A Crisis in the ER

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http://www.motherjones.com/commentary/columns/2004/04/04_300.html

 

A Crisis in the ER

 

As the nation's overburdened and underfunded emergency rooms are pushed to the

brink, our medical safety net is starting to unravel.

David Hilfiker

March/April 2004 Issue

As I enter the parking lot of Providence Hospital in northeast Washington at 3

p.m. on a Monday afternoon, there are three ambulances in the lot. Four more

crowd the ambulance entranceway to the ER, and I hear the approaching sirens of

two more. I elbow my way through a narrow reception area that is now packed with

four patients on ambulance stretchers waiting for triage, six or seven ambulance

attendants, and assorted nurses, clerks and orderlies who've been caught in the

crush. I finally reach the relative calm of the island in the middle of the

large, open emergency room where doctors and nurses write reports or consult one

another and clerks staff computers. Providence is the only hospital in northeast

Washington. It's a private, non-profit hospital with a reputation in the city

for good care and an active desire to serve the poor. Founded and for many years

run by the Daughters of Charity (the CEO is still a nun), Providence has, like

most urban hospitals in the country, become

part of a larger conglomerate, although it remains non-profit. Twenty years

ago, I had privileges there and admitted occasional patients to the hospital.

 

Looking around at the patients littered everywhere, Dr William Strudwick, chief

of the Emergency Department, says to no one in particular, " If ten more people

come, where are they going to go? " Then, perhaps remembering his role as head of

the department, perhaps for my benefit, he adds, " ... except for the sick ones,

of course. " Gesturing to the four people waiting on ambulance stretchers, he

says, " None of these are sick, really. " As a physician, I know what he means by

" sick " : patients needing immediate medical attention for truly life-threatening

illnesses. And he's right, I suppose. None of the four who are waiting (and few

of those being attended to in the ER cubicles) are " sick " by that definition.

But a layperson might be forgiven for thinking that these people are sick

enough. One man lies on a stretcher next to the reception desk, nursing a bruise

on his forehead acquired during a seizure he's still recovering from. Two

elderly patients, apparently unconscious, lie on

ambulance stretchers with oxygen tubes in their nostrils. They are probably

nursing home patients whose condition has worsened so that they need in-patient

attention. They're sick enough.

 

Dr Strudwick calls Emergency Medical Services (EMS), the branch of the District

of Columbia Fire Department that runs the ambulances, to request " diversion " for

the emergency room. Under diversion, any ambulances headed for Providence will

be rerouted to one of the other two hospitals in this sector of the city,

Washington Hospital Center or Howard University Hospital. But both Hospital

Center and Howard are already on diversion, and EMS policy prohibits closing all

of the ERs in any given sector. Despite the overflow, Providence will continue

to receive ambulances-including those that would have gone to the other two

hospitals.

 

Ambulance diversion is an astonishingly common necessity. According to a 2003

report from Congress' Government Accounting Office (GAO), two-thirds of all

hospitals turn away ambulances at some point during a given year, and of those

hospitals, 10 percent average over 5 hours a day on diversion. In one four-month

period, all 29 ERs in metropolitan Phoenix's went on diversion simultaneously on

eight occasions. In a one-month period all the ERs in Cleveland's were on

diversion simultaneously for an average of over two hours a day.

 

Not only do crowded ERs lead to poorer patient care and worse results, but by

tying up ambulances (like the seven now idling outside Providence), they also

slow the city's ambulance system's ability to respond. Although the District

fire department would not release official figures, Kenneth Lyons, a paramedic

and president of the local paramedics' union, estimated that about 40 percent of

the time, all the district's ambulances are occupied.

 

" When patients have to wait 12 to 24 hours in the emergency room to get a

hospital bed, " said Mark Smith, Chairman of the Department Emergency Medicine at

Washington Hospital Center, " I think that's a crisis. But we're also close to a

tipping point. We haven't had a flu epidemic for two years; the next one we

might find ourselves in a real crisis. " As it is, Washington Hospital Center is

on diversion an average of about five hours a day.

 

The Providence emergency department always looks crowded. Even on slow days, all

of the ER's 17 beds in 12 cubicles are occupied and patients overflow into the

" hallway beds, " eight places carved out of open space along the walls and

officially designated as beds. And today is not a slow day. Three of the

cubicles meant for one person are doubled up. Two patients are in dialysis, but

will return soon; one is in x-ray. In addition to the four ambulance patients on

stretchers packing the reception area, one man sits in the middle of the hallway

in his wheelchair, apparently unattached to any regular spot. There are 35

patients in an emergency room built for twelve.

 

Why are emergency rooms so crowded so often? For one thing, more and sicker

patients are showing up for care. The GAO reports that nationwide, the number of

emergency room visits increased 15 percent from 1997 to 2000. And contrary to

conventional wisdom, it's not mostly people with minor illnesses clogging the

system-one large national survey found that only 10 percent of patients coming

to ERs are non-urgent, meaning that they could wait more than 24 hours to be

seen.

 

Nursing-home patients account for some of the increase in ER visits, and also

for the worsening illnesses; in addition, fewer and fewer primary care

physicians now practice in the large cities where most ER crowding occurs, so

patients either have no regular doctors or face months-long waits for

appointments, forcing them into the ER.

 

At the same time that more people are coming to the emergency rooms, the number

of hospitals with emergency departments has declined across the country. The

District of Columbia has been especially hard hit with the closure of four

hospitals over the past ten years. In 2001, District officials closed DC General

Hospital, the only public hospital in the city, because they couldn't afford to

keep it open. The emergency patients previously seen at DC General were shunted

to the remaining hospitals. This pattern has been repeated across the country.

Between 1992 and 2001, the number of hospitals with emergency rooms declined by

15%.

 

Jessica Richardson is waiting in Room 8 for admission to the hospital. She was

at her routine dialysis appointment around 10 this morning when she felt the

sudden need to defecate. What filled the toilet bowl, however, was bright red

blood. She was rushed to the Providence ER where the doctors promptly made the

diagnosis--bleeding diverticuli (outpouchings of the colon). She should have

been admitted to the Intensive Care Unit (ICU) in order to receive blood, to be

closely monitored, and to be evaluated for possible surgery to repair the

ruptured diverticulum. But there are no beds available in the ICU. In fact,

there are no open beds available anywhere in the hospital, so Ms Richardson has

been " boarded " here in the emergency room and will wait for almost five hours

before an appropriate bed opens up upstairs. Yes, she is receiving the needed

transfusion and being watched closely. She will eventually be transferred to the

ICU, and surgeons will successfully operate on her abdomen

just after midnight to stop the bleeding. But she will demand a great deal of

time and energy from the staff here in the emergency department. National

standards recommend that one emergency room nurse should devote full-time to

critical patients like Ms Richardson, while one nurse should have no more than

four routine patients. Today, each of the nurses has at least five patients at

any time.

 

Mistakes are far more likely to happen under these crowded conditions. I look

around again. An ambulance attendant stands arguing with an inebriated man who

alternately threatens to leave if he can't be seen right away and then not to

leave until someone sees him. A young woman lies thrashing about in Hallway Bed

1, apparently suffering some kind of drug overdose. A doctor is tying her legs

down to restrain her. A nurse says that the patient in Hallway Bed 6 needs a

cardiac monitor, but all of the monitors in the ER are currently in use. Maria,

the charge nurse, realizes suddenly that the ER is completely out of beds and

sends the orderly to the dialysis department to retrieve the stretchers of the

two patients who were taken over there. Elizabeth Lilly, the triage nurse,

wheels in a patient who has come in by car and needs to be seen immediately.

Even when ambulances are being diverted, federal regulations require the

emergency room to see any patient who comes to the ER on his or

her own.

 

Why don't the hospitals just build bigger emergency rooms and more intensive

care units? Why don't they open more hospital beds? The answer to this question

requires a brief detour into the murky world of hospital finance. Prior to 1980,

hospitals offset the cost of caring for the uninsured by charging Medicare and

private insurers an amount greater than the actual cost for patients who did

have coverage. But over the past 20 years, both the government and private

insurers have dramatically cut the amounts they reimburse hospitals. At the same

time, non-profit hospitals began to face competition from an increasing number

of for-profit hospitals, most of which set up shop in areas with few uninsured

patients; many of these hospitals also didn't have emergency rooms, closing down

the main access point for uninsured patients.

 

Finding themselves squeezed by ever-lower reimbursements and growing

competition, hospitals responded by downsizing and closing beds. Not only did

the District of Columbia, for instance, lose four hospitals over the decade,

other hospitals also closed nearly a third of their beds. Nationwide, 17 percent

of intensive care beds disappeared during the 1990s. This made the hospitals

more efficient, but cost them the ability accommodate any surge in

patients-whether from a minor flu epidemic or from a terrorist attack. As LA

Times economic reporter Peter Gosselin has written, " In a market-based system,

the sensible thing for a hospital is to fully utilize its resources by filling

as many beds as possible. The problem is that when a hospital does that, where

do you put the emergency patients? " We've forgotten that emergency rooms are the

medical safety net for the country.

 

Ultimately, then, it all comes down to our unwillingness to adequately fund the

basic health care infrastructure of our country. The increasing numbers of

people unable to get timely care at clinics who flood the ER are the refugees

from a health care system that does not provide enough primary care doctors.

Cities close public hospitals because taxpayers cannot see far enough ahead to

recognize their own need for them. Finally, the growing number of uninsured

(and, just as importantly, underinsured) put unbearable strains on the finances

of the system.

 

Emergency medical services is the point of intersection between the increasingly

private system of American medical care, which is the best in the world, and the

public medical care system, which is not. Affluent patients with comfortable

insurance policies may believe that the problems of the uninsured will not

affect them. But they, too, suffer from the prolonged response time of the

ambulance, the inability to get to an emergency department physician promptly,

the chaos of an overcrowded emergency room, or the inability to get into the

intensive care unit. None of us schedules his heart attack or picks its place.

 

 

 

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© 2004 The Foundation for National Progress

 

 

 

 

 

 

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