Emergency Rooms

HEALTH REFORM: A Day in the Life in an Emergency Room

Meredith Hughes — Tue, 08 Sep 2009 20:54:00 -0400

A day in a real hospital ER has as much drama, triumph, and heartbreak as any TV show. USA Today chronicled 24 hours at the University of Virginia Medical Center in Charlottesville, VA. They asked everyone -- patients, doctors and nurses, concerned family members, housekeeping staff -- to share their experiences with the health care system, and what they think about changing it. USA Today writes,

Their experiences and observations underscore why changing the health care system has proved so hard for presidents and policymakers: the complexity of the system, the pressure from chronic diseases, the shortfall in preventive care, the high costs, the competing demands -- and the life-or-death stakes.

Everyone agrees they want to preserve the quality and technological advances of American medicine...Beyond that, though, the consensus frays.

And the interviews the reporters conducted suggested that a lot of the misinformation spread about health reform this summer had gotten through.

Few of those interviewed in the ER have much idea of even the broad outlines of what's being considered in the House and Senate. In a sobering sign for Obama and congressional Democrats, what has broken through more clearly are warnings from opponents that congressional action is likely to raise their taxes, limit their choices, increase their waiting times and lead to "socialized medicine."

While 14-month-old Clara recovered in a hospital bed from a possible seizure, her mother, Tyler McNeely told USA Today the care her daughter received was great, and she worries that things might get worse if the health system changes.

University of Virginia freshmen Leilani Herzog and her mother Susan sought treatment at the ER for Leilani's sudden severe rash. They have an HMO back home in California, but can't yet access her "guest care" at a Virginia HMO. They "appreciate the savings," in their plan back home, but don't like the quality of care.

Last year, Susan diagnosed Leilani's sinus infection (which required surgery) by herself over the internet, she told USA Today. Susan wants low-income families to have health coverage, but worries a government-run plan would limit her choices, and raise her taxes. From the account in the newspaper, she did not seem to realize that health reform is not a "government-run plan." If the public option survives, it will be just that, an option.

Four in ten Americans visited the ER in past year, either for treatment or accompanying someone who needed treatment, reports USA Today. In just 24 hours, 197 patients came through the UVA Medical Center ER, surpassing the 59 bed capacity in the ER from about afternoon until midnight. Nurses like Judith Miller are used to working 12 to 16 hour shifts to deal with the short-staffing and the constant influx of patients. Miller told USA Today she was concerned health reform wouldn't save money, and wanted health professionals, not politicians, to have a greater say in legislation.

The ER treats everyone, regardless of ability to pay. "We cannot close. We cannot turn away. Whatever comes through that door, we have to care for," said nurse Jonathan Bartels. Dr. Robert O'Connor told USA Today he wishes the government would realize how strapped the hospital is for resources. The state of Virginia reimburses UVA Medical Center $70 million for uncompensated care, $10 million short of the actual cost.

When the uninsured and underinsured get sick, they often have no where else to go but the emergency room. Because they cannot afford to pay for treatment out of pocket, many wait until they become seriously ill before seeking treatment.

Robert Bowers, 22, is a landscaper who cannot get insurance through his job, and cannot afford $400 per month for individual coverage. He came into the ER for the first time in two years because of swelling in his jaw. The last time he saw a doctor he was in an emergency room seeking treatment for an ear infection, he told USA Today. What could be a simple prescription for antibiotics becomes costly and inefficient in an ER. Overcrowding forces patients to wait hours for care that is, typically, more expensive.Overcrowding is exacerbated by patients who have insurance, but can't get into their doctors as quickly as they want or need.

June Logan is a housekeeper in the UVA Medical Center. Logan told USA Today she lost her job and was uninsured before she came to work at the hospital, making it difficult for her to afford the medication she needed after her heart attack. She is relieved she once again has insurance -- not just for her own health, but for her invalid son, who is bed bound and needs frequent medical treatment.

Logan says she has hopes the changes to the health care system will improve the lives of people less fortunate than her. "I think they should push this new health care reform. There are so many people who come through here with no insurance. It can be overwhelming. They have no choice.

The emergency room is a great microcosm of the health care debate in general. The health care professionals in the ER do the best they can for their patients but are held back by limited resources. The ER gives amazing care that helps patients and saves lives, but at the same time, care is overly expensive and inefficiently delivered. Patients and doctors are dissatisfied with the current health care system, but are nervous about the consequences of change. Change is scary, of course, but the cost of doing nothing on health reform is scarier. Any doubts? One look around the emergency room should convince you.

HEALTH CARE: It's Child's Play

Joanne Kenen — Tue, 08 Sep 2009 15:30:00 -0400

As the Politico's Pulse told our Blackberry at 5:39 a.m, "Welcome to the first day of the rest of health reform's life."

Politico goes on to outline five keys for the weeks ahead, but we want to welcome you back with this:

Remember those Scholastic Books order forms from grade school? Well, they are online and up-to-date these days, filled not only with classic books that make kids fall in love with reading but with all sorts of kid versions of adult electronics. And there's this:

The catalogue copy for the ER Mania (special -- 25 percent off) says:

The E.R. is packed and the doctors are out golfing! Race against the clock treating 16 patients in more than 35 wacky levels -- everything from car accidents to tummy aches.

Skills: Problem Solving, Simulation

It promises to develop problem solving and simulation skills. And the pathetic thing is no matter how ridiculous this is, it's better than half of what was said about health reform this summer...

COST: Emergency Room Utilization on the Rise

Meredith Hughes — Mon, 13 Jul 2009 22:02:00 -0400

Americans are still feeling the effects of the recent economic recession. Many who have lost their jobs have also lost their health care coverage, leaving hospital emergency rooms inundated with people seeking care, according to the Washington Post.

This year, DC's Providence Hospital reported emergency room visits increased by 13 percent. Larry Gage, president of the National Association of Public Hospitals and Health Systems, told the Post, "The absolute number of people using emergency rooms has gone up as much as 20 to 30 percent in the last six to eight months due to the recession and people losing their jobs. The only option in their minds is going to the hospital."

This trend is visible not just in DC and the surrounding area, as the Post reports, but across the nation. Back in April, the American Hospital Association reported that approximately 60 percent of hospitals were seeing more uninsured patients in their ERs, and 70 percent of hospitals were seeing higher rates of uncompensated care.

The problem with emergency room care, as we've discussed before, is that an ER is not a good substitute for primary care. The ER is just that -- a place for emergencies. And emergency treatment is far more costly than simple preventative measures. Additionally, hospitals have no way to provide emergency care for free -- it, like all other care, costs money. The cost of ER care for uninsured patients doesn't disappear. Uninsured patients often are billed directly for treatment but are unlikely to have the ability to pay. This cost strains hospital budgets and can be indirectly shifted onto families and individuals that do have insurance coverage in a "hidden tax" of higher premiums (Most estimates put the hidden tax somewhere between $1,000 and $1,300)

"I'm hearing a lot of people say: ‘Please help me. I lost my job,'" Raolat Abdulai, director of Howard's free clinic, told the Post. "It just shows how desperate things are right now. People really need health care."

An alternative to emergency room care, regardless of insurance status, is a community health clinic. The Post reports that community clinic utilization in Montgomery County has also increased recently, up by 43 percent in the past year. We've argued many times that wellness and preventive care saves money and improves patient health, something which is especially true for the uninsured who seek care in emergency rooms. Many community health centers have received federal stimulus funds, in hopes of expanding their outreach to more patients.

Albertha Boone, a DC resident, suffers from asthma, high blood pressure, and needs knee surgery, but she is unable to afford health insurance and relies on ER visits and over the counter medication to manage her conditions. Rather than seek emergency room care, Boone would probably benefit greatly from visits to a community health clinic. Instead of waiting for her hypertension to grow into something more serious (such as a stroke), she could receive check-ups from a primary care doctor and prescription medications that would allow her to manage her condition.

As we follow the health care debate, (and we know it's easy to get caught up in the drama of DC) it's important to remember why we're having this debate in the first place. Most Americans are not getting the care they need and deserve from our health care system. When we talk about fixing the health care system, we're talking about everything that goes into that conversation -- bringing down costs, improving quality, and making sure that everyone has sustainable, affordable coverage. It won't be easy, but it is necessary.

HEALTH CARE: If This Is An Emergency, Please Press "Can't Afford It"

Joanne Kenen — Wed, 13 May 2009 19:11:00 -0400

Imagine being sick enough or hurt enough to rush to an emergency room—and then leaving without getting the recommended tests or treatment because you can't afford it.

Doctors have a name for those discharges—"Against Medical Advice." It seems to be happening more often, both in the ER and in the rest of the hospital as health costs rise and insurance coverage falls.

MSNBC interviewed several doctors and patients about how the economy is affecting emergency care. A patient with acute appendicitis needing emergency surgery who waited for his mother to drive him to the hospital so he wouldn't have to pay for an ambulance. A patient with an infected kidney stone. People with chest pains who were not in the throes of a life-threatening heart attack that very minute but who couldn't or wouldn't follow up to find out what the pains signaled. A 31 year old knocked unconscious in a bike crash, who asked about the cost of the recommended follow up, only to be told by the ER doctor, that she was "a physician, not an accountant." Declining treatment, he still got a $600 bill.

"I have definitely seen an increase in this problem," said Dr. Sara L. Laskey, who works in the emergency department of MetroHealth Medical Center in Cleveland, Ohio. "They're really making conscious decisions about what they do and don't want done."

Just last month, Laskey saw a woman with bronchitis and pneumonia with life-threatening oxygen levels who refused hospital admission because she had no insurance. Even when Laskey arranged for her to have an oxygen kit to take home, the woman turned it down because of the cost.

"She refused, saying she would share her husband's oxygen," Laskey said. "Ultimately she left without the oxygen or an admission."

In 2006, only about 1.3 percent of the nearly 120 million emergency room visits were categorized as discharges against medical advice. But that's still 1.5 million people. And that was before the recession. Doctors told MSNBC that they believe the numbers are under-reported, and growing.

This of course doesn't mean that every patient who ends up in the ER has a life-threatening condition; we've often written that ER crowding reflects the gaps in our primary care system. Nor does it mean that ER physicians should automatically order boatloads of tests without considering how much they cost, or whether all the tests are really needed or even advisable. "Testing is out of control," said Dr. Jeffrey Sankoff, who works in the emergency department at the Denver Health Medical Center in Colorado. "I think it's good we're having those conversations about risks and benefits."

But not getting tests and treatments that are necessary in an emergency isn't exactly smart either. Particularly if you are at risk—as some of these patients are—of ending up back in the hospital, even sicker, facing even bigger bills.

One of the myths you hear from foes of health reform is that anyone can show up in an emergency room and get care. he law, in fact, states that ERs must screen and stabilize patients. It doesn't mean that the care is free. Or affordable. Or that they get the follow up care that they need to get well or stay well. And you also hear that patients (or "health care consumers") will make smarter decisions if their own money is at stake. Not true. Not if they don't have money.

COVERAGE: The Pandemic Motivator

Joanne Kenen — Thu, 30 Apr 2009 17:39:00 -0400

We write all the time about the economic and moral imperative for covering all Americans. Today, we'd like to address the public-health we're-all-in-it-together pandemic flu imperative for covering all Americans.

We don't yet know how bad the outbreak will become, and it goes without saying that along with everyone else on the planet, we hope it is mild. But the fact that we have 46 million (probably more given the recession) people who are uninsured and don't have easy access to care, outside the emergency room, is making us nervous. The border States have particularly high rates of insurance. One-in-four Texans lack insurance, nearly as many New Mexicans, one-in-five Arizonan s and Californians, (and that's 2007 data, it may well be higher now). And think about all the people who do have some insurance but may still postpone going to the doctor because they have a bare bones or high-deductible insurance policy. Times are tough, and they'll try to ride it out because they can't afford the co-pay or deductible. Delayed care can mean more serious illness—and more spread of disease.

We know we don't have a good enough primary care system in this country, and people are going to flock to emergency rooms in an epidemic or a pandemic. But think of how much WORSE that could be because people are already flocking to overcrowded emergency rooms because they don't have any place else to go. And we wonder, are our ultra-specialized specialists going to help take care of flu patients? Will they know how? Maybe the answer to this is some part of an emergency plan we haven't read yet. Comment, please, if you know—and no, we don't mean specialists are heartless or don't care about patients, we just don't know how well someone who's only done cornea transplants or rotator cuff surgery for 30 years can deal with patients with severe respiratory distress. We did see that AHRQ has resources for hospitals to plan surge capacity and to train more non-respiratory therapists to run respirators, and USA Today reported that many communities are activating their emergency plans.

Then there's the whole sick pay problem. President Obama told us to stay home if we're sick, and think about what to do if our kids' schools close. That's easy enough for those of us who can telecommute or who have paid sick days. But as our colleague, Julie Barnes, pointed out long before the current flu outbreak, we don't all have paid sick days. Or paid days to take care of sick kids. As the National Partnership on Women and Families has reminded us, nearly half the private sector workers don't have paid sick leave, and nearly 100 million workers don't have a paid sick day they can use to care for a sick child.

We know that in the past few years (partly because Sen. Edward Kennedy and former Sen. Bill Frist, who wisely seized a bipartisan post-anthrax moment and figured out how to use bio-terror defense legislation to beef up the weakened public health infrastructure for natural disease outbreaks as well, and partly because of the response to SARS and bird flu) we began improving public health capacity that had severely eroded. But the recession has taken its toll, draining "hundreds of millions of dollars and thousands of workers from the state and local health departments" the New York Times reports.

We know that some of the response to a severe flu outbreak will be via public health channels and emergency capacity and clinics, not through our everyday health infrastructure. (And the emergency response is going to have to take illegal immigrants—the third rail of health politics—into account, because no matter what you think about our nation's immigration policy, having an untreated contagious disease among illegal immigrants isn't good for any of us) But a public health crisis superimposed on a tattered health safety net and a broken delivery system makes the job harder. Even if this flu is contained, or turns out to be relatively mild, there will be another crisis. And another one after that. So reforming health care and covering everyone isn't just the morally correct and economically sensible thing to do. It's the self-interested healthy thing to do. So let's do it.

COST: Hospitals Hurting in Economic Downturn

Paul Testa — Tue, 28 Apr 2009 15:23:00 -0400

Long considered a recession-proof industry, hospitals have been increasingly hard hit by the economic downturn. That isn't good for the quality of health care. And it's another blow to local communities, where hospitals are often major employers.

In a country where losing your job very often means losing your health insurance, more Americans are delaying basic and necessary medical care. When they can wait no longer, too often they enter the health care system through the doors of the ER.

A new survey released Monday by the American Hospital Association captures these trends. The majority of hospitals report fewer patients are seeking inpatient and elective care. At the same time six out of ten hospitals report seeing a greater proportion of patients without insurance coming through their emergency departments and 70 percent report increasing rates of uncompensated care. (See chart below.) Those costs are made up, in part, by charging higher rates to insured patients.

"[P]eople put off care when they lose their job, which can complicate health care issues for many down the road," said AHA President and CEO Rich Umbdenstock in a press release. At the AHA conference where the report was released, Nancy-Ann DeParle, director of the White House Office of Health Reform, told listeners, "Across the country, the American people are demanding healthcare reform and refusing to accept more of the same."

Health care has been one of the few areas of job growth during the recession. That too may be ending. Hospital operating margins have decreased and nearly half of all hospitals surveyed had reduced staff to meet economic challenges. Such cuts impact both the health of our communities and the health of our economy. Health care spending accounts about one sixth of our nation's GDP with hospital spending accounting for close to one third of that. In many communities, as Jane Sarasohn-Kahn notes, "hospitals are in the top tier of the largest employers." The plight of hospitals during this economic downturn—made worse by the growing number of uninsured—should serve to further illustrate rebuilding our economy will require reforming health care.

QUALITY: Seniors Get Special ER Unit at Maryland Hospital

Joanne Kenen — Tue, 27 Jan 2009 17:50:00 -0500

Holy Cross Hospital, just outside Washington, has created a special emergency room section for older patients, complete with staff trained in geriatrics and communication, wooden handrails for safe walking, comfy chairs for family members, and extra thick ER mattresses designed to protect the fragile skin of the elderly against fast-developing bedsores.

Hospital CEO Kevin Sexton got the idea after, what else, a stressed out phone call from his elderly mom in a New Jersey emergency room. "It was the combination of her being there quite some time and it being very crowded and chaotic. It came to me we really do treat seniors poorly in that setting," he told the Washington Post. Developed with the assistance of outside experts on aging, there is apparently only one similar program in the country.

Elderly patients with traumatic injuries or acute crises (i.e. car crashes or heart attacks) will go into the regular ER, but most elderly patients seek emergency treatment because of pain, falls, or problems related to chronic conditions. They will be steered to the special seniors section.

The article focused on stress reduction and comforts, but the care model also has implications for better outcomes, even beyond those extra precautions about falls and bed sores (which can be very dangerous).

Once the patient is stable, nurses screen for cognitive loss, depression, possible interactions from taking multiple medications, and alcohol and drug use. They also perform a risk assessment for falls, neglect or abuse. Those who test positive in any of these areas are referred to community resources and receive a follow-up call from a geriatric nurse practitioner or social worker.

We've been doing some reporting recently on the high risk the elderly have on ending up back in the hospital after one ER trip so this screening, coordination and follow up may prevent or minimize that revolving door. That saves money, and it's much, much better for the patient. It will be interesting to see how this program evolves—anecdotally the patients and family members in the Post story were quite pleased— and whether other hospitals develop similar strategies for the aging population.

QUALITY: Poor Marks for Nation's ERs

Paul Testa — Fri, 12 Dec 2008 19:25:00 -0500

The good news is, none of you failed. The bad news is most of you did pretty terribly.

We had flashbacks to our own collegiate career when the American College of Emergency Physicians released its National Report Card on the State of Emergency Medicine this week. (Executive Summary here, overall results here.)

Overall the U.S. earned average grade of C- reflecting performance on these five categories:

Access to Emergency Care: D-
Quality and Patient Safety Environment: C+
Medical Liability Environment: C-
Public Health and Injury Prevention: C
Disaster Preparedness: C+

The D- in access to emergency care is particularly troubling with 12 states receiving a failing grade (see map below).

ACEP summarizes the situation well, saying:

The nation has too few emergency departments to meet the needs of a growing and aging population. Over the past decade, the number of patients coming to the nation's emergency departments annually has increased 32 percent, from 90.3 million to 119.2 million. At the same time, the number of hospital emergency departments has dropped nearly 7 percent, from 4,109 to 3,833. In addition, shortages of health care professionals at multiple levels--nurses, primary care physicians, emergency physicians, and other specialists--also jeopardize access to quality emergency care.

One way out of this mess of course could be grade inflation. But we can think of a lot better ways to solve the problem. Better management of hospital beds, admissions and discharges. Getting everyone insured so they don't turn to the ER for care. Prevention and chronic disease management, meaning fewer crises requiring emergency intervention. More access to primary care. You've heard it before — learn more here.

QUALITY: Another Look at the ER Crowding Challenge

Joanne Kenen — Wed, 22 Oct 2008 16:18:00 -0400

More evidence that it's not just the uninsured clogging up our ERs. It's the whole flawed health care system clogging up the ERs.

A study in the Journal of the American Medical Association, described in USA Today, shows that emergency room crowding has multiple causes. Yes the uninsured are part of the problem, and in some cities they are a big part of the problem, but typically the uninsured try to avoid ERs because they are so expensive.

"There's a myth that the emergency department provides free care," JAMA co-author Manya Newton, an ER physician at the University of Michigan, told the newspaper. "Yes, we see anyone who shows up at the door, but when we see you, we will send you a bill. The uninsured don't want to pay thousands of dollars to come in for the sniffles." In fact, the study found that a higher proportion of people with public insurance including Medicare and Medicaid are more likely to use the emergency room. (Medicare patients are of course age 65 and older, or disabled, and naturally the aging population is more likely to get sick than the young and healthier population. But good primary care, chronic disease management and advanced care planning reduce ER use even amongst older and frailer patients.)

As readers of our blog know, other reasons for emergency room crowding are lack of access to primary care doctors (particularly during off hours). "We need to strengthen access to care in the community, regardless of what type of insurance people have," Ann O'Malley of the Center for Health System Change said. "It's misdirected to make the uninsured the bad guys."

Researchers have also identified "patient flow" as an ER chokepoint. That refers to the the process of admitting and releasing other patients in the hospital, making room for folks who need to be admitted from the Emergency Department. If there's no bed, patients wait in the ER, which in turns adds to the ER crowding, wait time and backlog. A shortage of psychiatric beds is also a factor.

QUALITY: The View From the Emergency Room

Joanne Kenen — Tue, 14 Oct 2008 19:16:00 -0400

We posted recently about a New America event on health care quality, but we wanted to highlight in more detail some of the points made by one of our speakers, Brent Asplin, MD, MPH. Dr. Asplin is the head of emergency medicine at Regions Hospital in St Paul. Minn, and he talked about what the quality challenges look like from the ER. He called the ER, "a room with a view," and noted, "If there's a problem with quality or access in your community, you will see it first in the ER." US ERs get about 115 million visits a year, he said. Behind that number are 115 million individual patient stories.

There's a common perception that the ER crisis is largely due to the uninsured who have no place else to go. There's an element of truth in that; the uninsured are a burden on the ER. But that's just one of many problems—lack of access to primary care, poor management of chronic disease, shrinking numbers of ER beds, and inefficient "flow," meaning if that beds aren't freed up efficiently in the rest of the hospital, patients needing admission pile up in the ER.

Some of this should be familiar to our readers by now. But one point Dr. Asplin stressed that was new to us was the shortage of psychiatric beds. I had seen this first hand when I visited hospitals in New Orleans after Katrina, but I hadn't realized it was reaching crisis proportions even in states like Minnesota, where health care overall is pretty good. After hearing Dr. Asplin discuss this, I tracked down a report by the American College of Emergency Physicians last June that found that psychiatric patients waiting twice as long as other patients. Often they are getting little or no psychiatric care while they wait. Our mental health infracture is too weak, and our ERs are too overwhelmed to fill in the gaps.

Dr. Asplin told us about a depressed, suicidal 72-year-old patient with multiple medical problems who was at the ER when Dr. Asplin arrived at 8:30 a.m. on a Saturday. He was still waiting for a bed at 4:30 that afternoon, when Dr. Aplin left. And he was still waiting when Dr. Asplin returned to work on Sunday. And on Tuesday. He ultimately spent 75 hours in the emergency department waiting for a psych bed. (Asplin remembers too that this occurred precisely as some Institute for Healthcare Improvement experts were at Regions that very day helping them address their patient flow problem...)

Dr. Asplin maintains that we can and should be able to improve emergency departments through some internal changes in hospitals—his own hospitals is already working on patient flow and related problems that lead to the crowding that concerns him every time he looks up at the board and sees how many patients are waiting for a hospital bed and how long they have been waiting. But the big fix for ERs nationally needs a big fix for the health care system as a whole—how we cover people, how we pay for care, how we treat patients. Dr. Asplin wishes we had health care counterpart to the NIH—a National Institute on Health Care Delivery. And he supports health reform proposals that change the payment and delivery systems, so that we pay for good care, not just lots of care, and can reward doctors who effectively manage high-cost patients. He's happy to see them in his ER when they belong there. But he'd rather that we have a health care system that keeps them healthy outside of the hospital, outside the ER, when they don't.