The Unmet Need

Magnitude of the Problem

Recent landmark reports by the National Academy of Science’s Institute of Medicine point to a high incidence of adverse events and medical error in U.S. hospitals, accounting for as many as 98,000 preventable deaths annually. Because the Emergency Department (ED) serves as the point of entry to the health care system for many individuals, improving patient safety in Emergency Care is a high impact area.

ED Visits

• One in 10 Americans visited the ED for treatment of an injury in the year 2000 (CDC, MMWR 2001; 50: 340-6).
• Nearly 103 million visits are made to the ED annually. ED admissions are increasing at a rate of 5% per year (AHA, 1999).
• More than 65% of all hospital admissions come through the ED (AHA 1999)
• EDs treat 30 million children each year (Child Health USA 2000 – HRSA)
• Patients wait an average of 48.7 minutes to see a physician (CDC 2001). However, the time from patient arrival to disposition (admission or discharge) ranges from 30 minutes to 5 hours (Southall AM J Emerg Med 1999). The average time from arrival to disposition is 1 hour 20 minutes for small rural hospitals and 3 hours 24 minutes for major teaching hospitals.

Adverse Events in the ED

Because the majority of ED patients are not subsequently admitted to the hospital, little data exist on the incidence and severity of ED-related adverse events over the continuum of care. However, much can be gleaned by examining those few studies that do exist on adverse events in the hospital setting.

Inpatient

• 31.7 million patients are admitted to U.S. hospitals annually. Over 920,000 of these patients will experience an adverse event (UTCO 2000).
• 3% of all hospital-reported adverse events occur in the ED. At least 1,148 deaths result from these adverse events.
• 52% of ED adverse events can be classified as below "standard of care" or negligent, a higher proportion than for any other area of the hospital. Of adverse events attributed to emergency physicians, 95% can be deemed negligent, negligence being defined as “well below the acceptable standard of care “(Thomas et al. Med Care 2000).
• Nearly 70% of deaths from ED-related adverse events were preventable.

Outpatient

• Medical errors account for 7.8% of all revisits to the ED (Liaw 1999).
• 1.93 million patients revisit the ED annually. Over 150,000 of these visits are attributable to medical error, misdiagnosis, or inappropriate treatment.
• Applying the same incidence for death due to an adverse event in inpatients and outpatients, it can be calculated that as many as 10,000 outpatients die annually due to adverse events suffered in the ED.

Traffic Accidents and ED Visits

• The CDC reports 1.5 million visits to the ED annually for traffic-related accidents, accounting for 1% of all ED visits (CDC). In 1999, nearly 42,000 people died in traffic accidents (NHTSA 1999).
• Motorcyclists accounted for 2,472 traffic fatalities and 50,000 injuries.
• Per registered vehicle, motorcyclists are three times more likely to die in an accident than automobile occupants.

Children in the ED

• Using the incidence rates above, it can be estimated that 45,300 children revisit the ED annually because of medical errors. As many as 3,540 of these children may die as the result of ED-related adverse events (UTCO 2000, Liaw 1999).
• Currently, no study documents the incidence of ED-related adverse events in children. However, children may be at greater risk for harm because of increased ED utilization compared to adults.

Complications of the ED Environment and Lack of Research Evidence

• It is likely that the above numbers represent only a small part of the true picture of adverse events in the ED. Few studies exist on patient safety in the ED. Indeed, several unique characteristics make the ED particularly vulnerable to adverse events and complicate research into this problem. (Wear 2000)
• ED-related adverse events may be manifested in locations away from the hospital. The site of follow up care is often unknown and follow-up caregivers may be unaware of ED visit.
• Chart documentation in the ED is often shorter and less detailed than in other parts of the hospital. Many ED-related adverse events may go undocumented.
• Important patient information is often unavailable to the ED physician at the time of the patient encounter.
• ED physicians work under severe time constraints, with as many as 4 to 6 patient dispositions per hour.
• ED physicians receive little to no feedback on the outcome of their care. The riskiest procedures are performed infrequently, leaving little opportunity for practice.
• Little to no data comparing ED’s in small and large hospitals. No data on ED revisits, negligence, and death.

Community Hospitals at Risk

Profile of community hospitals

• 2,268 American hospitals have less than 100 beds, accounting for 46% of all hospitals.
• On average a small hospital will have 1,500 admissions and 7,000 ED visits per year.
• Small hospitals experience disproportionately more ED visits than large hospitals. Small hospitals receive 16.1% of all ED visits and only 10.6% of all hospital admissions.
• Small hospitals are often not as well financially and operationally equipped as larger hospitals.
• Non-profit organizations or state/local government own over 90% of rural hospitals.
• Medicare, Medicaid, and other government sources represent 53% of net patient revenue at rural hospitals.

Cost

A business case around the cost of ED adverse events is currently being developed along with a proforma that will allow institutions to assess new products, services and technologies that can enhance the quality of care and safety in the ED.