Emergency Rooms

Quality is too often Jan in the Brady Bunch of health reform issues. The media and public tend to focus on the Marcias of cost and the Cindys of coverage. But New America's Health Policy Program has been dedicated to promoting an informed discussion of the entire family of issues. Today's event (video here) helpedto illustrate that improving quality must be central to any sustainable health reform.

Christine Bechtel, Vice President of the National Partnership for Women and Families, began the discussion with a broad overview about why we care about quality and what we can do about it. Bechtel noted that we spend nearly $1.3 trillion dollars a year on health care, of which nearly 30 percent is wasted on poor-quality care. Medical errors are the eighth leading cause of death in the U.S. and, in general, patients have only a 50 percent chance of receiving the right care. Bechtel stressed the fact that issues of cost, coverage and quality are fundamentally related and must be addressed as a package.

Slate's Medical Examiner struck a chord examining the why people go to the E.R. when they shouldn't. It's the site's most emailed story this week, and begins the discussion by dispelling some conventional wisdom that it's only the supposed E.R. abuser clogging out system and raising our costs:

The oft-repeated claim is that if we can just find a way to get the abusers out of the E.R. waiting rooms, we'd eliminate many of the high costs associated with health care in the United States.

The problem is that this story of the healthy, cavalier, uninsured E.R. abuser is largely a myth. E.R. use by the uninsured is not wrecking health care. In fact, the uninsured don't even use the E.R. any more often than those with insurance do. And now, a new study shows that the increased use of the E.R. over the past decade (119 million U.S. visits in 2006, to be precise, compared with 67 million in 1996) is actually driven by more visits from insured, middle-class patients who usually get their care from a doctor's office. So, the real question is: Why is everybody, insured and uninsured, coming to the E.R. in droves? The answer is about economics. The ways in which health information is shared and incentives aligned, for both patients and doctors, are driving the uninsured and insured alike to line up in the E.R. for medical care.

It sounds like a nutritional supplement, the kind with whey protein and effectiveness measured in degrees of creatine. But the Inova HealthPlex—a freestanding emergency department in Franconia-Springfield, Virginia—may have an even more important formula: one for strengthening overburdened ERs.

Profiled in today's Washington Post, the HealthPlex treats some 33,000 patients a year, helping relieve the pressure on ERs in Inova's other hospitals. An average patient visit takes about two and half hours—close to half the average time for the ERs in the state of Virginia.

Its success can be attributed to how it processes patients as well as its unique position in the market.

We recently published an issue brief and blog posts (here, here, and here) on ambulance diversions. That's when your local emergency room is so crowded that it temporarily shuts its doors to more ambulance traffic and sends patients elsewhere. So we noticed when today's Boston Globe reported that Massachusetts has ordered its hospitals to stop the practice by January 1.

The state's director of healthcare safety and quality Paul Dreyer said ambulance diversions may give ERs momentary breathing room but it doesn't solve the underlying problem of crowded emergency departments with patients backed up in hallways waiting for an open bed in the hospital.

Last week we posted (here and here) about our new issue brief on ambulance diversions. Here are a few thoughts about what we can do to fix the problem, which is a threat to all of us, regardless of our wealth or insurance status. Shutting emergency departments, even briefly, to ambulance traffic is a a sign of the strain on our overall health care system.

One part of the solution is to set standard criteria for when a hospital can put itself on diversion. Criteria might include: percentage of hospital beds currently in use, the number of staff on duty, and the number of people in the ED waiting room. Hospital accountability for reporting and abiding by diversion standards could be tied to federal funding. For instance, failure to report diversion rates in a timely manner would jeopardize hospital funding. It would help if we could do a comprehensive national study to assess hospital capacity, and diversions' impact.

New America's Dr. Guy Clifton and Hannah Graff this week posted a new issue brief on ambulance diversions—when hospital Emergency Departments can't handle more patients and divert ambulances elsewhere. Yesterday we wrote about how common diversions are, and how they can affect anyone, regardless of whether they have good, bad or no health insurance. Today we'd like to talk about three reasons why diversions happen, and what they say about the troubled state of our health care system. If you've been following our earlier posts on emergency room crowding, you'll know that the problem is not just the uninsured.

Whether you are rich or poor, insured or uninsured, a savvy "health care consumer" or a blithely not-so-savvy one doesn't matter if you are lying critically ill or injured on an ambulance gurney and the nearest ER is on "diversion"—meaning temporarily closed to ambulance traffic and sending patients elsewhere. Dr. Guy Clifton and Hannah Graff, two members of our health policy team, have published a new issue brief explaining what ambulance diversions are, why you should care, and what we should do about it. We'll share the highlights in three blog posts from today through Monday.

When an ambulance is diverted from one hospital emergency department and sent to another, critical care can be delayed by precious minutes. A threat to both the insured and uninsured populations, diversions are also a barometer of how badly our struggling health system needs comprehensive reforms. Diversions are not an occasional problem, nor are they restricted to certain regions or types of hospitals. Every minute in the United States, an ambulance is diverted. In 2004, almost half of all hospitals and nearly 70 percent of urban hospitals reported at least some time on diversions. Diversions affect both people being rushed to the nearest hospital at the onset of a medical crisis, as well as those being transferred from one hospital to a larger or more specialized one that can deliver life-saving care.

Emergency physicians are chiming in about the comments by self-described McCain adviser John Goodman. As you probably heard, Goodman, president of the National Center for Policy Analysis in Dallas, told the Dallas Morning News last week that we don't have uninsured people because they can all get care in ERs. "The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American—even illegal aliens—as uninsured," Goodman said.

Now the American College of Emergency Physicians has shot back, the LA Times' health blog tells us. The group's president Dr. Linda Lawrence said:

Emergency physicians can and do perform miracles every day, but taking on the full-time medical care for 46 million uninsured Americans is one miracle even we cannot perform. Access to care in the emergency department is no substitute for the comprehensive healthcare reform policy that should be at the heart of the platform of any presidential campaign.

If you need to brush up on the lessons of supply and demand, U.S. emergency rooms provide an all too vivid example. Demand is up. Supply is down. The system is a mess.

Emergency room visits jumped more than 32 percent from 90.3 million in 1996 to 119 million in 2006, the most recent year statistics are available, according to the National Center for Health Statistics, a division of the CDC. About 13 percent of the patients get admitted to the hospital, meaning they are pretty sick. That proportion is pretty stable but the overall numbers are increasing. By 2006, more than half of all admitted patients had shown up first in the ER. That's a 36 percent increase since 1996, and it says a lot about the increasing problems people face in getting primary care.

And before you assume that this is the inevitable result of having 47 million uninsured Americans, think again. Increasingly, the ER patients are insured.

"There are more people arriving at the ERs. And there are fewer ERs," Dr. Stephen Pitts, author of the report and a CDC fellow who teaches emergency medicine at Emory University's School of Medicine was quoted by the AP as saying. The number of emergency departments fell from 4019 to 3833.

You've heard about "superbugs" causing infections in hospitals. Meet the "super-users" contributing to the crisis in emergency rooms.

The Newark Star-Ledger has an interesting, detailed article about repeat visitors to ERs, the so-called "super-users." Repeat users doesn't mean eight or ten visits a year. It means 100 visits, even 200 visits, or in at least one case in Camden, N.J. 314 visits.

Camden is a very poor city, with high rates of people who are uninsured or on Medicaid. But it is shaping up as a laboratory to study ways of fixing the costly national problem of emergency care. "Researchers say a seemingly intractable problem could be solved, in large part, by focusing on just the top one percent of emergency room users, who in Camden alone cost $46 million over five years," the article by Carol Ann Campbell says.