1 f

Editorials

specialty Status Progress Reaches Critical State

We are about to take a critical step - - a giant step - - toward recogni t ion of emergency medicine as a board- certified specialty.

After years of preparat ion we are ready to under take the cu lmina t ing task of developing a certification exami- ~ation.

This is a step toward which the American College of Emergency Physicians has been preparing since its in- ception in 1968. Our most fundamenta l purpose has been

build common recognition of our professionalism_ We have long recognized certification as our u l t imate goal and I do not hesi ta te to identify this event as a giant step ahead.

The f raming of an acceptable examinat ion is a complex and t ime-consuming under taking. Nearly two years will be needed for the f inal izing of policies, the development of procedures, the prepara t ion of texts, the tes t ing of methods, the t r a in ing of examiners and the fulf i l lment of along list of other requirements . Our prel iminar ies al- ready have been underway for near ly two years and we are well into the development process. We in tend that the board examina t ion in emergency medicine shall set new ttandards for both thoroughness and equity.

Thus far the cost of these prel iminar ies had been ab- sorbed in ACEP operat ing budgets. The burden has been ~0rne to a major extent by the freely offered contribu- ions of many of your colleagues. For example, the 25- aember task force which met last summer to specify the xamination content did so ent i re ly at its own expense. ~0w, however, formal funding mus t be provided. For this ,urpose the ACEP Council has recommended and the 10ard has approved a special assessment to f inanc ia l ly upport the examina t ion development. The assessment aounts to $50 annua l l y for three years.

We are nea r ing fruit ion of all the t ime and effort we ~ave invested in advancing the professional matur i ty of aergency medicine. You are being asked to solidify this ~vestment by a further demonstrat ion of confidence in r future.

CEP members will soon be receiving a notice of this cial one: t ime assessment tha t will support the crea-

and implementa t ion of the examinat ion. Our objec- is an examina t ion procedure tha t will be exemplary

very way, which will establish new and higher stand- lids for specialty certification as a whole.

I t rus t tha t everyone who unders tands the need for this c ruc ia l g i a n t step ahead wil l respond p rompt ly and generously.

Harris B. Graves, MD President

Defining Quality of ED Care A Complex Problem

THE PROBLEM OF DEFINING qual i ty of care in an emer- gency d e p a r t m e n t is an i n t e r e s t i n g and c h a l l e n g i n g one. I th ink that the approach t aken by McNamara et al in '~Assessing the Quali ty of Care by House Staff in a Munic ipa l Hospi tal Emergency Depa r tmen t " leads to some in t r igu ing conclusions.

As one who works in an emergency department~ it is clear to me that the major portion of qual i ty control is organizat ional ly based. By tha t I mean tha t no mat ter how competent the physician is, no mat ter how dedicated, hard working, or compulsive, the system can stitl defeat the p h y s i c i a n . I t seems to me t h a t i t ' s t ime t h a t emergency medicine defines some of the areas of organi- zational responsibility.

The authors have alluded to some of the problems in del ivering heal th care in an emergency setting, such as inexper ienced house staff who are asked to del iver a large service component to a wide var ie ty of pa t ients with no strong organizat ion of pa t ient flow. In addition, one aspect not ment ioned in the article is tha t the group of workers del ivering the care have no special reasons for being in the emergency department . Unless the house of- ricer is there for the purpose of l e a r n i n g emergency medicine, he will not have the mot ivat ion for seeing the full range of patients_

Also, the in te res t and dedication is immedia te ly de- pendent upon having an interested and dedicated attend- ing staff physically present to supervise the area dur ing peak times. Final ly , the qual i ty of care is dependent on the organizat ion of pa t ien t flow. While it will continue to be the responsibil i ty of every emergency depar tment to allow the pa t ient to define what an emergency is and see everybody who signs in, it is the responsibi l i ty of the de- pa r tmen t to segregate the nonemergen t pat ients from the l ife-threatened and u rgen t problems so that these can be cared for first.

The emergency depar tment is also responsible for or- ganizing a system of care outside of the department. Any

~[]~P April 1976 Volume 5 Number 4 Page 273

single facility can overload and the day has yet to come when we see a funct ioning system whereby an overloaded emergency depar tment can divert pat ients to a less busy, nearby hospital. There should also be advanced notifica- t ion of the arr ival .of the l ife-threatened patients. This is rarely obtained in the Uni ted States although, as more and more ambulance and paramedic systems develop, it is becoming more common.

Final ly , the emergency depar tment mus t define the l imits of responsibi l i ty for care of a par t icular episode. Many of the cri t icisms of emergency depar tment care have been about lack of follow-up ini t ia ted either by the ED or the patient . This is indeed part ly the emergency depar tment ' s responsibil i ty. It mus t not only establish a clinic for pr ivate physician referral but mus t make the pa t ient aware of the need for the referral and the l imits of what can be accomplished in the emergency depart- ment. Of course, this is ext raordinar i ly difficult with an overloaded outpa t ien t hea l th delivery system that cannot immediate ly process patients. Therefore, they end up in your emergency depar tment or somebody else's because their heal th care problem has not been resolved.

We are seeing a growing group of pat ients who appar- en t ly h a v e no desir e f o r on-going care from a s ingle physician or an outpa t ien t clinic but who feel that their

heal th care needs can be met by the episodic approach mul t ip le visi ts to an emergency department_ Nob0d~ would define this as high qual i ty care bu t we have yet t~ come up with an adequate solution for the pat ient ~h~ will not take responsibil i ty for his own care.

Final ly, the physical s t ructure and the organizatioa the emergency depar tment i tself plays an important rol~ in the type of care generated. If there is inadequate spac~ and support personnel - - nurses, social workers, c/~isis i~. tervent ion workers, and other anci l lary personnel - - thel once again the care of the pa t ient will be seriously inte~ fered with.

In conclusion, unt i l the t ime comes when we are will ing to rea l i s t ica l ly assess the physical and organiza t ional flaws of an emergency depar tment , we will co~ t inue to fail to produce a consistent method of evaluati~l care in an emergency depar tment by simply looking chart reviews of physicians' performances.

Peter Rosen, IVIL JA CEP Contributing Edito~

(Dr_ Rosen is Professor and Director, Division o, Emergency Medicine at The University of Chicago Hospi tals and Clinics, Chicago, Illinois.)

Page 274 Volume 5 Number 4 April 1976 ~ t