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On-Call Specialist Crisis Downgrades Oregon's Trauma System

Nearly half of Oregon's hospitals cannot provide on-call specialist treatment around the clock to emergency patients in at least one specialty, despite paying substantial stipends, and 13 percent of Oregon's hospitals have had their trauma designation dow

Nearly half of Oregon's hospitals cannot provide on-call specialist treatment around the clock to emergency patients in at least one specialty, despite paying substantial stipends, and 13 percent of Oregon's hospitals have had their trauma designation downgraded as a result.  Researchers from Oregon Health & Science University, Sutter Emergency Medical Associates, the University of Iowa and the Office of Oregon Health Policy and Research published their findings online in the Annals of Emergency Medicine ("The On-Call Crisis: A Statewide Assessment of the Costs of Providing On-Call Specialist Coverage").

"Shortages of specialists willing to take call in the emergency department are a nationwide problem and represent a major change in the way we provide emergency care," said lead study author K. John McConnell, PhD, of Oregon Health & Science University.  "Many hospitals are paying substantial amounts to maintain their roster of on-call specialists, and some hospitals have been forced to drop 24-7 coverage for certain specialties. These changes affect everyone coming to the emergency department - regardless of whether you're uninsured, or covered by Medicaid, Medicare or a private health plan."

The statewide survey, conducted in the summer of 2005, showed coverage shortages in most specialties, with the most acute shortages in orthopedics and neurosurgery.   More than half of all hospitals expressed difficulty in maintaining specialists on call for three or more specialties.  The eight specialties measured were trauma surgery, general surgery, neurosurgery, plastic surgery, hand surgery, neurology, orthopedics and obstetrics.

A recent change in the way that the Centers for Medicare and Medicaid (CMS) interpret the Emergency Medical Treatment and Labor Act (EMTALA) - a federal law that governs hospital emergency departments - appears to have exacerbated hospitals' on-call difficulties, the study authors speculated.  However, a number of other factors fuel specialists' reluctance to take emergency call, including: inadequate reimbursement, particularly for uninsured patients; fears of malpractice; and the growth of ambulatory surgery centers and specialty hospitals.

"Thirteen percent of hospitals have already had their trauma designations affected by an inability to provide sufficient on-call specialist coverage," said Dr. McConnell.  "A continuation of the current situation could place significant financial burdens on hospitals, degrade the effectiveness of the trauma system and adversely affect the quality of emergency care."

Nearly half (43 percent) of all hospitals provided some subsidy to at least one specialty, on average approximately $1,000 per night, in an attempt to attract more consistent specialty coverage.  Ninety percent of large, urban hospitals in Oregon are compensating at least one group of specialists through stipends or guaranteed rates of pay.

"This study adds to a mounting body of evidence that the on-call crisis is a serious threat to the integrity of our emergency care system and is the weak link in the chain-of-survival in many communities throughout the United States," said contributing author Loren A. Johnson, MD, FACEP, Chief Medical Officer, Sutter Emergency Medical Associates in Davis, California. "Impending workforce shortages in several key specialties will compound this problem, and we need a comprehensive plan to address resource, accountability, liability and workforce needs."

Although the study concerns Oregon, study authors note that the problem may be substantially worse in other states, citing specific data from California where the total annual cost of stipend payments exceeded $600 million in 2005.

"Emergency physicians provide the highest quality emergency care possible, but we can't do everything," said Dr. Brian Keaton, president of the America College of Emergency Physicians.  "If the emergency department cannot find a specialist when it needs one, patient care is inevitably compromised."

Annals of Emergency Medicine is the peer-reviewed scientific journal for the American College of Emergency Physicians, a national medical society with more than 25,000 members. ACEP is committed to advancing emergency care through continuing education, research, and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies. For more information visit

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