Rabin Elaine, Patrick Lisa
Department of Emergency Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY.
Southern California Permanente Medical Group, San Diego, CA.
Am J Emerg Med. 2016 Apr;34(4):687-93. doi: 10.1016/j.ajem.2015.12.059. Epub 2015 Dec 22.
Nationwide, hospitals struggle to maintain specialist on-call coverage for emergencies. We seek to further understand the issue by examining reliability of scheduled coverage and the role of ad hoc coverage when none is scheduled.
An anonymous electronic survey of all emergency department (ED) directors of a large state. Overall and for 10 specialties, respondents were asked to estimate on-call coverage extent and "reliability" (frequency of emergency response in a clinically useful time frame: 2 hours), and use and effect of ad hoc emergency coverage to fill gaps. Descriptive statistics were performed using Fisher exact and Wilcoxon sign rank tests for significance.
Contact information was obtained for 125 of 167 ED directors. Sixty responded (48%), representing 36% of EDs. Forty-six percent reported full on-call coverage scheduled for all specialties. Forty-six percent reported consistent reliability. Coverage and reliability were strongly related (P<.01; 33% reported both), and larger ED volume correlated with both (P<.01). Ninety percent of hospitals that had gaps in either employed ad hoc coverage, significantly improving coverage for 8 of 10 specialties. For all but 1 specialty, more than 20% of hospitals reported that specialists are "Never", "Rarely" or "Sometimes" reliable (more than 50% for cardiovascular surgery, hand surgery and ophthalmology).
Significant holes in scheduled on-call specialist coverage are compounded by frequent unreliability of on-call specialists, but partially ameliorated by ad hoc specialist coverage. Regionalization may help because a 2-tiered system may exist: larger hospitals have more complete, reliable coverage. Better understanding of specialists' willingness to treat emergencies ad hoc without taking formal call will suggest additional remedies.
在全国范围内，医院都在努力维持专科医生的应急值班覆盖。我们试图通过检查预定覆盖的可靠性以及在没有预定覆盖时临时覆盖的作用来进一步了解这个问题。
对一个大州的所有急诊科主任进行匿名电子调查。总体而言，对于10个专科，要求受访者估计值班覆盖范围和“可靠性”（在临床有用的时间范围内：2小时内应急响应的频率），以及临时应急覆盖填补缺口的使用情况和效果。使用Fisher精确检验和Wilcoxon符号秩检验进行描述性统计以确定显著性。
在167名急诊科主任中，获得了125人的联系信息。60人回复（48%），代表了36%的急诊科。46%报告为所有专科安排了全面的值班覆盖。46%报告可靠性一致。覆盖和可靠性密切相关（P<0.01；33%同时报告两者），并且较大的急诊科规模与两者都相关（P<0.01）。在任何一个方面存在缺口的医院中，90%采用了临时覆盖，显著改善了10个专科中8个专科的覆盖。除了1个专科外，超过20%的医院报告专科医生“从不”、“很少”或“有时”可靠（心血管外科、手外科和眼科超过半数）。
预定的值班专科医生覆盖存在重大漏洞，且值班专科医生频繁不可靠，这使问题更加严重，但临时专科医生覆盖可部分缓解这一问题。区域化可能会有所帮助，因为可能存在两级系统：较大的医院有更完整、可靠的覆盖。更好地了解专科医生在不承担正式值班的情况下临时治疗紧急情况的意愿将提示其他补救措施。
