COVER STORY

What will it take to solve the ER crisis?

Overcrowding and ambulance diversion are the symptoms. Physicians are part of the problem—and part of the solution.

By Robert Lowes
Midewest Editor

Instead of roaring through stoplights, an ambulance transporting an elderly woman with pneumonia recently pulled off the road in St. Louis. Emergency rooms at six nearby hospitals had just told paramedic Larry Ashby that they were on diversion—that is, filled to the gills with patients and unable to take any more.

He was left with no destination.

"I spent 20 minutes phoning ERs while I was parked," says Ashby, who works for the Creve Coeur Fire Protection District. "Finally I called a hospital that had turned me down moments earlier and said, 'We're ignoring your diversion and bringing her in.' "

This woman was somebody's patient. Her experience forces doctors everywhere to wonder, "Is it safe to send my patient to the ER?"

Overflowing ERs and ambulances turned away are a national phenomenon. Ashby's patient eventually got the care she needed and returned home, but stories are cropping up about patients who may have died as a result of breakdowns in emergency medicine.

Some doctors say our ERs are so imperiled that a severe winter flu season and its deluge of patients might overwhelm them. "I fear to think what will happen," says Davis, CA, ER physician Loren A. Johnson, president of the California chapter of the America College of Emergency Physicians (ACEP).

There are no easy fixes. ERs where patients wait hours to be seen and hours more for a scarce hospital bed are merely a symptom of a health care system that's financially sick. "You can't have quality health care when you constantly squeeze resources out of the system," says Rick Wade, a spokesperson for the American Hospital Association. ER doctors and others say we're reaping the consequences sown by 20 years of cost-cutting: a shortage of hospital beds and the nurses to staff them. Add to the mix 39 million uninsured Americans—many of whom use ERs for primary care—and it's easy to see why Larry Ashby's ambulance was temporarily grounded.

But physicians are another cause of the crisis. When a primary care doctor is so booked up that a patient must wait five weeks for an appointment, that patient is liable to head to the nearest ER. And specialists? An increasing number of them won't take ER call, sometimes leaving patients in a deadly lurch. But like overcrowded ERs, what doctors do or fail to do is also rooted in the perverse economics—and laws—of the times.

Overcrowded ERs: Incubators for burnout?

This isn't the first time sirens have sounded about ERs. In 1989, for example, Los Angeles's ERs and trauma centers were themselves emergency cases. Half were filled to the brim on a typical Friday or Saturday night, and the resulting widespread ambulance diversion drew national attention.

In 2001, however, the hurting is far worse, says ER physician and insurance company medical director Charlotte S. Yeh of Hingham, MA. "In the past, overcrowding was cyclical," says Yeh, who heads an ACEP task force on the uninsured. "It used to coincide with flu season. Now it's constant. There are no peaks and valleys."

MASH-like conditions in ERs can quickly burn out doctors and nurses. "I have never seen my colleagues so frazzled," says Yeh. "One nurse quit to work in a prison—she said it'd be less stressful."

The state public health department of Massachusetts calls ER overcrowding its No. 1 problem. In Boston, some hospitals divert ambulances an average of three to four hours a day. ERs with "no vacancy" signs aren't seen only in large cities, either. In Louisville, KY, population 256,000, the city's 10 hospitals average six diversions a day in 2000, triple the number in 1996.

When ERs say they're full, they mean it. "Patients are double-bunked in ED rooms and put in hallways," says Yeh. Many of them are "boarders" who, having been treated, are waiting for an inpatient bed to open up. In Massachusetts, it's not uncommon for them to spend the night, says Yeh. "I know of one patient who was boarded for four days." These patients in limbo further tax an ER's resources.

"We're trained to stabilize and diagnose patients, not monitor them over long periods of time," says Susan M. Nedza, an ER physician in Chicago who chairs an ACEP task force on ER safety. "We're not set up to feed people. A nurse who delivers a meal has less time for people with acute, urgent problems."

Such chaotic conditions may have contributed to the death of an 80-year-old woman in a Massachusetts ER following a recent auto accident. She died of a spinal cord injury and associated pulmonary dysfunction. The state public health department faulted the hospital for not consistently monitoring her neurological status while she lay for 25 hours in a hallway boarding area awaiting transfer to an inpatient bed.

Bed shortages keep patients waiting in the ER

The lack of beds results, the AHA's Rick Wade explains, from three factors—low reimbursements from managed care companies and Medicare, the shift to outpatient treatment, and the trend to shorter lengths of stay. As a result of hospital closings and bed closures by those still open, the nation lost more than 103,000 staffed beds during the 1990s, as well as 7,800 in medical-surgical ICUs.

Even when beds are available, there may not be personnel to staff them. "We have openings for 126,000 RNs," says Wade.

ERs themselves are seeing an upsurge in patients. Visits nationwide climbed 14 percent from 1992 to 1999. But there are fewer ERs—approximately 500 disappeared in the 1990s. Some were lost when hospitals closed. Others were shut down because hospitals found them unprofitable.

The changing mix of patients strains ERs financially, too. The percentage of ER patients who are privately insured—which usually means the best reimbursement—declined from 43.3 to 38.9 percent between 1992 and 1999. In contrast, self-payers—read indigent or uninsured—rose from 13.8 to 16.2 percent.

In the comfy days of fee-for-service medicine, hospitals could give away ER care by shifting the cost to insured patients. But with the cutthroat reimbursement levels of managed care, that's no longer possible, says the AHA's Wade.

ERs often lose money on insured patients as well. Medicaid pays poorly, and managed care plans frequently sidestep payment by using their old "no prior authorization" and "not a true emergency" excuses. There's been progress on the managed care front, though. So-called "prudent layperson" laws in 32 states and the District of Columbia now require health plans to pay for ER visits even if what looked like a heart attack turned out to be just bad indigestion.

Private, federally regulated ERISA plans aren't covered by these laws, but such plans would fall under the prudent layperson provisions of the proposed patient bill of rights before Congress.

Whether an ER stands to get paid or not, the federal Emergency Medical Treatment and Active Labor Act (EMTALA) requires it to offer care to anyone who comes through the door. Critics concede that the 1986 law was needed to stop hospitals from denying care to indigent ER patients, but they wish the federal government would pick up the resulting tab for services rendered. "It's a massively unfunded mandate," says emergency physician Loren Johnson.

Poor primary care access means more ER visits

If ERs handled only emergencies, they wouldn't be in as bad a fix as they are. But patients with non-urgent conditions constitute at least 9 percent of all ER visits, according to a survey done by the Centers for Disease Control and Prevention.

Some physicians decry patients who take sore throats and sprains to the ER instead of making a doctor's appointment. "They use the ER like the 7-Eleven," says general practitioner Patricia L. Elliott of Rapidan, VA.

But what about the patient who can't get an appointment for three weeks? More and more, he shows up in the ER—and often at the direction of his primary care doctor, says ER physician Robert A. Bitterman of Charlotte. "Doctors know that hospitals can't turn away patients because of EMTALA."

To some, such ER visits illustrate why the country needs more primary care doctors. "FPs and internists are overwhelmed," says Madison, WI, FP Richard G. Roberts, immediate past president of the American Academy of Family Physicians. "They can't handle any more patients."

Managed care also weakens their motivation to do so. A primary care physician paid through capitation has less incentive to see a patient needing urgent care than a fee-for-service doc does. The 9-to-5 mentality of doctors employed by large groups also diminishes access, says St. Louis ER nurse Ellen Weis. "They feel little need to build a practice, so they send people to the ER instead of working a little later to see them."

Not surprisingly, longer office hours for primary care doctors—that is, evenings and weekends—are another widely recognized prescription for fixing the ER crisis. Another is leaving more slots open for same-day appointments. "If doctors could do that at least during the flu season," says Susan Nedza, "it would help out a lot."

Specialists refuse to take ER call

Unavailable specialists represent yet another breakdown in the nation's ERs. ER doctor Loren Johnson recalls a patient he wasn't qualified to help—and how he couldn't find a doctor who was.

Several years ago, Johnson encountered an IV drug abuser whose arm was developing gangrene. Johnson needed an orthopedist to perform a fasciotomy, but the orthopedist on call refused to respond. Attempts to summon other orthopedists to the ER failed. "The woman died for want of a surgical procedure," says Johnson, who now works elsewhere.

What used to be, in Johnson's words, the "dirty little secret" of emergency medicine is now making headlines—patients here and there are dying because a specialist didn't come to the ER.

They especially won't come if taking ER call isn't a condition of hospital staff privileges. That's the case for 50 percent of California doctors. Of these, 40 percent have reduced ER call and another 20 percent have dropped it altogether, according to a CMA survey last year. Such numbers loom even larger given that dropouts are concentrated among specialties such as neurosurgery, orthopedics, plastic surgery, and others that come into play during trauma care.

Once again, the financial ills of the entire health care system enter the picture. In California, 55 percent of doctors reported they had difficulty getting paid more than half the time for on-call services.

Increasingly, specialists feel more freedom to detach from ERs because they're no longer a source of paying patients. And if taking ER call is a condition of belonging to the hospital staff—well, fine, doctors will abandon admitting privileges at selected hospitals to lessen their load. It's not a great loss for specialists who operate exclusively in their offices or ambulatory surgery centers.

The wear and tear of ER call also motivates doctors to cut back. "When you're on call, you usually don't get much sleep," says Lee Corwin, a neurologist in Plymouth, MA. "If this happens every third night and every third weekend, you're drained physically and emotionally. And the ER generates only 5 percent of my income." Accordingly, Corwin has pared back his ER coverage to one hospital.

EMTALA gives specialists a legal excuse to abandon ER work. The law requires on-call doctors to respond to emergencies promptly or risk a fine of up to $50,000. But what's a specialist to do if he's covering two hospitals the same night and each has a case for him at 11 pm? "Neurologists are resigning from hospital staffs because of EMTALA," says Pacific Palisades, CA, neurologist Marc R. Nuwer. "You can't be in two places at once."

What would get the specialists to come back? Some hospitals have resorted to paying key specialists as much as $2,000 a day for ER coverage, according to ER physician Michael B. Hill, president of a Richmond, CA, hospital redesign firm called EMPATH. "One California hospital that I consulted for was spending $5 million a year on ER call, " he says.

Most hospitals, of course, can't afford such heavy money. Even if they could, some doctors would still shun the ER for the sake of simplifying their professional lives, according to Hill.

What has to happen before we fix the ERs?

The dearth of specialists is just one more example of what ERs suffer from—every kind of shortage except a shortage of patients. So what's the cure? If Larry Ashby had to park his ambulance because resources were squeezed out of the health care system, then resources must be poured back in.

That's exactly what the ACEP proposes. Its long-term prescription for emergency medicine includes higher reimbursements to hospitals and doctors from federal and private payers, federal incentives for recruiting and training nurses, and universal health coverage. The ACEP recommends incremental steps toward universal coverage, including tax credits to small businesses and individuals buying health insurance and enrolling more people in Medicaid and State Children's Health Insurance Programs (SCHIPs).

Fixing the system will take a bundle of money, and a large portion must come from the federal government. But will—or can—Washington come through? Earlier this year, Congress was considering several bills that would have partially fulfilled the ACEP's wish list, but then came Sept. 11. Besides staggering an already-weakened economy, the disaster diverted Washington's attention from health care and redirected its spending priorities to national defense. Suddenly health legislation found itself on a back burner. "This is a debate for another day," acknowledged the AHA's Rick Wade.

However, the threat of continued terrorism may force Congress to heed the state of the ERs that must care for the victims, says Wade. "Our best hope is that Congress will tie emergency medicine into our overall public safety system, and improve its preparedness for handling disasters."

ER doctors make the same argument—ERs are as much a public service as police and fire departments, and therefore deserve the same taxpayer support. California ERs nearly got it. A bill in the state legislature this year would have given public-safety status—and $300 million—to ERs and trauma centers. However, the bill died in committee after the economic downturn and the state's electricity troubles made California lawmakers rein in their spending, says ACEP lobbyist James Randlett of Sacramento.

ER doctors worry that lawmakers and the general public won't get serious about solving the ER crisis until a spectacular mishap occurs—maybe the death of a celebrity in a diverted ambulance. "Access to ERs has to get worse before the urgency hits home," laments Susan Nedza. She likens emergency medicine to the proverbial canary in the coal mine that provided an early warning to poison gas—by perishing before miners did. "We're the canary of the health care system," says Nedza. "It's going to take a whole lot of canaries to die before anybody pays attention."

A Medical Economics Web Exclusive

Where doctors can–and do–help

By themselves, physicians may not be able to solve systemic problems that plague emergency rooms nationwide. But they can help make hospitals more efficient, whether patients are in the ER or on a regular floor.

Henry Medical Center in suburban Atlanta illustrates the point. The 124-bed hospital has strained to keep up with boomtown growth in Henry County, says emergency department director Sam Lorenzo. "Ambulance diversion isn’t a serious problem," he says, "but patients have waited as long as four hours to be treated in the ER, and we’ve kept them up to three days due to bed shortages."

Naturally, patients complain to anyone who will listen, including their doctors, says internist William Osborne, who, until July, had served as the hospital’s chief of staff. In 1998, the medical staff teamed up with administrators to form a task force to eliminate bottlenecks.

An obvious place to start was the ER. The task force discovered that a cumbersome registration process delayed triage for as long as an hour. "Now we triage them within 10 minutes and if need be, do the registration on the backend, sometimes at the bedside," says Osborne.

The hospital also sped up workflow by installing a pneumatic-tube system to shoot blood work to the hospital lab. And it began using beds in the facility’s ambulatory surgery area to handle ER overflow in the late afternoon and evening when ambulatory operations were finished for the day.

One solution involved the entire medical staff. Doctors used to refer patients to the ER if they learned that they couldn’t admit them as regular patients because no beds were available. Once in the ER, these patients might languish for 12 hours before a bed opened up. "We encouraged the medical staff to stop sending them to the ER, and if possible, delay the admission or try another hospital," says Osborne. "It took a couple of letters to get the point across, but we’ve seen change."

The task force also looked at how doctors could shorten hospital stays for their patients to free up beds for others admitted through the ER.

"We discovered that some doctors were slow to act on test results," says Osborne. "The results might come back in the morning, but doctors wouldn’t learn about them until early evening, perhaps because they rounded then," says Osborne. "Of course, the sooner you know the results, the sooner you can proceed to your next step in treatment. You might be able to discharge a patient in the early afternoon based on what you find out at 11 am."

Once outliers on the medical staff were apprised of these patterns, they developed new habits, such as rounding earlier in the day or calling the hospital more promptly about lab test results and X-ray reports. The hospital also made that information more accessible to everyone by posting it on a secure Web site.

The efficiency campaign is starting to pay off. Henry Medical Center has reduced the average ER stay from 3 hours and twenty minutes to 2 hours and 40 minutes since July 2000. And the length of the average hospital stay has dropped from 4.2 days to 4 days.

Hospital CEO Sam Ahern gives much of the credit for these initiatives to doctors such as Osborne and Lorenzo. "These improvements have occurred because the medical staff has pushed this harder than anybody else," says Ahern.

 

Robert Lowes. What will it take to solve the ER crisis? Medical Economics Dec. 3, 2001;78.