Emergency medicine in the Veterans Health Administration—results from a nationwide survey

Abstract

Study Objective We describe emergency physician staffing, capabilities, and academic practices in U.S. Veterans Health Administration (VHA) EDs. Methods As part of an ongoing process improvement effort for the VHA emergency care system, VHA-wide surveys are conducted among ED medical directors every three years. Web-based surveys of VHA ED directors were conducted in 2013 on clinical operations and academic program development. We describe the results from the 2013 survey. When available, we compare responses with the previously administered survey from 2010. Results A total of 118 of 118 ED directors filled out the survey in 2013 (100% response rate). Respondents reported that 45.5% of VHA emergency physicians are board-certified in emergency medicine and 95% spend the majority of their time in direct patient care. Clinical care is also provided by part-time (<0.5 full-time employee equivalent) emergency physicians in 59.3% of EDs. More than half of EDs (57%) provide on-site tissue plasminogen activator (tPA) for acute ischemic stroke patients and only 39% can administer tPA 24/7. Less than half (48.3%) of EDs have emergency OB/GYN consultation availability. Most VHA EDs (78.8%) have a university affiliation but only 21.5% participated in the respective academic emergency medicine program. Conclusions VHA emergency physicians have primarily clinical responsibilities, and less-than-half have formal emergency medicine board-certification. Despite the majority of VHA EDs having university affiliations, traditional academic activities (e.g., teaching and research) are performed in only 1 in 3 VHA EDs. Less than half of VHA EDs have availability of consulting services, including advanced stroke care and women’s health.

Community Emergency Care Use by Veterans in an Era of Expanding Choice

“…Notably, a substantial prevalence of pregnancy-related complications and trauma-related cases, such as hip fractures and organ injuries, were observed in community EDs. This observation likely stems from the fact that while VA EDs, although diverse in their capabilities, generally do not function as major trauma centers, serve a smaller population of female patients, and commonly refer obstetrical cases to community facilities . Additionally, a higher prevalence of conditions considered to be emergency care sensitive, such as cardiac arrest, hemorrhagic stroke, and sepsis, which necessitate timely access to emergency interventions for improved outcomes, might be influenced, at least in part, by proximity to community ED facilities.…”

“…This observation likely stems from the fact that while VA EDs, although diverse in their capabilities, generally do not function as major trauma centers, serve a smaller population of female patients, and commonly refer obstetrical cases to community facilities. 16 Additionally, a higher prevalence of conditions considered to be emergency care sensitive, such as cardiac arrest, hemorrhagic stroke, and sepsis, which necessitate timely access to emergency interventions for improved outcomes, might be influenced, at least in part, by proximity to community ED facilities. This suggests that the choice of care settings by veterans may be influenced by the specific nature of their medical needs.…”

Hospital‐level variation in risk‐standardized admission rates for emergency care–sensitive conditions among older and younger Veterans

“…This may be further facilitated by the regional systems of care within the VA. Exploring the influence of granular department, staff, and resource characteristics, in addition to the observed associations with facility teaching status, complexity, and ED volume for some conditions, could be facilitated through climate assessment initiatives such as the VHA Emergency Departments and Urgent Care Clinics Survey 65 . This poses an opportunity to understand modifiable and local contextual drivers of variations that may influence the value of emergency care delivery that may be generalizable beyond the VA.…”

Reducing Adverse Drug Events

“…More than 2.3 million ED visits occurred across EDs within VHA medical centers in 2013, 4 many of which were for patients older than 65 years, who were prescribed multiple medications, or both. The VHA medical centers and other integrated health care systems that share clinical data across inpatient and outpatient clinical settings may provide an ideal setting to study patients with ADEs in greater detail and develop interventions to prevent, identify, and address ADEs.…”

“…Emergency departments within Veterans Health Administration (VHA) medical centers and other integrated health care systems, such as Kaiser Permanente, were not eligible for inclusion in the NEISS-CADES survey and were therefore not included in the study by Shehab et al The types of excluded institutions are noteworthy because EDs from integrated health systems such as VHA medical centers may provide unique opportunities to address ADEs. More than 2.3 million ED visits occurred across EDs within VHA medical centers in 2013, many of which were for patients older than 65 years, who were prescribed multiple medications, or both. The VHA medical centers and other integrated health care systems that share clinical data across inpatient and outpatient clinical settings may provide an ideal setting to study patients with ADEs in greater detail and develop interventions to prevent, identify, and address ADEs.…”