Safety net research in emergency medicine: proceedings of the Academic Emergency Medicine Consensus Conference on "The Unraveling Safety Net".

A primary goal of the Academic Emergency Medicine Consensus Conference, "The Unraveling Safety Net: Research Opportunities and Priorities," was to explore a formal research agenda for safety net research in emergency medicine. This paper represents the thoughts of active health services researchers regarding the structure and direction of such work, including some examples from their own research. The current system for safety net care is described, and the emergency department is conceptualized as a window on safety net patients and systems, uniquely positioned to help study and coordinate integrated processes of care.

The Emergency Medical Treatment and Labor Act as a federal health care safety net program.

Despite the greatest economic expansion in history during the 1990s, the number of uninsured U.S. residents surpassed 44 million in 1998. Although this number declined for the first time in recent years in 1999, to 42.6 million, the current economic slow-down threatens once again to increase the ranks of the uninsured. Many uninsured patients use hospital emergency departments as a vital portal of entry into an access-impoverished health care system. In 1986, Congress mandated access to emergency care when it passed the Emergency Medical Treatment and Labor Act (EMTALA). The EMTALA statute has prevented the unethical denial of emergency care based on inability to pay; however, the financial implications of EMTALA have not yet been adequately appreciated or addressed by Congress or the American public. Cuts in payments from public and private payers, as well as increasing demands from a larger uninsured population, have placed unprecedented financial strains on safety net providers. This paper reviews the financial implications of EMTALA, illustrating how the statute has evolved into a federal health care safety net program. Future actions are proposed, including the pressing need for greater public safety net funding and additional actions to preserve health care access for vulnerable populations.

Tying a knot in the unraveling health care safety net.

The U.S. health care system continues to rely on a diverse and poorly organized health care safety net to provide care for its uninsured and underinsured residents. Last year, the Institute of Medicine (IOM) published a report entitled America's Health Care Safety Net: Intact but Endangered. The IOM cited several threats to the safety net, including inadequate monitoring of safety net function, poor integration of services, financial threats for core safety net providers, and the destabilizing effects of a rapid shift from traditional Medicaid to Medicaid managed care products. This paper reviews the findings of the IOM report, highlighting the key issues for emergency medicine. In response to the IOM's challenges, emergency departments should be used more effectively to monitor local safety net viability and to enhance the integration of community health care safety net delivery systems.

Access, quality, and cost control in emergency medicine: can we have all three? A resident's perspective on the future of emergency medicine.

The triad of access, quality, and cost provides a useful framework for the discussion of health care reform. A quote from a recent review of the Oregon Health Plan illustrates the conflict between these three factors very well. "The administrators of the plan are realistic people; they once placed a sign on the wall: 'Cost, access, quality--pick any two."

High discharge survival rate after out-of-hospital ventricular fibrillation with rapid defibrillation by police and paramedics.

STUDY OBJECTIVE: To assess outcome in patients with ventricular fibrillation (VF) treated by defibrillator-equipped police and emergency medical technician-paramedics in an advanced life support (ALS) emergency medical services (EMS) system. METHODS: We carried out a retrospective observational outcome study of all consecutive adult patients with atraumatic cardiac arrest treated from November 1990 through July 1995. The study was carried out in a city with a population of 76,865 in an area of 32.6 square miles. Central 911 dispatched police and an ALS ambulance simultaneously. Accurate intervals were obtained with the synchronization of all defibrillator clocks with the 911 dispatch clock. The personnel who arrived first delivered the initial shock. After shocks delivered by police, paramedics provided additional treatment if needed. Main outcome measures were time elapsed before delivery of the first shock, restoration of spontaneous circulation (ROSC), and survival to discharge home. RESULTS: Of 84 patients, 31 (37%) were first shocked by police. Thirteen of the 31 demonstrated ROSC, without need for ALS treatment. All 13 survived to discharge. The other 18 patients required ALS; 5 (27.7%) survived. Among the 53 patients first shocked by paramedics, 15 had ROSC after shocks only, and 14 survived. The other 38 needed ALS treatment; 9 survived. Call-to-shock time for all patients was less in the police group than in the paramedic group (5.6 versus 6.3 minutes, P = .038). For all patients, call-to-shock time was less in those with ROSC after shocks only than in those who needed ALS (5.4 versus 6.3 minutes, P = .011). Survival to discharge was 49% (41 of 84), with 18 of 31 (58%) in the police group and 23 of 53 (43%) in the paramedic group. Call-to-shock time for survivors was 5.8 minutes; it was 6.4 minutes for the nonsurvivors (P = .020). Neither ROSC nor discharge survival was significantly different between police and paramedic-shocked patients. ROSC after initial shock and call-to-shock time were major determinants of survival, whether the first shocks were administered by police or by paramedics. With ROSC after shocks only, 27 of 28 (96%) survived, whereas 14 of 56 (25%) needing ALS survived (P < .001). CONCLUSION: A high discharge-to-home survival rate was obtained with early defibrillation by both police and paramedics. When shocks resulted in ROSC, the overwhelming majority of patients survived (96%). Even brief time decreases (eg. 1 minute) in call-to-shock time increase the likelihood of ROSC from shocks only, with a consequent decrease in the need for ALS intervention. Short call-to-shock time and ROSC response to shocks only are major determinants of a high rate of survival after VF.

Prognostic value of end-tidal carbon dioxide pressures during out-of-hospital cardiac arrest.

STUDY OBJECTIVE: To assess the prognostic value of initial end-tidal CO2 pressures (PETCO2) during CPR in patients with out-of-hospital cardiac arrest (OHCA). DESIGN: A prospective observational study using a convenience sample. SETTING: Primary service area of an advanced life support (ALS) ambulance service, including a city with a population of 70,745 and the surrounding area, with a population of 30,000. PARTICIPANTS: Adults with nontraumatic OHCA. INTERVENTIONS: Quantitative monitoring of PETCO2 during CPR after endotracheal intubation using an infrared capnograph. RESULTS: PETCO2 after 1 and 2 minutes and the maximum PETCO2 during CPR were compared between the group in which restoration of spontaneous circulation (ROSC) was achieved and the group in which it was not. PETCO2 was measured during CPR in 27 patients. After 1 minute, PETCO2 was higher in patients who had on-scene ROSC than in patients without ROSC (23.0 +/- 7.4 versus 13.2 +/- 14.7 mm Hg, P = .0002). After 2 minutes, PETCO2 was higher in patients with ROSC (26.8 +/- 10.8 versus 15.4 +/- 5.7 mm Hg, P = .0019). The maximum PETCO2 during CPR was also higher in the ROSC group (30.8 +/- 9.5 versus 22.7 +/- 8.8 mm Hg, P = .0154). Thirteen of 27 patients presented in ventricular fibrillation (VF). The 1-minute (24.3 +/- 6.8 versus 12.0 +/- 4.2 mm Hg, P = .0022), 2-minute (28.2 +/- 11.4 versus 12.4 +/- 4.3 mm Hg, P = .0088), and maximum (33.0 +/- 10.2 versus 20.6 +/- 11.1 mm Hg, P = .0316) PETCO2 values during CPR were all significantly higher in patients in VF with ROSC. CONCLUSION: In this observation study of 27 patients, initial PETCO2 during CPR with automated ventilation was prognostic for ROSC in patients with OHCA. Patients with ROSC have higher PETCO2 values after 1 and 2 minutes than do patients without ROSC.

Subarachnoid hemorrhage: atypical presentation associated with rapidly changing cardiac arrhythmias.

Subarachnoid hemorrhage (SAH) typically presents with sudden onset of severe headache and is often associated with cardiac arrhythmias. The case of a patient with SAH in whom typical presenting signs and symptoms were absent is presented. This case was characterized by rapidly changing arrhythmias observed in the prehospital setting. The diversity and rapid evolution of arrhythmias can be attributed to the autonomic and electrolyte imbalances that often accompany SAH.

Out-of-hospital quantitative monitoring of end-tidal carbon dioxide pressure during CPR.

STUDY OBJECTIVE: To assess the feasibility and potential usefulness of quantitative measurement of end-tidal carbon dioxide pressure (PETCO2) during out-of-hospital cardiac arrest. DESIGN: Emergency medical technician-paramedics (EMT-Ps) were instructed in the operation of a portable battery-powered capnograph, the sensor for which was attached to the endotracheal tube following intubation. This was a preliminary pilot study limited to defining feasibility and potential utility in a small group of patients. SETTING: City with population of 70,745 served by an advanced life support emergency medical services system. PARTICIPANTS: Initial group of four patients who experienced out-of-hospital cardiac arrest and who were treated by EMT-Ps trained in operation of the capnograph. INTERVENTIONS: As soon as possible following endotracheal intubation a mainstream sensor was connected to the endotracheal tube and digital and capnographic waveform data obtained for the remainder of the resuscitation. Data were stored in memory and subsequently retrieved for the entire event, with digital readings at eight-second intervals. RESULTS: Capnographic measurements were obtained immediately after endotracheal intubation in all four patients. The capnograph was operated without difficulty throughout the resuscitations. Changes in performance of chest compression or changes in cardiac rhythm were reflected immediately in changes in (PETCO2). Persistent excretion of carbon dioxide during pulselessness was observed in two patients, consistent with "pseudo-electromechanical dissociation." CONCLUSION: These preliminary pilot observations confirm the feasibility of quantitative capnography during out-of-hospital cardiac arrest and indicate that early institution of this noninvasive procedure may provide insight into pathophysiologic mechanisms such as pseudo-electromechanical dissociation and may also track changes in pulmonary blood flow during chest compressions or during spontaneous circulation.