Editing Emergency medicine (section)

=== Care delivery in different ED settings ===

==== Rural ====
Despite the practice emerging over the past few decades, the delivery of emergency medicine has significantly increased and evolved across diverse settings related to cost, provider availability and overall usage. Before the Affordable Care Act (ACA), low-acuity emergency medicine visits were leveraged primarily by "uninsured or underinsured patients, women, children, and minorities, all of whom frequently face barriers to accessing primary care".<ref>{{cite journal |doi=10.1097/01.mlr.0000045021.70297.9f |pmid=12555048 |title=Emergency Department Visits for Ambulatory Care Sensitive Conditions |journal=Medical Care |volume=41 |issue=2 |pages=198–207 |year=2003 |last1=Oster |first1=Ady |last2=Bindman |first2=Andrew B. |s2cid=24666109}}</ref> While this still exists today, as mentioned above, it is critical to consider the location in which care is delivered to understand the population and system challenges related to overutilization and high cost. In rural communities where provider and ambulatory facility shortages exist, a primary care physician (PCP) in the ED with general knowledge is likely to be the only source of health care for a population, as specialists and other health resources are generally unavailable due to lack of funding and desire to serve in these areas.<ref>{{cite book |chapter=Improving efficiency and preserving access to emergency care in rural areas |publisher=MEDPAC |chapter-url=http://www.medpac.gov/docs/default-source/reports/chapter-7-improving-efficiency-and-preserving-access-to-emergency-care-in-rural-areas-june-2016-repo.pdf |title=Report to the Congress: Medicare and the Health Care Delivery System |date=June 2016 |access-date=28 November 2016 |archive-date=3 February 2017 |archive-url=https://web.archive.org/web/20170203083954/http://www.medpac.gov/docs/default-source/reports/chapter-7-improving-efficiency-and-preserving-access-to-emergency-care-in-rural-areas-june-2016-repo.pdf |url-status=dead}}</ref> As a result, the incidence of complex co-morbidities not managed by the appropriate provider results in worse health outcomes and eventually costlier care that extends beyond rural communities. Though typically quite separated, PCPs in rural areas must partner with larger health systems to comprehensively address the complex needs of their community, improve population health, and implement strategies such as telemedicine to improve health outcomes and reduce ED utilization for preventable illnesses.<ref>{{cite journal |doi=10.1111/j.1748-0361.2008.00156.x |pmid=18397454 |title=Nonemergency Medicine-Trained Physician Coverage in Rural Emergency Departments |journal=The Journal of Rural Health |volume=24 |issue=2 |pages=183–8 |year=2008 |last1=Peterson |first1=Lars E. |last2=Dodoo |first2=Martey |last3=Bennett |first3=Kevin J. |last4=Bazemore |first4=Andrew |last5=Phillips |first5=Robert L.}}</ref><ref>{{cite press release |title=$22.1 Million to Improve Access to Health Care in Rural Areas |publisher=Health Resources and Services Administration |date=26 September 2014 |url=https://www.hrsa.gov/about/news/pressreleases/140926ruralhealth.html |access-date=29 January 2017}}</ref> (See: [[Rural health]].)

Rural care has benefitted in the post-pandemic (2020) era by the rapid expansion of telemedicine programs, including those that assist with Emergency Medical care. This has enhanced the ability of non-Emergency Medicine boarded physicians, physician assistants and nurse practitioners to provide a higher level of care by partnering with Emergency Physicians at larger centers, via telehealth.<ref>Expanding access to emergency care in rural hospitals. Department of Health and Human Services. https://telehealth.hhs.gov/community-stories/expanding-access-emergency-care-rural-hospitals#:~:text=Rural%20hospitals%20can%20use%20telehealth,assist%20staff%20in%20rural%20hospitals. Accessed 2024-12-28.</ref>

==== Urban ====
Alternatively, emergency medicine in urban areas consists of diverse provider groups, including [[physician]]s, [[physician assistant]]s, nurse practitioners and registered nurses who coordinate with specialists in both inpatient and outpatient facilities to address patients' needs, more specifically in the ED. For all systems, regardless of funding source, EMTALA mandates EDs to conduct a medical examination for anyone that presents at the department, irrespective of paying ability.<ref>EMTALA. Centers for Medicare & Medicaid Services. https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/ . Accessed 2016-11-15.
</ref> Non-profit hospitals and health systems – as required by the ACA – must provide a certain threshold of charity care "by actively ensuring that those who qualify for financial assistance get it, by charging reasonable rates to uninsured patients and by avoiding extraordinary collection practices."<ref>Kutscher B. Hospitals fall short on ACA charity-care rules. Modern Healthcare. http://www.modernhealthcare.com/article/20151028/news/151029886 . Published 28 October 2015. Accessed 2016-11-16.</ref> While there are limitations, this mandate provides support to many in need. That said, despite policy efforts and increased funding and federal reimbursement in urban areas, the triple aim (of improving patient experience, enhancing population health, and reducing the per-capita cost of care) remains a challenge without providers' and payers' collaboration to increase access to preventive care and decrease in ED usage. As a result, many experts support the notion that emergency medical services should only serve immediate risks in urban and rural areas.

==== Patient–provider relationships ====
As stated above, EMTALA includes provisions that protect patients from being turned away or transferred before adequate stabilisation. Upon making contact with a patient, EMS providers are responsible for diagnosing and stabilising a patient's condition without regard for the ability to pay. In the pre-hospital setting, providers must exercise appropriate judgement in choosing a suitable hospital for transport. Hospitals can only turn away incoming ambulances if they are on diversion and incapable of providing adequate care. However, once a patient has arrived on hospital property, care must be provided. At the hospital, a triage nurse first contacts the patient, who determines the appropriate level of care needed.

According to ''Mead v. Legacy Health System'',<ref>{{Citation|title=Mead v. Legacy Health System|date=26 July 2012|url=https://scholar.google.com/scholar_case?case=3832184832260263822&q=Mead+v.+Legacy+Health+System,+283+P.3d+904,+352+Or.+267+(2012).&hl=en&as_sdt=2006|volume=283|pages=904|access-date=2016-11-21}}</ref> a patient-physician relationship is established when "the physician takes an affirmative action with regard to the care of the patient". Initiating such a relationship forms a legal contract in which the physician must continue to provide treatment or adequately terminate the relationship.<ref>{{cite journal |doi=10.1001/virtualmentor.2012.14.5.hlaw1-1205 |pmid=23351207 |title=When is a Patient-Physician Relationship Established? |journal=Virtual Mentor |volume=14 |issue=5 |pages=403–6 |year=2012 |last1=Blake |first1=V}}</ref> This legal responsibility can extend to physician consultations and on-call physicians even without direct patient contact. In emergency medicine, termination of the patient–provider relationship prior to stabilization or without handoff to another qualified provider is considered abandonment. In order to initiate an outside transfer, a physician must verify that the next hospital can provide a similar or higher level of care. Hospitals and physicians must also ensure that the patient's condition will not be further aggravated by the transfer process.

The setting of emergency medicine presents a challenge for delivering high quality, patient-centered care. Clear, effective communication can be particularly difficult due to noise, frequent interruptions, and high patient turnover.<ref name=":5">{{cite journal |pmid=15332069 |year=2004 |last1=Rhodes |first1=K. V. |title=Resuscitating the physician-patient relationship: Emergency department communication in an academic medical center |journal=Annals of Emergency Medicine |volume=44 |issue=3 |pages=262–7 |last2=Vieth |first2=T |last3=He |first3=T |last4=Miller |first4=A |last5=Howes |first5=D. S. |last6=Bailey |first6=O |last7=Walter |first7=J |last8=Frankel |first8=R |last9=Levinson |first9=W |doi= 10.1016/j.annemergmed.2004.02.035|url=https://repository.upenn.edu/spp_papers/108}}</ref> The Society for Academic Emergency Medicine has identified five essential tasks for patient-physician communication: establishing rapport, gathering information, giving information, providing comfort, and collaboration.<ref name=":5" /> The miscommunication of patient information is a crucial source of medical error; minimising shortcoming in communication remains a topic of current and future research.<ref>{{cite journal |doi=10.4300/JGME-D-11-00256.1 |pmid=24294436 |pmc=3546588 |title=Patient Communication During Handovers Between Emergency Medicine and Internal Medicine Residents |journal=Journal of Graduate Medical Education |volume=4 |issue=4 |pages=533–7 |year=2012 |last1=Fischer |first1=Miriam |last2=Hemphill |first2=Robin R. |last3=Rimler |first3=Eva |last4=Marshall |first4=Stephanie |last5=Brownfield |first5=Erica |last6=Shayne |first6=Philip |last7=Di Francesco |first7=Lorenzo |last8=Santen |first8=Sally A.}}</ref>

====Medical error====
Many circumstances, including the regular transfer of patients in emergency treatment and crowded, noisy and chaotic ED environments, make emergency medicine particularly susceptible to [[medical error]] and near misses.<ref name=":0">{{cite book |doi=10.1002/9781118292150 |title=Ethical Problems in Emergency Medicine |year=2012 |isbn=9781118292150 |editor1-last=Jesus |editor1-first=John |editor2-last=Grossman |editor2-first=Shamai A |editor3-last=Derse |editor3-first=Arthur R |editor4-last=Adams |editor4-first=James G |editor5-last=Wolfe |editor5-first=Richard |editor6-last=Rosen |editor6-first=Peter}}</ref><ref name=":1">{{cite journal |doi=10.1016/s0196-0644(03)00398-6 |pmid=12944883 |title=Errors in a busy emergency department |journal=Annals of Emergency Medicine |volume=42 |issue=3 |pages=324–33 |year=2003 |last1=Fordyce |first1=James |last2=Blank |first2=Fidela S.J. |last3=Pekow |first3=Penelope |last4=Smithline |first4=Howard A. |last5=Ritter |first5=George |last6=Gehlbach |first6=Stephen |last7=Benjamin |first7=Evan |last8=Henneman |first8=Philip L.}}</ref> One study identified an error rate of 18 per 100 registered patients in one particular academic ED.<ref name=":1" /> Another study found that where a lack of teamwork (i.e. poor communication, lack of team structure, lack of cross-monitoring) was implicated in a particular incident of ED medical error, "an average of 8.8 teamwork failures occurred per case [and] more than half of the deaths and permanent disabilities that occurred were judged avoidable."<ref>{{cite journal |doi=10.1016/s0196-0644(99)70134-4 |pmid=10459096 |title=The Potential for Improved Teamwork to Reduce Medical Errors in the Emergency Department |journal=Annals of Emergency Medicine |volume=34 |issue=3 |pages=373–83 |year=1999 |last1=Risser |first1=Daniel T |last2=Rice |first2=Matthew M |last3=Salisbury |first3=Mary L |last4=Simon |first4=Robert |last5=Jay |first5=Gregory D |last6=Berns |first6=Scott D}}</ref> Particular cultural (i.e. "a focus on the errors of others and a 'blame-and-shame' culture") and structural (i.e. lack of standardisation and equipment incompatibilities) aspects of emergency medicine often result in a lack of disclosure of medical error and near misses to patients and other caregivers.<ref name=":0" /><ref>{{cite journal |doi=10.1111/j.1553-2712.2008.00147.x |pmid=19086213 |title=Emergency Medical Services Provider Perceptions of the Nature of Adverse Events and Near-misses in Out-of-hospital Care: An Ethnographic View |journal=Academic Emergency Medicine |volume=15 |issue=7 |pages=633–40 |year=2008 |last1=Fairbanks |first1=Rollin J. |last2=Crittenden |first2=Crista N. |last3=o'Gara |first3=Kevin G. |last4=Wilson |first4=Matthew A. |last5=Pennington |first5=Elliot C. |last6=Chin |first6=Nancy P. |last7=Shah |first7=Manish N. |doi-access=free}}</ref> While concerns about malpractice liability are one reason why disclosure of medical errors is not made, some have noted that disclosing the error and providing an apology can mitigate malpractice risk.<ref>{{Cite web|url=http://news.health.com/2010/08/17/when-doctors-admit-mistakes-fewer-malpractice-suits-result-study-says/|title=When Doctors Admit Mistakes, Fewer Malpractice Suits Result, Study Says|date=2010-08-17|website=Health News / Tips & Trends / Celebrity Health|access-date=2016-11-19|archive-url=https://web.archive.org/web/20161128195708/http://news.health.com/2010/08/17/when-doctors-admit-mistakes-fewer-malpractice-suits-result-study-says/|archive-date=28 November 2016|url-status=dead}}</ref> Ethicists uniformly agree that the disclosure of a medical error that causes harm is a care provider's duty.<ref name=":0" /> The critical components of the disclosure include "honesty, explanation, empathy, apology, and the chance to lessen the chance of future errors" (represented by the mnemonic HEEAL).<ref name=":0" /><ref>{{cite journal |doi=10.1001/jama.289.8.1001 |pmid=12597752 |title=Patients' and Physicians' Attitudes Regarding the Disclosure of Medical Errors |journal=JAMA |volume=289 |issue=8 |pages=1001–7 |year=2003 |last1=Gallagher |first1=Thomas H. |last2=Waterman |first2=A. D. |last3=Ebers |first3=A. G. |last4=Fraser |first4=V. J. |last5=Levinson |first5=W |doi-access=free}}</ref> The nature of emergency medicine is such that error will likely always be a substantial risk of emergency care. However, maintaining public trust through open communication regarding a harmful error can help patients and physicians constructively address problems when they occur.<ref name=":0" />