Emergency Rooms in America: A Deadly Prognosis
Wednesday, March 12, 2008
By Donald Snyder
In a crowded Arizona emergency room, a 10-year old boy struggles to breathe. He is having an asthma attack.
Within 15 minutes, he is dead.
Had he not been turned away from two children’s hospitals closer to his home, he might be alive.
However, those ERs were too full to take the boy.
“The boy might be alive today if he was treated at one of the children’s hospitals instead of the ambulance being diverted to my crowded emergency department 20 to 30 minutes away,” said a doctor who formerly worked in that emergency department, speaking on the condition of anonymity.
The practice of diverting ambulances from overcrowded emergency rooms has become widespread — and the delay in treatment can have fatal consequences.
Consider these overwhelming statistics:
— One ambulance per minute is diverted — that’s 500,000 per year, according to the Institute of Medicine of the National Academies.
— In 2000, Columbia University in New York City found that fatalities from heart attacks increased by as much as 47 percent as a result of diverting ambulances.
— In Houston, Texas, the average rate of diversion was 14 percent in 2001. Today, the rate is 40 percent, said Dr. Guy Clifton, a professor of neurosurgery at the University of Texas in Houston.
— Americans are using emergency rooms more than ever in today’s society. In 2005, 115 million Americans went to the ER, up five million from the year before, according to the Centers for Disease Control.
— Between 1994 and 2004, there was a 20 percent increase in the demand for emergency care, according to the CDC, which is most likely due to an increase in the nations’ uninsured and growing elderly population.
During those years, 9 percent of the nation’s ERs closed, having lost money from inadequate reimbursement, according to the CDC.
— A recent Harvard study found the average waiting time for a patient to see a doctor in the ER jumped from 22 minutes in 1997 to 30 minutes in 2004. The same study showed patients with coronary episodes waited 8 minutes in 1997; in 2004, they waited 20 minutes.
— Of 1,000 doctors polled by the American College of Emergency Physicians last year, 200 said they knew of a patient who died because of failure to deliver prompt care in an overcrowded emergency department.
Combine these factors and the system is at a breaking point.
Dr. Brian F. Keaton, chairman of the board of directors of the ACEP, practices emergency medicine in Akron, Ohio. His story illustrates the situation faced by many doctors.
“I have people who come to my clinic with a headache caused by high blood pressure. I give them the medicine to bring the blood pressure down and a prescription,” Keaton said in an anguished tone.
“Many of them don’t have the money to fill it. I have no place in the system to care for them until they end up back here with a stroke because they weren’t taking their medication.”
Bellevue Hospital Center, the nation’s oldest public hospital, treats many of New York City’s disenfranchised residents. Few of these patients can afford private doctors.
One night last February, a doctor moved effortlessly from one cubicle to another inside Bellevue’s emergency department; her voice rising above the din of frenzied activity.
“He lives paycheck to paycheck and sometimes runs out of his heart medication and gets sick,” the doctor said about a distinguished-looking, white-haired man who sat on a bed, seemingly unfazed by the noise around him.
The doctor moved on to another bed, where a sleeping man was covered by blankets to warm his cold body. She recorded his temperature and added two more blankets. He was found sleeping in a doorway in the bitter cold.
This is a snapshot of an American emergency system in meltdown.
“Today we have a crisis that we cannot continue to survive in,” said Dr. Linda Lawrence, president of the ACEP. “We often don’t have beds for emergency patients. We don’t have enough heart monitors to go around. The nursing staff is badly stretched. We’re at a breaking point.”
One cause of emergency department gridlock is the practice known as “boarding.”
Admitted patients are left in the emergency department for extended stays until hospital beds become available — and patient care suffers.
“Studies show that patients are not receiving antibiotics on time when they have serious infections and that patients are not receiving adequate pain control,” Lawrence said.
Robert Roth, a New York resident, wrote a letter to the New York Times about his mother’s boarding experience at an emergency room.
“My mother, who is 89, recently had two extremely traumatic experiences in the emergency room,” he wrote. “One time she waited over 36 hours, the other time over 20 hours before they found a room for her. Both times she emotionally came apart and her condition dramatically deteriorated.”
One possible solution is to create more public clinics for preventive care, which would reduce the use of emergency departments for routine visits.
Bellevue has a large outpatient clinic, which treats 500,000 to 600,000 patients a year, said Dr. Lewis Goldfrank, chairman of emergency medicine at the hospital.
“Every patient who comes to the emergency department is a failure of the public health system,” Goldfrank said. “Many of the patients have chronic diseases that are monitored and treated at the outpatient clinic.”
The American College of Emergency Physicians supports Congressional passage of the Access to the Emergency Medical Services Act. This bill would recognize the need for more money to sustain an ailing system that must provide care to everyone, including those who can’t pay by creating a national bipartisan commission to examine the delivery of care in the nation’s emergency departments.
The act also calls on the government to collect data on the widespread practice of boarding so that new guidelines can be applied. A vote on the bill is expected by April.
“The system is sick and in danger of breaking,” Keaton said. “When it fails, it will be a catastrophic failure.”