get about developing the industry-standard dictionaries and nomenclatures that will allow ED outcomes to be captured and analyzed regardless of which specific vendor's computerized patient charting system is deployed.