IMPROVING THE MEDICAL STAFFING OF THE EMERGENCY ROOM OF THE MANILA DOCTORS HOSPITAL, 8 study Presented to the Faculty of the Graduate Program in Hospital Administration College of Public Health University of the Philippine Manila In partial fulfillment of the requirenents af the course in Master of Hospital Administration by REYNALDO 0. JOSON, M.D. Nay, 19911 persons: Dre Dr. The The ACKNOWLEDGMENT Wish to give due acknowledgment to the following Ruben N. Caragay and Dr. Arturo M. Pesigan, ay advisers, for their guidance and suggestions in the preparation of this studys Ambrosio F. Tange, the Medical Director, and Sr. Philip Galeno, Spe, the Administrator of the Man- ila Doctors Hospital, for their encouragement to conduct such a studys antonio N. Montalban, the Head of the Energency Room of the Manila Doctors Hospital, for the permission to conduct such a studys Francisco Rarros, the Head of the Emergency Room of the Nakati Medical Center, for the interview granted mo on the setup in his institutions somar GS. Fernandez, the Chief Nurse of the Emergency Room of the Manila Doctors Hospital, for all the data of MOH-ER and suggestions; active medical staff of Manila Doctors Hospital, for answering ay questionnaires medical interns and residents of Manila Doctors Hospital, for their views on the MDH-ER} Ma. Lilibeth D. Ramos, for the secretarial work; and, last but not the least,Jacquiline Tek-doson, my wife, and Rey Benjamin and Camille Marie Therese, my children, for their understanding during my masteral study in Hospital Administration. REYNALDO 0. _JOSON, M.D. May, i991College pF Public Heal th University of the Philippings Manila Petiro ft, Ermita, Maniva May 8, 1991 Ambrosio Tangco, M.D: Medical Director Manila Doctors Hospital United Nations Avenue, Nanita Dear Dr. Tange Tt is with pleasure that T submit a copy of ay management study antitied “Improving the Medical Staffing of the Emergency Room of the Mansta Doctors Hospital". T hope that this managenent study may be able to contribute produclively to the improvement of quality medical care in the Emergency Room of the Hanila Doctors Hospital. Respectfully yours,College of Public Health University of the Philippines Manila Podro Gil, Ermita, Manila Nay 8, 1993 Sr. Mary Philip Galeno, Spc Administrator Manila Doctors Hospi tal United Nations Avenue, Manila Dear Sr. Pitt It is with pleasure that 1 submit a copy of ay management study entitled “Improving the Medical Staffing of the Emergency Roon of the Nanita Doctors Hospi tal” 1 hope that this management study may be able to contribute productively to the inprovenent of quality medical care in the Energency Room of the Manila Doctors Hospital. Respectfully yours, REYNALDO 0. JO5ON, M.D.TABLE OF CONTENTS asstRACT CHAPTER THE PROBLEM .... : CHAPTER IT ~ REVIEW OF RELATED LITERATURE CHAPTER Itt = - METHODS CHAPTER IV RESULTS ceeeeee z CHAPTER ov = ANALYSTS AND DISCUSSION . nee CHAPTER vi = CONCLUSTONS AND RECOMMENDATIONS . REFERENCES pea : é ‘APPENDICES 1, POLICIES AND PROCEDURES, MDH ER .. 2, CHARGING, MDH-ER - 3. STATISTICS, MDH-ER (1968-1990) 4, LEADING CAUSES OF CONSULTATIONS, MOH-ER (1988-190). S. QUESTIONNAIRE «ABSTRACT The Emergency Room of the Nanila Doctors Hospital (MDH ER) is presently being manned by a medical intern who has no. license yet to practice medicine. Referrals to residents have to be made for actual management of patients in the ER. Consultants are called only when necessary. There is no. i active supervision of the intern and resident trainees.” This present set-up is associated with delays and inadequate ox Pertise in the managenent of patients in the ER. ‘The primary objective of this study is to find a way in which the medical staffing of the MDH-ER can” be” improved. The following were studied to achieve the objective: 4. The policies of MDH-ER 2. The statistics of MDH-ER 3. The charging system of MDH-ER 4. The medical staffing system of Makati Medical Genter Emergency Room 5. The views and opinions of nurss residents, and consultant staff interns, The results of the studies show the following: 4. The medical intern should net be the emergency room officer (ERO). 2. The ideal set-up would be to have graduates of emergency medicine mand the ER. 3. Through the ER income, it is possible for provide adequate compensation for ERO consultants. 4, It ‘is difficult to recruit graduates of energency medicine at present because of the sheer lack in fhe country. 5. A fen (7) MDH consultants have expressed willing- ess to be ERO in the MDH-ER, going on 24-hour duty every 3 to 4 days. This willingness has to be Verified. If verified, they can be tapped to be ERO consultants. 4. In a survey consisting of 70 respondents, "96x are in favor of an ERD consultants = 96% “are in favor of a training program in NDH-ERS 77% are willing to serve as faculty. 7. For ER officerships, residents in emergency medi- cine are preferred over residents of the five” eX— isting clinical departments. ‘The conclusion is that the best medical staffing system for the MDH-ER is for graduates of emergency medicine to man it. A proper compensation can be decided by the medicalstaf# and the hospital administration. In the interia that no. ER consultants can be recruited, active staff menbers of MDH can fill in the gap by serving as ERO, by putting up a training program in emergency medicine, and by recruiting residents for the program. Graduates of the MDH-ER training program will in the future be tapped to serve as ERO coneult=CHAPTER 1 THE PROBLEN INTRODUCTION The emergency room of a hospital is a very important department, not only from the point of view of hospital administrators but also from the point of view of the patients and future patients. It is important because of the function that it is suppo 1d to and expected to perform, Tt 4s an area in the hospital which is established primarily to service all patients with acute and critical problens, 24 hours @ day and all year round. Because of its important function and the expectations of the community, the hospital administrator should make sure that the emergency room is properly equipped with facilities land personnel to ensure quality medical care to those people ho seek its servic In the Philippines, in so far as equipment requirenent oF the emergency room is concerned, there are black and white rules set down by the Bureau of Licensing and Regulations of ‘he Umrar tuont (oF Health -| ais) enersency cones) in) ectige existence and licensed to operate can be presuned to eet the equipnent requirement of the Department of Health. with regards to personnel staffing requirenent of the emergency room, there are also rules and standards set down by the Bureau of Licensing and Regulations of the Department1 of Health . The personnel staffing includes the physicians, the nurses, and the nursing aides, with the physicians being at the top of the hierarchy. The medical staffing of the emergency room has many In teaching hospitals, where there are interns and residents, these trainees are part of the medical staff ef the emergency. They work under the supervision and responsibility of a consultant. The consultant may be a menber of the hospital active staff or somebody hired by the hospital. In nonteaching hospitals, the energency room may be handied by the menbers of the consultant staff or somebody outside the staff hired by the hospital. THE EMERGENCY ROOM OF MANILA DOCTORS HOSPITAL (HDH-ER) The Emergency Room of the Manila Doctors Hospital is open 24 hours a day. It is managed by a team of medical and pursing personnel. It is properly equipped meeting the requirements prescribed by the Bureau of Licensing and Regulations of the Department of Health. The MDH-ER entertains all patients who enter it to seek medical consultation and treatment. By all patients is meant all types of patients, males and females, young and old, and patients with all types of problems, whether medical, surgical, or obstetric, whether traumatic or nontraumatic, and whether acute ar non-acute.THE MEDICAL STAFFING OF THE MOH-ER At present, the medical personnel who is physically present all the time in the NDH-ER and who is first menber of the medical staff to see all patients brought to the ER is an intern. A medical intern is a postgraduate or post-H.D. intern who has not taken the Philippine Board of Medicine Examination. He is stil1 under medical training and has no License yet to practice medicine. At the MDH-ER, a medical intern on duty is in the front Line. He manages initially all patients brought to the MoH ER. He diagnos ys and provides initial treatment if needs to be done right away. He then refers all these patients to a more senior medical personnel, who is a resident, for final disposition. By MDH regulations, @ medical intern can- not make any decision on his own on the management of any patient, be it diagnostic and more so, therapeutic. There are five clinical departments in MDH with an accredited residency training program. These are, namely: Department of Medicine, Department of Surgery, Depart} nt of Pediatrics, Department of Obstetrics and Gynecology, and Department of Ophthalmology. Except fer Ophthalmology, each department has two residents on 24-hour duty everyday. one of these two residents is assigned to answer referrals from the ER. In effect, there are five residents from five different specialties who are ready to answer referrals from the ER. These five residents do not stay in the ER. Theyare within the premises of the hospital when they are on duty and they are called when needed by the intern on duty at the ER. The intern to resident referral is such that the intern refers a patient with a specialty problem or a patient of a specialty consultant to the resident of the correspend- ing specialty. Thus, the intern will refer a patient with a surgical problem to a surgical resident; a pregnant patient to an obstetrical resident; a pediatric patient to a pedia~ tric residents and so on. After a referral is made, the concerned resident will go. to the ER to evaluate the patient and to make a decision on the manageneni. The resident can provide emergency treatment if called for. He can discharge or admit the patient. He also makes another kind of decision, whether to calla consultant or not. Tf he has a problem in deciding what to do to the patient, if the patient is to be admitted, and if the patient needs urgent attention and tri ‘tment by the consultant, then the resident calls the consultant on call or the attending physician of the patient. Everyday there are consultants on call at the MDH-ER. Th consultants are not physically present at the MOH-ER. Most of the time, they are not within the hospital premises. Tt takes quite some time before they can be reached or before they can cone to the hospital to manage an emergency patient. Thus, at the MDH-ER, a patient consulting it will haveto pass through a hierarchy of medical personnel before he gets a definitive management. If he wants to get a treatment by a consultant, he passes through two tiers of medical the intern and the resident. personnel, namely: PROBLEMS ASSOCIATED WITH PRESENT SYSTEM OF MEDICAL STAFFING OF MDH-ER The problems astociated with the present system of medical staffing of the MDH-ER can be grouped into two categories. The first category consists of those problems belonging to or from the point of view of personnel of the MDH-ER. The second category consists of those problems belonging to or from the point of view of the patients consulting the MDH-ER. The first category problem is essentially a disposition problen. ith na authority to dispose patients at the ER, the interns, and also nurses, complain of piling up of patients in the ER until they are disposed by the residents. In many instances, the same problem is sean on the part of the residents. With uncertainty on how consul t= ants would 1ike their patients managed and the 1ong waiting period before the consultants can be reached or can arrive to the hospital, patients tend to pile up also at the ER. The second category problem is essentially a quality of medical care problem. This is more important than the first category problem. In this category, complaints may consistOf the following nature: A patient consults the MOH-ER. He knows MDH is a Private hospital. He knows he has to pay whatever Price is charged to him. In return, he assunes that the medical care that will be rendered to hia are those coming from physicians who are legally authorized and most qualities to do so and these Physicians should be the consultants and not the residents or the interns, At present, most pa. tients do not realize the hierarchical set-up in the MOH-ER. IF they know, they will surely raise hell and will demand that they get worth the money they are paying the NDH-ER. The waiting time a patient has to spend in the HDH- ER before he receives a definitive management by the residents or the consultants may be too auch to sone, if not most, patients. The emergency room staff is expected to treat 1ife- threatening conditions as quickly and as accurately a5 possible. A second delay and an error may spell the difference between life and death. To have an intern who is still under training as the emergency room officer and to have residents and consultants on call, which entails waiting time, do not satiaty the demands of patients with life-threatening con dition coming to the MDH-ER.Very recently, sometime in October of 1990, the Medical Director, Dr. Ambrosio Tangco, had suggested the improvenent of the medical staffing of the MDH-ER. He had suggested the hiring of board-certified physicians who will man the MDH-ER on a full-time basis, Up to now, this suggestion has not been implemented or realized either because of lack of a formal study or a lack of taker on the compensation offered. OBJECTIVE OF STUDY This paper is a management study, or specifically, a feasibility study, on how to improve the medical staffing of the MDH-ER. Tt will try to answer these to questions: 1. Is it advisable and economically feasible to have board certified physicians with emergency room specialty man the MDH-ER on a full-time basis 7 2. Is it advisable and economically feasible to have residents man the MDH-ER on a full-time basis 7 The objective of the study is to come out with a plan that will improve the medical staffing of the MDH-ER, a plan that will be acceptable to the consultant staff and to. the hospital administration. SIGNIFICANCE OF STUDY The significance of the study is that st will help improve the quality of medical care being rendered at the MDH-ER.CHAPTER 2 REVIEW OF PERTINENT LITERATURE A review of the literature was conducted along two topics that are pertinent to the present study. These two topics are, namely: 1. The changing trend in the emergency room with ry pect to the types of patients being seen. 2. The patterns of medical staffing in the emergency If a hospital provides an emergency room, then it should be responsible for its performance. Tt should be a5 responsible for its coverage and staffing.” It should be responsible for its equipment and facilities. The emergency room nowadays has taken on a new role in the delivery of health services. Before, it used to be an accident room, trauma center, or @ unit of the hospital which served only emergency cases. Today, it has become the center of medical care for all kinds of disorders, either emergent, 47 urgent, or non-urgent. To the public, the emergency room is still visualized a5 4 special site within the hospital where a well-trained edical team is available 24 hours a day to handle medical emergencies. However, with the disappearance of “house calls," with the non-availability of general practitioners, with the inconvenience of visiting a private physician's office, and with the problem of locating 2 proper physician,the public has now ragarded the emergency room as the most convenient and the best place to go to whenever they have any nedical problem. Thus, at present only about 50-40% of cases seen in the energency room represent real energency as den 8 fined by any set of professional standards,” great najority of canes are not real enargencies. Nowadays, nobody argues snymare on what type of patients should be handled in the emergency room. Before, there nad been a tot of futile discussions on what constitutes an emergency and who datersines i an esergency Is present or not. Today, it is an energency 1 the patient thinks it. a Thus, all patients entering the emergency oon should he received and managed accordingly, regardless of their having true or imaginary emergent problems. The public has regarded the emergency roos as tho nedical center to which 1t should turn to, at any hour, for real or feared ener gency. The change in the character of the emergency room can be sunearized as the community expecting it to function peyond the care of the acutely 411 and injured pationts and to extend its services to include appropriate care £0 those sufferings from any conditions considered by either the patient or his physicians to require immediate attention. With such a change in the character of the energency room, the trend now is to regard emergency room services! as a meena Transforming the emergency room into a department of emergency services or department of emergency sedicine aay 9be the first step in responding to the changes. The department should now be equipped with proper physical facilities and personnel so as to make it run effectively and efficiently to meet the needs and demands of the public. There are several medical staffing patterns in the department of emergency services on medicine. The basic Besta) patterns are as follows: 1, Staffing by interns and house staff 2. Staffing by attending star 3. Staffing by one or more individual salaried physicians 4, Staffing by a group of physicians The staffing pattern may be a combination of any two of the four basic patterns or just one pattern. The staffing pattern utilizing interns and residents is Usually seen in those hospitals which have such trainees. These trainees can be utilized to man the emergency department but they need supervision. The supervision can come from the attending staff, from a salaried physician or a group of physicians hired to man the emergency department. In hospitals where th are no trainees, the attending staff may be used to man the emergency department either on a voluntary or compulsory basis and on a rotation basis. Medical staffing of the emergency department has also been done using one or more individual physicians, hired by the hospital. 10The last staffing pattern is the hiring of a group of This staffing ez] pattern is exemplified by the Alexandria Plan. In 1961, physicians to man the emergency department. Alexandria of Virginia appropriated a sum cf money for the hospital to be applied to the treatment of indigent patients and this represented the basic funding of a group of Physicians who were to assume the emergency department duties. The group were menbers of the hospital staff but had nto admitting privileges. They were allowed private practice oniy at the emergency department and in their clinics during off-duty days. They billed the patients separately from the hospital. ‘The pattern of medical staffing adopted by an emergency Separtment is dependent on a lot of factors. These are, namely: + The presence or absence of trainees, both interns and residents. 2. The presence of attending staff willing to go on duty at the energency department. The economic feasibility and viability of employing individual or group of physicians to man the emer— gency department. 4. The consent of the medical staff and administration fon the type of staffing pattern. Whatever be the staffing pattern there should be adequate coverage by competent physicians who are physically Present in the emergency department and who shall be utsupported by the medical staff with full clarification of all professional, 1egal, and financial Laplications. The Comittee on Trauma of the fnerican College of erecorey has stated that "medical staff coverage should be adequate to insure that an applicant for treataent will be seen by a physician within 15 ainutes after arrivalt. Ina true energency, 15 minutes is usually too long. The ideal is to have a qualified physician stationed at the eaergency department so that no precious time is wasted. The 1987 Accreditation Manual for Hospitals has stated the following as standards with regards to edical staffing oF the emergency departments 1. The method of providing medical staff coverage is defined. Acceptable ethods include the use of house staff under adequate medical supervision: the use of contract groupe whose mesbers oust be mem bere. of the medical staff; unlees therstisy pro- vided by Lm) or assumption of mich coversoe by wedical ataft amber, 2. When the medical staff has assumed the responsibility, its members have an obligation for emergency room coverage as determined by the medi~ cal staff, each in accordance with his clinical competence and privileges. 3. Specialties in limited practice are available en an ystablished schedule to provide consultation on the needs of emergency patients or to provide special 12servic to emergency patients. When physicians are employed for only brief periods of time, such as evenings, weekends, or holidays, their professional and personal qualifications are evaluated through the established medical staff credentializing mechanism to assure appropriate licensure, privilege delineation, staff categorize tion, and approval by the governing body. A physician is responsible for the degree of evaluation and treatment provided to any patient ho presents himself or is brought to the emergency 6 The priority with which persons seeking emergency care will be seen by a physician may be determined by specially trained personnel using guidelines established by the emergency department/service Sirector and approved by medical staff. Rosters designating medical staff menbers on duty or of, cA for selene cheers. enh Semelsdadea sultation are posted in the energancy care area. Regarding the type of physician who should man the esergency departaont, it in aald that any ¢ull-piedged teeateer sik chy bees hk eee ea SLES Im capucin per Farle Piet Akar. emai natures and i slo capable of asking # tentative diagnosis Indicating proper referral for further care when this is ceceerany iil However, with the advent of specialization, with 13the lack of constant practice and exposure to general medicine and gency medicine at that, the best persons to nan the onergency department will turn out to be physictans who have trained in thia area. Energency Room Hedicine 1s tablished as a specialty in the United States and other ports of the world. In the Philippines, only Makati Medical See known to have a training program in emergency room nedicine. It has produced 7 graduates since the stert of ite program in 1985. The energency room physician should be able to handle all kinds of patients he encounters in the medi cin Considering the spectrum of diseasi that may be encountered in the present day emergency department, the physician manning it must be an all-around physician. specialist in a particular field will find it difficult to cope up with the demands of the present day emergency room. Thus, the most qualified physician to man the emergency department wiil be a graduate of a training program in emergency roon medicine. 14CHAPTER 111 NeTHoDS To achieve the objectives of this study, the following were done: Fs 4. The manual stating the philosophy, goals, objectives, and policies of the MDH-ER was reviewed. The 1988 to 1990 statistics of MDH-ER were ana~ lyzed, noting the average nunber of patients per day, the types of cases seen, and the number of mortalities. The charging system in the MDH-ER was studied. fn interview with Dr. Francisco Barros, the Head of the Emergency Room of Makati Medical Center was made on the evening of April 10, 1991, at the Makati Medical Center. Questions were asked re- garding the set-up and the costing of putting full-time ER consultants. The costing of hiring residents was gathered from the Administration Office. The newly appointed Head of the Manila Doctors Hospital ER, Dr. Antonio N. Montalban was con- sulted. During a meeting of the Medico-Nursing Committee of the Manila Doctors Hospital, last April 11, 1991, where the problens of delay in answering ER referrals and patients piling up in the ER were 15brought up, @ discussion was done to look for solutions to these perennial problens. Interns and residents were consulted. A questionnaire was distributed to active medical staff members of MOH asking them who they want the ERO to be, how should the ERO be compensated, and whether they are in favor of putting up a training program for ER medicine (Appendix 5). 16cHePTER Iv RESULTS: OBJECTIVES AND POLICIES OF MDH-ER Appendix 1 contains the objectives and policies of the MDH~ ER. Here are sone of the highlights of Appendix 1 that are of importance to the present study in the improvement of medical staffing: 1, The first specific objective is to provide imediate attention and care to patients who are brought te the ER. 2, The Emergency Room Officer is a medical intern who is Physically present in the ER to initially evaluate pa tients and then to refer them to residents. 3. There are five residents, one each from the Departments Of Medicine, Pediatrics, Surgery, Obstetrics and Gyne cology, and Ophthalmology, who are assigned daily to receive calls from the intern on duty at the ER. They stay within the hospital premises but they do not stay in the ER. They answer referrals from the ER only when they are called and when they have a patient in the ER who belong to their specialty. 4. Consultants are called by the residents only when necessary. There are no consultants who are physically present on a 24-hour basis at the ER. 7CHARGING OF PATIENTS AT THE MDH-ER ALL patients seen at the MDH-ER are charged accordingly. Appendix 2 contains the revised ER charging as of January 15, 19971. There are three important points to take note of with pect to the present study. These are, namely: 1. The consultation fee is P 120.00. 2. There is a follow-up consultation fee of P 100-00. 3. In general, the charging for the surgical procedures done at the ER are low compared to those in the opera- ting room. There is no professional fee for surgical procedures done at the ER. STATIBTICS AT MDH-ER The statistics of the MDH-ER during the past 3 years were studied. Appendices 3A to SC contain the 1968 to 1990 censuses of the MDH-ER. These appendices are summarized in Table 1. Table 1 reveals the following information: 1. fn average of 42 patients was being seen at the MOH-ER daily. 2. An average of 71% of the patients seen at the MDH-ER was not admitted. Only an average of 29% was admitted. 3. There were 14, 35, and 15 patients who died at the MOH- ER in 1966, 1909 and 1990 respectively. There are no data on the causes of death af these patients. 18Table 1, Statistics of MDHER ( 1988 - 1990 ) 1988 1989 1990 attended 14,733 15,154 16,236 Daily Census 40. ay aa Outpatient 70% 7% 72% Admitted 30% 29% 28% Death on Arrival 15 5 6 Expired at ER 14 3 15 Appendices 48 to 4C show the ten leading causes of consultation at the MDH-ER from 1988 to 1990. Table 2 shows the 5 leading causes of consultation during the past S years. Acute gastroenteritis tops the list, followed by respiratory infection, cardiovascular diseases, bronchial asthma, and accidents. Table 2. Five (5) Leading Causes of Consultation ‘at MDHER (1988-1990) 1. Gastroenteritis 2 Respiratory Infection Sl Cardiovascular Diseases 4. Bronchial Asthma 5S. Accidents Table 3 shows the breakdown of consultations at the MDH-ER by specialty. Medicine had the most number of consultations. This was followed by Pediatrics, then Surgery, then Obstetrics and Gynecology, and lastly, Otolaryngology and Ophthalmology. Table 3. Breakdown of Consultation at MDH-ER. by Specialty ¢ 1988 - 1990) 1988 1989 1990 Medi cine 3,980 3,420 4,650 Pediatrics 23230 33128 25907 Surgery 1,332 1,120 23093 Obstetrics 38 920, ‘31 Bynecol ogy 5 705 ais ENT 8 420 581 rcNUMBER AND COSTING OF RESIDENTS fs of 1991, there are 43 breakdown. A resident receives a basic higher Level and ranking resident more than a more junior resident. residents. Table 4 shows the salary of P 2,250 per month. A receives about P 250 per month The chief resident receives an additional P 150 per month. At present, the Chief Resident receives P 2,800 per month. Table 4. MDH Residents, 1991 Department, No. of Residents Medicine un OB-GYN, o Ophthalmology a Pediatrics 8 Radiology, 2 Surgery 10 43 ‘THE MEDICAL STAFFING SYSTEN AT THE EMERGENCY ROOM OF MAKATI MEDICAL CENTER The medical Makati a qualified duty. four days. The ERO responsible for all patients seen about 130 patients a day, starting system at the emergency room ER physician and who stays in the ER when he oversees the running of the ER of the Medical Center is such that the ERO is a consultant who is There are four such consultants and each goes on duty every everyday. He is at the ER. The daily census is with only about 15-20% needing acute andcritical care, For those patients who need to be admitted, the ERO provides initial management at the ER. Upon admission, another consultant takes over. This consultant is either thé physician of the patient or the physician on duty on a particular day. In effect, the ERO treats all patients entering or brought into the ER and gives treatment only at the ER. bhatever servic he renders at the ER, he gets a professional fee. This is how an ERO at the Makati Medical Center Emergency Room gets compensated. Working under the supervision of the ERO are residents who belong to the ER training program. The duration of the ER training program is four years, the first two years being spent in didactics) the third year, practicum; and the last year, as chief resident. The training program is accredited with the Philippine College of Emergency Medicine and Acute Care, Inc. which was established in 1968. There is a certifying board known as the Philippine Board of Emergency Medicine. RESULTS OF SURVEY OF MDH ACTIVE STAFF OF the 150 questionnaires given out to the active staff of Manila Doctors Hospital, (the questionnaire wore given only to those who hold a clinic and who are still in active practice in the hospital), only 70 questionnaire were retrieved. The results of the survey, based on 70 respondents, showed the folloming: 1, The medical intern was the last choice for the emergency room officership. aMajority (67/70 = 96%) preferred a consultant in emergency medicine to be the ERO. OF the 12 respondents who suggested a resident to be the ERO, majority (9/12 = 75%) preferred a resident training under @ straight emergency room specialty program. Majority (67/70 = 96%) were in favor of putting up a training progran for ER physicians at MOH-ER. Only 7 active staff members (7/70 = 10%) answered they were willing to be an ERO going on a 24-hour duty every 3 to 4 days. Majority (67/70 = 96%) were in favor of having full-time ER physicians (graduate of ER specialty) as a way of improving the medical staffing of the MDH-ER. For those who were in favor of having full-tine ER consultants, 59% (38/64) answered honorarium plus pro- fessional fees as the way of compensation; 25% (16/64), fined salary per month; and 16% (10/64), professional fees for services rendered at ER. 2The CHAPTER v ANALYSIS present set-up in the medical staffing of the Manila Doctors Hospital Emergency Room (MDH-ER) needs to be changed medical present namely: he for it to be able to offer a better quality of care. There are at least four reasons why the set-up needs to be changed. These reasons are Patients going to the MDH-ER are aware that they are going to a private hospital and they know that they have to pay for whatever services rendered to them. then they go to the MDH-ER, they expect services to be rendered by qualified physicians and not by trainees. In the present set-up, services are being rendered by the intern and the resident trainees with practically no supervision from the consul tant. ‘The ER of any hospital is traditionally pictured as a place where patients with life-threatening conditions are brought to and the physicians manning the ER are expected to be experts in saving these patients. In the present set-up, the acute responsibilities in managing critically 11- patients coming to the MDH-ER are beyond the ERO intern’s capability. As stated in the manual of policies of MDH-ER, the first specific objective is to provide immediate 2attention and care to patients who are brought to the ER. The ERO interns may be able to provide immediate definitive treatment and care. In the present set-up, the ERO intern has to refer to a resident for final disposition. With the resident not stationed in the ER, no matter what arguments are sued, there will some amount of waiting and delay, which may at times be critical, before a definitive management can be instituted to the patients. Such a set-up has also often led to the piling up of patients in the MOH-ER with consequent complaints, foremost, from patients and from nursing staff. The result of the questionnaire is the strongest point asking for a change in the present set-up in the MDH-ER. All the 70 ri pondents, which consisted of MDH active staff members, were unanimous in saying that the medical intern should be the last physician to be designated as ERO. Actually, the main objection in the present set-up in medical staffing is the designation of a medical intern as the ERO. The bottom-line objection is that the medical intern is not qualified to be the ERO. This is so because he is still in training. He has no license yet to practice medicine. Futhermore, the responsibilities of the ER are too much for an intern to handle. 24Thus, the present set-up in medical staffing of the MOH-ER should be changed. The next question then to be asked 1s to change to what? The answer to this question lies in getting first the ideal way of staffing. In case the ideal way 18 not feasible, then alternative methods should be Looked for. 80, what is the ideal way of medical staffing of the MDH-ER? The ideal staffing system should fulfill at least the following two requirements: 1. The ERO should be a licensed physician who main- tains his basic knowledge and skills in general medicine and who has training in the diagnosis and treatment of medical energenci: 2. The ERO should be stationed at the ER. As the survey has shown, the ideal way is to have graudates of an energency medicine program be the ERO. The graduates of this program must, however, be still well-versed sm general medicine in order to answer the needs of the present-day ER. The MDH-ER statistics show that only 29% of patients are being admitted to the hospital, The rest of the 71% can be managed on an outpatient basis. After stating the ideal way of medical staffing of the MDH-ER, the next thing to decide is where to get these graduates of ‘emergency medicine program. Are there consultants in emergency medicine anong the active staff monbers of the Manila Doctors Hospital? The answer is nonk fre there graduates of energency medicine in the Philippin 2swho can be recruited for the MDH-ER? There are seven graduates Who are products of the training progran in Makati Medical Center. From the interview with Dr. Barros, these seven graduates are presently not available for the MDH-ER. They are at present catering to the emergency room of Cardinal Santos Memorial Hospital as well as that of Makati Medical Center. Suppose there are available graduates of emergency medicine who can be recruited for the MDH-ER; how many are Needed and how will they be compensated? Three consultants can be recruited with each ene going on a 24-hour duty every three days. As compensation, the survey shows the following results: 38 respondents fer honorarium plus professional fees; 16 for fixed monthly salarys and 10 for professional fees. Analysis of the costing and the statistics of the MDH ER shows that at P 120.00 per consultation, at an average of 42 patients per day, the total daily income from consultation fees alone would be P 5,040.00. At one month, the total income would be P 151,200.00. This income in the ER can be used to compensate the ERO consultants. Although the survey shows that majority of the respondents were for honorarium plus professional fees, the form of compensation will have to be decided upon by the medical staff and the hospital administration. The survey shows that 96%(67/70) of the respondents are in favor of an ERO consultant in the MDH-ER. Staffing the 26MDH-ER with an ERD consultant trained in emergency medicine is the ideal way. There is an ER income which can be used to compensate the ERD consultants. The problem is there are no such ERO consultants available. The next alternative would be to look for consultants in the MOH roster who will be willing to be ERO. From the survey, there were seven out of 70 respondents who signified their willingness to be an ERO going on a 24-hour duty every 3 to 4 days, Verification has to be done and if they are really willing, then they can be tapped as ERO for the MDH- ER. It has to be clarified to these seven persons that their duties and responsibilities are not limited to their specialty. They have to have sone refresher course in general medicine. Again, the compensation will have to be @iscussed and decide upon by the medical staff and the hospital administration. In the survey, there were 12 respondents who said that residents can be utilized as ERO. Nine out of twelve suggested residents in energency medicine, which have yet to be recruited. Three suggested residents of the existing five elinical departrents, namely; Surgery, Pediatrics, OB-GYN, Medicine, and Opthalmology. The best schene that utilize residents to be ERO is the one with training in emergency medicine. Three residents can be recruited and they can be adequately covered by the ER income. Each resident goes on a 24-hour duty every three days. A formal training program in emergency medicine must 27be put up by the hospital. The faculty can come from the MDH active staff menbers. In the survey, 96% (67/90) of the respondents are in favor of putting up a training program in the MDH-ER. seventy-seven percent of the respondents are willing to serve as faculty. fn avantage of this schene is that after Sto 4 years, depending on the duration of training, the graduates of the emergency nedicine training program can now be ERO consultants in the MDH-ER. At this time, the ideal way of medical staffing of the MDH-ER would be achieved. In the survey, three respondents suggested utilizing the residents of the presently existing five clinical departments to serve as ERO in place of the interns, With such residents, two schenes are possible. One is that each departnents fields in a resident to be the ERO every five days. The second schene is that all departments have their residents stationed at the ER everyday. The problem with the fist scheme is that the ERO resident will still have to refer cases not belonging to this specialty and which he cannot handle. He is going to refer to residents who are stationed outside the ER. Thus, the problone of delay and inadequate expertise associated with the present set-up remain. In the second scheme, the problems of delay and inade~ quate exportise are obviated. However, the question of cost~ benefit will crop up.The number of patients being seen at the MOH-ER averages 42a day. With five residents stationed at the ER all at the same time, with the 42 patients divided equally among them, each resident will be handling only 8 to 9 pationts in 24 hour Based on the 1990 census, medical cases averaged 17 per days pediatric cases, 11 per day; surgical cases, 95 obstetrical and gynecological cases, 5; and EENT, 2, with five different residents stationed at the ER all at the sane time and with each resident taking care only of cases belonging to his specialty, then there willbe maldistribution of load. Thus, the second schema, although it provides solution to the problem of delay and inadequate expertise, is not cost-beneficial. 29CHAPTER VI CONCLUSIONS AND RECONMEDATIONS The ideal way of medical staffing of the NDH-ER is to have graduates of emergency medicine serve as ERO consultants. Assisting them are the resident and intern trainees. At Present, it is hard to recruit such ERO consultants because ef shear lack in the country. The next alternative would be to tap MDH active staff menbers who are willing to be ERO consultants going on a 24 hour duty at the ER every 3 to 4 days. Hand in hand with ‘this search for ERO consultants among the MOH active staff is the putting up of a training program in energency medicine. Three residents can be recruited and each will #0 on a 24 hour duty at the ER every S days. If there is an ERO consultant, then these residents will work with and assist him together with the interns. If there is no ERD consultant who can be recruited to go on, duty at the ER then the resident will serve as the ERO. In the latter situation, the resident will be closely supervised by the faculty of the emergency medicine program. After 3 to 4 years, these ERO residents, after graduating fron the program, can now be recruited to be ERO consultants of the MDH~ER. So, in 3 to 4 years time, the ideal way of medical staffing of the MDH-ER could be achieved. 3010. REFERENCES: Bureau of Licensing and Regulations, Department of Health. The Emergency Department in the Hospital: A Guide to organization and Management. American Hospital Associa tion, 1962, p 46. Emergency Department. Handbook for the Medical Staff. american Medical Association, 1966, p. 133. Bergon RP: Who should provide emergency care ? JAMA 210: 775, 1969. carter JHt Planning and operation of the emergency Foon. Hosp Top 44 7, 1968. Bkudder PA, Wade PA: The organization of energency medical facilities and services. 9 Trauma 41358, 1964. oaks Wil, Spetzer & Moyers 3H (eds): Emergency Room care: the Twenty - third Hahnesann Symposium, New York, Grune and Straten, 1972. ps 300- Walker Lt Criteria devised to evaluate patient's needs to utilize emergency room services. Hosp Top 24127, 1973. A Model of a Hospital Emergency Department. American College of Surgeons, 1764. 0° Leary DS: Accreditation Manual for Hospitals, 1987. at41, Interview with Dr. Francisco Barros, Chief, Department Of Emergency Medicine, Makati Medical Center. April 10, 1991. 32the APPENDIX 1 POLICIES AND PROCEDURES OF THE EMERGENCY ROOM Emergency Roon iz a unit in the Nursing Service which ains to provide the innediate assistance to” patients coming creed. SPECIFIC OBJECTIVES in for treatment regardless of religion, color or To provide immediate attention and care to patient whe are brought to the Emergency Room. To render assistance in the initial procedure and treatment to 111 patients for admission as ordered by the physician. To cultivate apcng the personnel, the spirit of cooperation and understanding through proper coor~ dination with the different departnents. To provide and maintain hospital recerds of the services rendered to. emergency and outpatients treated in the Emergency Roon. STANDARD OPERATING PROCEDURES ‘ADMISSION All patients for admission should pass the Enorgency Room if there are no written orders fron the attending physician or when attending physician fs not with then 1. AS soon as the patient is brought into the Emergency Room, the nurse on duty takes the vital signs of the patient. 2. Inmediately call the I0D'or ROD to see the patient, until their ovn attending physician 3. Patient can always have a doctor of his own preference. If the patient has no doctor of Ris own or when the physician of choice Cannot be located or contacted, the patient is informed, and he is referred to the consultant fon duty for the day. 4, Bll. "stat" orders will be administered at the ER. 5. IV fluids should be started at the ER except in cases where the patient requests it to be in~ serted in his room. &. All x-ray should be done before bringing the patient to the fleor during office hours, after 3swich x-ray will be done the following da Only “stat” x-rays are done after office hours. 7. The ER nurse on duty informs the nursing stat fen of necessary room preparations, e-g.02 set py suction apparctus, Iv stand before oringing patient to nis room: | The ER nurse on duty Should make a proper sndorsenent of the patient to the floor. 8. All critica! cases should be accompanied by the ER juirse to the ward and make proper endorse ment. to, the floor nurse on city. This in cludes: B.a Patient’s data ib P.E, and initial diagnosis Gic Doctors’ orders regarding medications, treatments, diagnostic procedures and ot~ her. pertinent information regarding the patient. 9. All medicines, IV fluids and supplies used ‘should be charged to the patient. 10. An admission fee is charged to every patient admitted at the E.R. CONSULTATION i. Have the patient £111 up the admission sheet for the new patients and get old charts for old patients. 2. Ask for the chief complaints and take the vital ‘signs and record. 3. Refer to the TOD or ROD. 4L paninister medications as ordered and record. 5. Record. nursing care and procedures done to the patient. Keep the patient at the ER for observation for St least’ 2-S hours 1f necessary, or advice Admission if indicated. 7. In cases where the patient refuse to be admit— ted, have him/her sign the "Discharge Against. Advice Fora” and also note it down at his/her Chart. and have his/her affix his/her signature on it. Bo not discharge patient without the knowledge of the ROD. Ce WALK-IN-PATIENTS: @ walk-in-patients is defined as one who seeks to Consult a specialist and/or to be admitted into the hospital without seeking the services of any specificconsultant. This definition is extended to cover those persons who, ae out-patients, seek medical services fron the Hospital Staff at the Emergecny Room and who are subsequently advised admission by the Resident in the Emergency Room. The ER resident on duty is responsible for adait- ting walk-in-patients and for referring them to the appropriate consultants on duty for the day. tea. Non-urgent cases: i.a.t ER physician prescribes initial mana~ genent f.a.2 Patient is then adnitted under the Service of the consultant on day- Leb. Urgent/Ii¢e threatening casest tibel If the consultant on duty is not available and the ER resident sees the need for his presence, the ER resident admits the patient: 1.b.2 Referral to the appropriate consult~ ant for the following day is made. 1.b.1 If not appropriate consultant is immediately available, ER resident admits the patient t.b.2 ER resident administers indicated primary treatment. t.b.S ER resident on duty or Senior Resi- dent issues preliminary orders. t.b.4 Referral to the consultant most ac— cessible is made. - The nature of the presenting illness or injury shoud be made the primary basis for the choice of appropriate consultants to whom the case is to be referred. 3. All trauma cases are to be considered surgical emergencies and mist be referred to the appropriate Surgical consultant. All cases oF poisoning are to be considered medical emergencies and mist be referred to the Internist on duty. (CODE BLUE — CARDIO-RESPIRATORY ARREST AND SHOCK In cages such as shock and cardio-respiratory ar- rest, the Emergency Room nurse will start and main~ tain’ the following?4. Call for Code Blue whent tia The patient’s pulse cannot be felt in major vessels. tsb Pale face and dilating pupits, fle Cessation of previously spontaneous brea~ thing. 1.8 Patient is in shock (ow BP) 2, Level patient's head 3. Start cardio-pulmonary resuscitation: Airway = clear mouth of any secretion Suction the patient hyperextend the neck Breathing - give D2 inhalation right aways or resuscitate with the use. of ‘anbo bag, mouth to mouth resus~ Eitation is done when necessary. Circulation ~ do external massage by compress— ing lower third of the sternum 4-5 times in-regular rhythm. 4. Begin intravenous infusion of DSH. 5. Administer medicines as ordered, oral or pa~ renteral. 6 Attach EKG electrode and maintain constant oni tering of the heart. 7, Start use of equipment available to assist respiration. SURGICAL CASES Always have the consent signed for any surgical procedures done to the patient. Cot" the patient sign of the nearest relative sign the consent before doing any surgical procedure to the patient at the ER or sending the patient to the Operating Roos in cases of “stat” operations. in cases of “stat” operations, give the necessary pre-operative preparations before sending the pa~ tient to the Operating Room, $a shave the operative site 3:b change to surgical gown Sic check the IV flued 3:d give assurance to the patient 6ay COMPANY PATIENTS Company patients under the pre-paid medical plan maybe ‘referred to the Pre-paid Departeent, during office hours, and are seen at ER after office hours, upon presenting their IDs. Charges for’ services rendered are sent to the Accounting (send the Bill) or paid in cash depend= ing en the company’s agreement to the pre-paid plan. Eompany patient not under the pre-paid medical plan should present a letter of authorization from the Company.” Charges would be sent to the Accounting (send the Bill) if they have letters of authoriza~ tion, otherwise, they have to pay in cash. Company patients for admission must be referred or under the service of their respective company phy~ Company patients not under the pre-paid plan, Seeking adaiseion fro Executive Check-up may be referred to the Pre-Paid Department. ER BENEFIT OF MDH EMPLOYEES Any enployer needing medical care should submit himself to Dr. “Zavala or any Pre-Paid Doctor. 0900 - 12004 1400 - 1700H - Honday to Friday (9800 ~ 1200H = Saturday All prescriptions must be issued by the above of- fice and mist be signed by the Administrator before presenting it to the Pharmacy. In emergency cases after office hours, the ROD may See any employee at the ER. If there is a need for a consultant, the Pre-Paid Doctor may refer the case to the corresponding specialist. Innediate members of the family may follow the sane procedure.ADPENUIX 2 NIION: To ALL Concern Revised _Eme Jonsul tation (A) I (B) 240700 Follow-up (A) 5 —-. f00700 (B) 170200 Injection (IM) 20100 (iy) 3000, (st) 20200 Dressing Fee 40200 and up Removal of Suture 25100 Debridement (Burns) — 480100 and up Cutdown Fee 20000 Suturing Fee 230-00 and up @ isn 150:00, Removal ‘of Nail 150200 intubation 200200 Monitor Fee 25000 and up Defibriliation £0200 NGT insertion 70.00 Gastric Lavage 40/00 Catheterization— 80100 Rectal Examination 20200 Internal Examination. 40:00 Speculum Examination 50200 Blood pressure reading 20100 Alevaire Inhalation 60/00, Oxygen 90.00 per hour Sue ion ing 80:00 450100 Thoracentesis ——— Removal of Foreign body (ENT) 80700 Ear and Eye irrigation 60700 @ Paracentekts 180/00 Manual Extraction. 79:08 Gdmission Fee 6900 Size Tamp | “¢A) 18000 (B) 2 200/00 code Blue. 390100 Datascope use 20000 fiectrodes 20.90 spinal Puncture 50:08 Bone Marrow (In) 75000 (ants 200700 Tracheostomy: Nitrol pagte (1 inch} Removal of Cast- Please be guided Accordingly. Approved by: eaage) a 38 SFT Mary lip Galeno, SPC AdministratorJanuary February March Apri May Sune duly august September Getober Novenbor Decenber Banuary February, March april May Sune may August: Septenber October Novenber Decenber APPENDIX 3-8 MOHER Statistics, 1988 ATTENDED ADMITTED oF 1,390 486 eee 12139 466 654 1085 385 69 13107 392 702 1,073 367 670 43135 355 763 1,452 399 566 1,376 373 961 ise 235 553 13198 533 522 1,298 552 508 4,323 323 975 4,496 9,851 APPENDIX 3-B MOWER Statistics, 1989 ATTENDED ADMITTED OP_~DOA 1,355 364 a1 0 aise. 360 e060 43137 317 a2 0 967 298 e740 1,288 372 87% 0 saa 404 1,037 1 13384 aio 9740 1254 72 ea 2 4,245 326 39°00 1,357 583 7a 0 1,222 389 os 2 4,579 402 7 0 15,154 4391 10,7635 9 DOA EXPIRED coco~oso0KuH EXPIREDJanuary February March ori May tune auly August September October Novenber December ATTENDED 1,535 43175 1,248 1311 13389 4,273 1,449 1,499 i274 1,494 14308 13485 16,236 APPENDIX S-C MDH-ER Statistics, 1990 ADMITTED OP bon 350 ves 0 360 Bis oo 367 8570 Sei m0 4 Seo 1,027 oo 391 Bez 420 1,029 377 11020 325 39 426 1,070 407 sor oo 408 1,077 2 4,610 40 11,6286 EXPIRED10, APPENDIX 4-0 10 LEADING CAUSES OF CONSULTATION, MOH-ER, 1986 No. acute gastroenteritis 1,460 Pneumonia 4, 100 Bronchial asthma 1,093 PTB 2624 Vehicular accidents 365 corp 1,460 nippy 750 URT 3,375 Enteric fever 15095 CUAyHPN, 2,480 appendix 4-6 1D LEADING CAUSES OF CONSULTATION, MDH-ER, 1989 Now Acute gastroenteritis, 2,238 Respiratory tract infection 1,817 acute bronchitis 1,023 Bronchial asthma 985, NIDDM 887 urr a0 CyA/HEN, 730 Vehicular accident 730 Lacerated wound & infection ve oevn 20 APPENDIX 4-0 410 LEADING CAUSES OF CONSULTATION, MDH-ER, 1990 heute gastroenteritis 4,330 Bronchial asthma 1.113 Db-GYN/STD 4,200 Chest pain ‘980 Vehicular accidents 380 Essential Hypertension 873 ASH 594 PTB aa1 Acute conjunctivitis 349 Enteric fever 342 aAPPENDIX 5 April 12, 1991 Deer Colleague, eee an een aie satrap eRe Sgn Sr nae tae ae Soyo eee OE SO ee a Sco ae eee a ea See eat Casi Se RES atc lene ne oe ae oe eee ee emma a REYNALDO 0. JOSON, M.D. Lara ena PIECE POE RDO IA EER OE 1, If you were a victim of a vehicular accident and you Were brought Unconecicus to the MDH-ER, who do you lake ‘the Bnergency Room Officer (ERO) to be to evaluate and treat you right away? a. a postgraduate intern TTT! a “resident of the Department of Obetetrice-Gynecology who is on duty that, day at the ER c. a teeident of the Department of Energency Medicine (uppoeing there is such 8 Department) a, a consultant of the Department of Emergency Medicine stationed at the ER (Suppose there is such a Department) 2. I£ your eon is euffering from scute respiratory obstruction, who do you Like the BRO to be to evaluate and treat him right away? 4. 2 postgraduate intern bo a resident of the Department of Ophthalmology who 1s on duty that day at ‘the ER ce. a resident of the Department of Bnergency Medicine a. a consultant of the Department of uergency Medicine who 1s stationed at the ER. Tf you were an eolanptic patient with on-going seizures and you were brought. to the MDH-ER, who do you want the BRO to be to evaluate and treat you right away? a. 4 postgraduate Intern Tae a resident. of the Department of Pediatrics who 1s on duty that day at the ER a reeident of the Department of Emergency Medicine d. a coneultant of the Department of Bnergency Medicine who io stationed at the ER. ee11 you wore suirering irom acute myocardial infarotion and you were brought to the MDH-ER, who do you like the ERO to be to evaluste and trest you right away upon arrival at the ER? a. a postgraduate intern =. b. a resident from the Department of Surgery who happens to be on juty that day at the ER o. a resident of the Department of Emergency Medicine etationed in the ER d. a consultant of the Department of, Emergency Medicine stationed in the ER. If you were suffering from acute myocardial infarction and you were brought to the MDH-8R, who do you like the ERO to be to evaluate and treat you right away upon arrival at the ER? a. a postgraduate intern bl a firet-year resident from the Department cf Medicine who happens to be on duty that day at the ER c. a third-year reeident of the Department of Energency Medicine stationed in the ER If you wore suffering from acute myocardial infarction and you were Erought to the MDH-ER, who do you like the ERO to be to evaluate and treat you right sway? a. 8 postgraduate intern b. a senior reaident from the Department of, Medicine who happene to be stationed at the BR c. 2 senior resident from the Department of, Emergency Medicine stationed at the ER. Choose who you like the HR0 to be at the MDH-ER, Place a number before each item (1 = first choice; 4= last choice). 2. 2 postgraduate intern %l 4 Peaident fron each of the five clinical rotating every 5 days to be co. s resident of the Department of Emergency Medicine stationed at the ER (Suppose there is such a Department) d. a consultant of the Department of Euergenoy Medicine stationed at the ER (Suproge there is such as a Department) If 4t is possible to have full-time ER physicians (graduate of BR specialty) for the MDH-ER, would you be in favor of euch s set-up to improve the medical staffing of the MDI-ER? vas sve a nO Té NO, Why?10 | mo You willing to be an BRO hour duty every ood Soyer yee St MOH-ER, going on 24 ‘oper compensation? jee 2 YES no. Are you in favor of for ER physiciane at ting up @ training progran YES Are you willing to serve as a faculty for the training progran of ER physicians in the MDH-ER? yes No. If yes, what spe How do you think (consultants) should be compensated? a. Profesional fees for services rendered to patients brought to the ER —_v. Fixed salary per month Te! Honor ofessional fess a. Othere WAKE DEPARTAENT