AMERICA’S EMERGENCY
CARE ENVIRONMENT

Oklahoma



Oklahoma improved from 50th to 37th in the nation overall, largely due to major improvements in Disaster Preparedness. Unfortunately, the state failed to improve upon its poor grade in Access to Emergency Care and fell further behind in Public Health and Injury Prevention.

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Strengths

Oklahoma's Disaster Preparedness grade benefitted substantially from having implemented a statewide medical communication system with one layer of redundancy and a statewide syndromic surveillance system, as well as having significantly increased bed surge capacity (from 444.8 to 686.3 per 1 million people) and intensive care unit beds (312.5 to 412.6 per 1 million). The state passed Uniform Emergency Volunteer Health Professional Act model legislation to provide additional liability protections to health care workers during an event. The Oklahoma Medical Reserve Corps played a crucial role in rescue, shelter and recovery in the devastating EF5 tornadoes in Oklahoma in spring 2013.

Oklahoma continues to support a favorable Medical Liability Environment, having established and maintained a medical liability cap on noneconomic damages, collateral source rule reform, and case certification by expert witnesses. As a result, Oklahoma has medical liability insurance premiums below the national average for both primary care physicians and specialists and average malpractice award payments that are 18% lower than the average across the states.

While Access to Emergency Care in Oklahoma overall is poor, there were some highlights. The state ranks among the top 10 for many aspects of its hospital capacity, including emergency departments (ED) (30.7 per 1 million people), psychiatric care beds (46.7 per 100,000 people), and low hospital occupancy rate (57.3 per 100 staffed beds). As a result, it has the eighth lowest ED wait time: 211 minutes from ED arrival to ED departure for admitted patients. Some hospitals in the state are building freestanding EDs that could continue to expand timely Access to Emergency Care.

Challenges

With regard to Access to Emergency Care, Oklahoma continues to struggle with shortages of emergency physicians, specialists, primary care providers, mental health providers, and registered nurses. The state has made little-to-no progress in recruiting and retaining health care providers since the 2009 Report Card, despite reducing the proportion of children without health insurance by nearly half and increasing Medicaid fee levels for office visits.

Oklahoma's Quality and Patient Safety Environment is lacking a number of policies and procedures aimed at improving emergency response. Survey data indicate that the state lacks a uniform system for providing pre-arrival instructions that could offer an opportunity for lifesaving care while awaiting an emergency medical services (EMS) response, as well as destination policies for ST-elevation myocardial infarction (STEMI) and stroke patients, although emergency physicians report that new state EMS protocols are supporting improvements in these areas. In addition, while Oklahoma supports the only real-time prescription drug monitoring program in the country, the state's hospitals fall well below average in adoption of electronic medical records and computerized practitioner order entry.

Public Health and Injury Prevention efforts in Oklahoma continue to lag behind the nation overall. Oklahoma has failed to pass smoke-free bans for restaurants, bars, or worksites, despite having the fourth highest rate of adult smokers (26.1%). The state also has among the 10 highest rates of fire- and burn-related deaths, poisoning-related deaths, which includes drug overdoses, and traffic fatalities.

Recommendations

Oklahoma should match its outstanding hospital capacity with an adequate physician workforce to improve overall Access to Emergency Care. The state must work to recruit and retain specialists, emergency physicians, primary and mental health care providers, and registered nurses. The Oklahoma Physician Manpower Commission is taking steps to address some of these problems through enhanced incentive programs for physicians, physician assistants, and nurses. They are currently focusing on filling primary care openings, especially in the rural areas of the state. A new emergency medicine residency program has graduated three classes with 94% of residents staying to practice in Oklahoma, and another emergency medicine residency program will open next year.

Oklahoma patients would also benefit from an increase in access to trauma centers and accredited chest pain centers: Currently, only 73% of the population is within 60 minutes of a level I or II trauma center, and the state has only 0.3 accredited chest pain centers per 1 million people. Increased access is important in light of the above mentioned Public Health and Injury Prevention concerns. Passing legislation that bans handheld cellphone use and texting for all drivers and requiring helmets for all motorcycle riders may help reduce Oklahoma's above-average rates of traffic fatalities for vehicle occupants, bicyclists, and pedestrians.

Access to Emergency Care

Title 2009
Report Card
2014
Report Card
Board-certified emergency physicians per 100,000 pop 6.1 7.3
Emergency physicians per 100,000 pop 7.4 8.6
Neurosurgeons per 100,000 pop 1.8 2.1
Orthopedists and hand surgeon specialists per 100,000 pop 7.4 7.3
Plastic surgeons per 100,000 pop 1.2 1.3
ENT specialists per 100,000 pop 2.5 2.6
Registered nurses per 100,000 pop 718.4 747.6
Percent of children able to see provider 94.5
Level I or II trauma centers per 1M pop 0.8 1
Percent of population within 60 minutes of Level I or II trauma center 67.9 73
Accredited chest pain centers per 1M pop 0.8 0.3
Percent of population with an unmet need for substance abuse treatment 8.4 8.4
Pediatric specialty centers per 1M pop 2.8 3.1
Medicaid fee levels for office visits as a percent of the national average 128.9 130.6
Percent change in Medicaid fees for office visits (2004-05 to 2007/2007 to 2012) 12 24.5
Percent of adults with no health insurance 21.2 20.3
Percent of adults underinsured 9.3
Percent of children with no health insurance 12.5 6.4
Percent of children underinsured 14.6
Percent of adults with Medicaid 5.3 6.8
Hospital closures in 2006/2011 0 0
Staffed inpatient beds per 100,000 pop 363.7 359.6
Hospital occupancy rate per 100 staffed beds 60.6 57.3
Psychiatric care beds per 100,000 pop 36.9 46.7
Median time from ED arrival to ED departure for admitted ED patients 211
State collects data on diversion NO YES

Disaster Preparedness

Title 2009
Report Card
2014
Report Card
Per capita federal disaster preparedness funds $8.69 $5.33
State budget line item health care surge YES
ESF-8 plan is shared with all EMS and essential hospital personnel NO YES
Emergency physician input into the state planning process YES, YES YES
Public health and emergency physician input during an ESF-8 response YES, NO
Drills, exercises conducted involving hospital personnel, equipment, or facilities per hospital
Accredited by the Emergency Management Accreditation Program (EMAP) NO YES
Special needs patients included in medical response plan NO YES
Patients dependent on medication for chronic conditions in medical response plan NO NO
Medical response plan for supplying dialysis NO NO
Mental health patients included in medical response plan YES
Medical response plan for supplying psychotropic medications NO
Mutual aid agreements in place with behavioral health providers LOCAL LEVEL
State requires long-term care and nursing home facilities to have a written disaster plan NO
State able to report number of exercises involving long-term care facilities or nursing NO
Just-in-time training systems in place STATEWIDE STATEWIDE
Statewide medical communication system with one layer of redundancy NO YES
Statewide patient tracking system NO NO
Statewide real-time or near real-time syndromic surveillance system NO YES
Real-time surveillance system in place for common ED presentations NR YES, STATEWIDE
Bed surge capacity per 1M pop 444.8 686.3
ICU beds per 1M pop 312.5 412.6
Burn unit beds per 1M pop 9.1 8.7
Verified burn centers per 1M pop 0 0
Physicians registered in ESAR-VHP per 1M pop 57.5 15.2
Nurses registered in ESAR-VHP per 1M pop 265.9 239.3
Behavioral health professionals registered in ESAR-VHP per 1M pop 26.7
Strike teams or medical assistance teams YES YES
Disaster training required for essential hospital/EMS personnel NO, NO NO
Percent of RNs that received emergency training 44.7 41.3

Medical Liability Environment

Title 2009
Report Card
2014
Report Card
Lawyers per 10,000 pop 13.8 17
Lawyers per physician 0.7 0.8
Lawyers per emergency physician 18.4 19.7
ATRA judicial hellholes (2009 range 0 to -7/2014 range 2 to -6) -1 0
Malpractice award payments per 100,000 pop 1.7 3.1
Average malpractice award payments $230,788 $254,431
National Practitioner Databank reports per 1,000 physicians 29.6 42.9
Apology laws: Apology is inadmissible as evidence in a court of law YES
State has implemented a patient compensation fund NO NO
Number of insurers writing medical liability policies per 1,000 physicians 7.6 10.3
Average medical liability insurance premiums for primary care physicians $12,809 $12,809
Average medical liability insurance premiums for specialists $51,811 $49,898
Presence of pretrial screening panels NONE NO
Pretrial screening panel's findings admissible as evidence N/A N/A
Periodic payments are: required, granted upon request, at court's discretion NO UPON REQUEST
Medical liability cap on non-economic damages $250,001-350,000 $250,001-350,000
Additional liability protection for EMTALA-mandated emergency care YES NO
Joint and several liability abolished PARTIALLY YES
Collateral Source Rule/Provides for Awards to be Offset YES, NO OFFSET
State provides for case certification YES YES
Expert witness required to be of the same specialty as the defendant NO NO
Expert witness must be licensed to practice medicine in the state NO NO

Public Health & Injury Prevention

Title 2009
Report Card
2014
Report Card
Bicyclist fatalities per 100,000 cyclists 7
Pedestrian fatalities per 100,000 pedestrians 6.8
Percent of traffic fatalities alcohol-related 34 36
Percent of front occupants using restraints 83.1 85.9
Child safety seat/seat belt legislation - score out of a possible 10 points 5 5
Helmet use required for all motorcylce riders NO NO
Distracted driving legislation score - out of a possible 4 points 0
Graduated drivers' licenses legislation score -out of a possible 5 points 0
Percentage of children aged 19-35 months who are immunized 80.4 77.3
Percentage of adults aged 65+ who rec’d an influenza vaccine in the last 12 mos 70.6 62.4
Percentage of adults aged 65+ who ever rec’d pneumococcal vaccine 70.2 72.8
Fatal occupational injuries per 1M workers 57.1 47
Homicides and suicides (non-motor vehicle)(per 100,000) 20.8 22
Unintentional fall-related fatal injuries (per 100,000) 6.2 11.2
Fire/burn related fatal injuries (per 100,000) 2 2
Rate of unintentional firearm-related fatal injuries (per 100,000) 0.5 0.4
Rate of unintentional poisoning-related deaths (per 100,000) 17.6
Total injury prevention funds per 1,000 persons $479.14 $437.88
Dedicated child injury prevention funding YES
Dedicate elderly injury prevention funding YES
Dedicated occupational injury prevention funding YES
Anti-smoking legislation score - score out of a possible 3 points 0
Infant mortality rate per 1,000 live births 8.1 7.6
Percentage of adults who binge drink 13.4 16.5
Percentage of adults who currently smoke 25.1 26.1
Percentage of adult population who are obese (BMI > 30.0) 28.8 31.1
Percentage of children who are obese 17.4
Cardiovascular disease disparity ratio 1.8
HIV diagnosis disparity ratio 6.3
Infant mortality disparity ratio 2.4

Quality & Patient Safety

Title 2009
Report Card
2014
Report Card
Funding for quality improvement within the EMS system NO YES
Funded state EMS medical director YES YES
Emergency medicine residents per 1M pop 2.2 18.6
Adverse event reporting required NO NO
% of counties with Enhanced 911 capability 76.9 83.5
State has a uniform system for providing pre-arrival instructions NO NO
State uses CDC guidelines for state field triage protocols YES (2011)
State has or is working on a stroke system of care YES YES
State has triage and destination policy in place for stroke patients NO
State has or is working on a PCI network or a STEMI system of care NO NO
State has triage and destination policy in place for STEMI patients NO
State maintains statewide trauma registry YES YES
State has triage and destination policy in place for trauma patients YES
Prescription drug monitoring program score (range 0-4) 4
% of hospitals with computerized practitioner order entry 9.3 60.7
% of hospitals with electronic medical records 19.8 84.4
% of patients with AMI given PCI within 90 minutes of arrival 52 93
Median time to transfer to another facility for acute coronary intervention 66
% of patients with AMI who received aspirin within 24 hours 99
% of hospitals collecting data on race/ethnicity and primary language 65.8
% of hospitals with or planning to develop a diversity strategy or plan 46.8

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