Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
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The assessment of pre-procedure fasting and control of sedation depth are prominent elements of widely disseminated procedural sedation guidelines and of the Joint Commission on Accreditation of Healthcare Organizations' standards. Both exist primarily to minimize the risk of pulmonary aspiration of gastric contents. This paper critically examines the literature on pre-procedure fasting and controlling sedation depth in association with pulmonary aspiration, and interprets this evidence in the context of modern emergency medicine practice. ⋯ It is noted that aspiration during ED PSA has not been reported in the medical literature and that aspiration during general anesthesia and labor and delivery is uncommon. The literature provides no compelling evidence to support specific fasting periods for either liquids or solids prior to PSA, and existing guidelines for elective patients are of necessity arbitrary and based upon consensus opinion. The article discusses the implications in the areas of training and preparedness, monitoring, and research for the emergency physician practicing PSA.
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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.
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The American health care safety net is threatened due to inadequate funding in the face of increasing demand for services by virtually every segment of our society. The safety net is vital to public safety because it is the sole provider for first-line emergency care, as well as for routine health care of last resort, through hospital emergency departments (ED), emergency medical services providers (EMS), and public/free clinics. Despite the perceived complexity, the causes and solutions for the current crisis reside in simple economics. During the last two decades health care funding has radically changed, yet the fundamental infrastructure of the safety net has change little. In 1986, the Emergency Medical Treatment and Active Labor Act established federally mandated safety net care that inadvertently encouraged reliance on hospital EDs as the principal safety net resource. At the same time, decreasing health care funding from both private and public sources resulted in declining availability of services necessary to support this shift in demand, including hospital inpatient beds, EDs, EMS providers, on-call specialists, hospital-based nurses, and public hospitals/clinics. The result has been ED/hospital crowding and resource shortages that at times limit the ability to provide even true emergency care and threaten the ability of the traditional safety net to protect public health and safety. This paper explores the composition of the American health care safety net, the root causes for its disintegration, and offers short- and long-term solutions. The solutions discussed include restructuring of disproportionate share funding; presumed (deemed) eligibility for Medicaid eligibility; restructuring of funding for emergency care; health care for foreign nationals; the nursing shortage; utilization of a "health care resources commission"; "episodic (periodic)" health care coverage; best practices and health care services coordination; and government and hospital providers' roles. ⋯ There is a base amount of funding that must be available to the American health care safety net to maintain its infrastructure and provide appropriate growth, research, development, and expansion of services. Fall below this level and the infrastructure will eventually crumble. America must patch the safety net with short-term funding and repair it with long-term health care policy and environmental changes.
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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. ⋯ 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.
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In virtually every community in this nation, the emergency department (ED) is an integral part of the health care safety net, often serving as the only available point of access to the health care system for many vulnerable and disenfranchised individuals. The authors present a brief overview of the March 2000 report released by the Institute of Medicine that described and assessed the current status of the nation's health care safety net. The authors discuss the role of the ED as a safety net provider and as a window onto the status of the rest of the health care system. The authors describe the Andersen behavioral model of health services use and suggest it as a useful theoretical framework for emergency medicine researchers who are interested in studying these issues.