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Improving the Medical Staffing of the Emergency Room of the Manila Doctors Hospital - Project Study for Master in Hospital Administration from the University of the Philippines College of Public Health - ROJoson - 1991
Оригинальное название
Improving the Medical Staffing of the Emergency Room of the Manila Doctors Hospital
Improving the Medical Staffing of the Emergency Room of the Manila Doctors Hospital - Project Study for Master in Hospital Administration from the University of the Philippines College of Public Health - ROJoson - 1991
Improving the Medical Staffing of the Emergency Room of the Manila Doctors Hospital - Project Study for Master in Hospital Administration from the University of the Philippines College of Public Health - ROJoson - 1991
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, 19911
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, i991College 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 medicalstaf# 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 Department1
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. Theyare 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 haveto 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 consistOf 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
9be 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.
10The 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
utsupported 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
12servic
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
13the 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.
14CHAPTER 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
15brought 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).
16cHePTER 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.
7CHARGING 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.
18Table 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
rcNUMBER 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 andcritical 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.
aMajority (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.
2The
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
2attention 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.
24Thus, 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
2swho 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
26MDH-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
27be 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.
29CHAPTER 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.
3010.
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.
at41, Interview with Dr. Francisco Barros, Chief, Department
Of Emergency Medicine, Makati Medical Center. April
10, 1991.
32the
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
3swich 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 specificconsultant. 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
6ay
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
AdministratorJanuary
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
EXPIREDJanuary
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
EXPIRED10,
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
aAPPENDIX 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. ee11 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