Despite a poor overall showing, Nevada managed to move up 12 places and improve its overall grade since 2009. This is due in large part to tremendous improvements in Disaster Preparedness; however, the state still faces a crisis in Access to Emergency Care and has seen further erosion of the Quality and Patient Safety Environment.
Nevada should be applauded for having implemented a number of policies and practices that have helped make its Disaster Preparedness grade among the best in the nation. The state has invested in a statewide medical communication system with one layer of redundancy, has implemented a patient-tracking system, and has strike teams or medical assistance teams to provide support during a disaster. In addition, the state has passed Uniform Emergency Volunteer Health Practitioners Act, model legislation that includes specific liability protections for health care workers during a disaster. Nevada ranks first in the nation in the proportion of registered nurses who received Disaster Preparedness training (57.2%).
Nevada supports a strong Medical Liability Environment. The state has maintained its $350,000 medical liability cap on non-economic damages and provides for awards to be offset by collateral sources. Nevada also allows periodic payments of malpractice awards on the request of one or both parties, as well as case certification by an expert witness. In addition, expert witnesses are required to be of the same specialty as the defendant.
Nevada continues to face a crisis in Access to Emergency Care, for which it ranks last in the nation. The state has a severe shortage of specialists, ranking last or next to last for the number of neurosurgeons (1.1 per 100,000 people); orthopedists and hand surgeons (6.1 per 100,000); and ear, nose, and throat specialists (2.0 per 100,000). Compounding these issues are financial barriers to care, including high rates of children and adults without insurance or who are underinsured. Nevada ranks 51st for the proportion of children without insurance (21.0%) and 43rd for those who have inadequate insurance (20.1%). It has only 8.7 emergency departments (ED) per 1 million people, compared with an average of 18.9 per 1 million people nationally, which has likely contributed to long wait times in the emergency department; the median time from ED arrival to ED departure for admitted patients was 337 minutes or 5.6 hours. Compounding these issues, Nevada supports the smallest nursing population, with only 605.5 registered nurses per 100,000 people.
Nevada's Quality and Patient Safety Environment has worsened compared to other states since 2009. The state does not have field triage protocols or guidelines for emergency medical services (EMS) response or a uniform system for pre-arrival instructions. The state has failed to implement destination policies that let EMS teams bypass local hospitals to transport stroke and ST-elevation myocardial infarction (STEMI) patients directly to a hospital specialty care center, despite having one of the highest rates of accredited chest pain centers in the country (5.4 per 1 million people). Finally, while the state has increased the proportion of counties with enhanced 911 capability since 2009 (70.6% versus 52.9%, respectively), Nevada still lags far behind the average across the states (96.9% of counties).
Nevada's poor showing in Public Health and Injury Prevention is marked by both positive and negative results. The state has the worst child immunization rate (66.7%) and ranks 50th for influenza vaccination among the elderly (53.7%). It also has some of the highest rates of homicides and suicides (25.6 per 100,000 people) and unintentional poisoning-related deaths, which includes drug overdoses (18.3 per 100,000 people). At the same time, the state has the eighth lowest rate of fall-related deaths (5.7 per 100,000). Similarly, Nevada ranks 10th best in obesity among adults (24.5%) but 10th worst in the proportion of children who are obese (18.6%).
Nevada must take immediate steps to address the crisis in Access to Emergency Care, including the specialist workforce shortage and financial barriers to care that continue to threaten the state's entire emergency care system. Recruitment and retention of providers must become a priority for Nevada policymakers to ensure that quality care is available as the Patient Protection and Affordable Care Act takes full effect.
Despite Nevada's strong showing for the Medical Liability Environment, there is ample room for improvement. The state's average medical liability insurance premiums for primary care providers and specialists have both decreased since the previous Report Card, but they still rank 42nd in the nation for both. The state should consider providing additional liability protections for care mandated by the Emergency Medical Treatment and Labor Act to further alleviate the burden on physicians who are willing to provide emergent, lifesaving care to patients. Nevada should also consider passing apology inadmissibility laws and implementing pretrial screening panels to create a more favorable Medical Liability Environment.