Emergency Rooms

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

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.

HEALTH CARE: It's Child's Play

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

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.

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

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."

COVERAGE: The Pandemic Motivator

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 Arizonans 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. 

COST: Hospitals Hurting in Economic Downturn

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."



QUALITY: Seniors Get Special ER Unit at Maryland Hospital

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).

QUALITY: Poor Marks for Nation's ERs

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:

QUALITY: Another Look at the ER Crowding Challenge

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.

QUALITY: The View From the Emergency Room

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.