Uninsured Patients, Few Beds Keep ERs Maxed Out

Dr. Art Kellerman Speaking at a press conference in Washington

Speaking at a press conference in Washington D.C., Dr. Art Kellerman explains the problem of overburdened emergency departments. Jeremy VanderKnyff, NPR hide caption

itoggle caption Jeremy VanderKnyff, NPR

Why is it that you almost always have to wait when you go to a hospital emergency room? For some people, the wait can even be as long as two days, according to a new report issued by the Institute of Medicine.

ERs in Crisis

Scroll down for key findings from a report on the state of the nation's emergency rooms, by the Institute of Medicine.

A night with the doctors at Grady Memorial Hospital's emergency room in downtown Atlanta, Ga., reveals a lot about what's causing the problems.

"I'd estimate we probably have 80 to 86 people out here right now spread out among the benches, says Dr. Arthur Kellerman. "The earliest check-in we have at this point was 10 hours ago."

Kellerman is chairman of emergency medicine at Emory University School of Medicine. He also practices at Grady, and if anyone knows how to negotiate an emergency room, it's Kellerman.

At the ER, Be Honest and Assertive

"First thing, it's important to tell the triage nurse and the staff exactly what your problem is," he says. "Be honest, be truthful, be factual. That's the best insurance you have that the nurse and the doctor on duty will make the right decisions and get you into the queue in the proper way and as fast as possible."

But if your wait turns into many hours, or even all night, Kellerman says it's OK at that point to be politely assertive.

"It is very appropriate to go back to the nurse and say, 'I'm feeling worse, or something is going on, or have they forgotten about me? My name is Jones, could you please check and see where I am in the queue?'"

Kellerman in his white coat is something of a target in this waiting room. He's 6-foot-2, and people grab at his sleeve as he walks by.

He kneels to talk to some of them to get a sense of how long they've been waiting. The reason for the backup in the waiting room can be found through the swinging metal doors around the corner.

Beyond the waiting room and in the main emergency department, there are even more patients. Sitting on chairs or lying on gurneys in rooms and in the hall.

Kellerman checks with the charge nurse to see whether any space is available. She tells him there are no vacant beds; all of the resources of the emergency department are occupied.

After-Hours Back Up in the ER

It's 10 p.m. and about two-thirds of Atlanta hospitals have closed or partly closed their emergency rooms, which means despite the crowding here, more ambulances are coming to Grady Memorial.

One reason his emergency room is backing up, Kellerman says, is that few beds in the main part of the hospital open up at night. So when a patient is stabilized in the ER, there aren't any beds in other departments to move the patient to.

Upstairs, surgeon Grace Rozycki in the Intensive Care Unit says she has the same problem Kellerman has. Her 50 beds are almost always full, and so are her spillover beds.

"There is no place else to put them," says Rozycki, "and while we're waiting for beds to open, the patients have to wait downstairs in the emergency department. So we have a very sub-optimal situation, not infrequently, but rather frequently. This is a crisis."

Uninsured Patients a Strain on the System

The emergency department is losing money in no small part because it's seeing more uninsured patients. Hospital officials are reluctant to open more beds in other parts of the hospital because they say they can't afford to keep nurses and doctors on-hand to service what might sometimes be empty beds.

And so the emergency department gets backed up, especially at night, forcing people to wait.

To limit the wait, Grady has set up a fast track for people who aren't likely to need a bed after they've been treated. But even that unit is backed up. People without a primary doctor or without insurance fill this part of the ER every night.

As it gets later, the crowding eases a little. But Kellerman is worried by the fact that many evenings are so busy.

Who to Turn to When the ER is in Crisis

"If we're struggling to deal with tonight's 911 calls in city after city across the United States, how in the world are we supposed to handle an epidemic of pandemic flu or a major terrorist attack or the next natural disaster?" he asks.

And because the ER is so often crowded, he worries that some night, he and his overworked staff may not notice the beginnings of a heart attack in someone waiting on a gurney in the back hallway.

"When I come to work, as I get ready to leave my driveway, I say, 'Dear Lord, help me not to make a mistake tonight,'" he says. "And when I leave the hospital, I say, 'Dear God, thank you for getting me and my patients through another night.'"

As Kellerman pulls out of the parking lot, you can see the blue and white bumper sticker on the back of his car. It reads, "If I'm injured in a crash, take me to Grady."

Reports: U.S. Emergency Care Overloaded

Ambulance

The reports find that while emergency departments are on the decline, demand for emergency care is rising quickly. IStockPhoto hide caption

itoggle caption IStockPhoto

A series of three reports from the Institute of Medicine describe the nation's emergency medical system as "overburdened, under-funded, and highly fragmented." Among the findings: Some patients may have to wait in the ER for up to 48 hours before they can get admitted to the hospital — because the beds are full.

Read results and recommendations from the reports, published by the National Academy of Sciences.

KEY FINDINGS

• Many emergency departments (ED) and trauma centers are crowded. Demand for emergency care has been growing fast; ED visits grew by 26 percent between 1993 and 2003.

• But over the same period, the number of EDs declined by 425, and the number of hospital beds declined by 198,000.

• ED crowding is a hospitalwide problem. Patients back up in the ED because they cannot get admitted to inpatient beds.

• As a result, patients are often "boarded" — held in the ED until an inpatient bed becomes available — for 48 hours or more.

• Also, ambulances are frequently diverted from crowded EDs to other hospitals that may be farther away and may not have optimal services. In 2003, ambulances were diverted 501,000 times — an average of once every minute.

Emergency care is highly fragmented.

• Emergency Medical Services (EMS) agencies do not effectively coordinate EMS services with EDs and trauma centers. As a result, the regional flow of patients is poorly managed, leaving some EDs empty and others crowded.

• EMS agencies do not communicate effectively with public safety agencies and public health departments — they often operate on different radio frequencies and lack common procedures for emergencies.

• There are no nationwide standards for the training and certification of EMS personnel.

• Federal responsibility for oversight of the emergency and trauma care system is scattered across multiple agencies.

Critical specialists are often unavailable to provide emergency and trauma care.

• Three-quarters of hospitals report difficulty finding specialists to take emergency and trauma calls.

• On-call specialists often treat emergency patients without compensation because many emergency patients do not have health insurance.

• These specialists also face higher medical liability exposure than those who do not provide on-call coverage.

The emergency care system is ill-prepared to handle a major disaster.

• With many EDs at or over capacity, there is little surge capacity for a major event, whether it takes the form of a natural disaster, disease outbreak, or terrorist attack.

• EMS received only 4 percent of Department of Homeland Security first-responder funding in 2002 and 2003.

• Emergency Medical Technicians in non-fire based services have received an average of less than one hour of training in disaster response.

• Both hospital and EMS personnel lack personal protective equipment needed to effectively respond to chemical, biological, or nuclear threats.

EMS and EDs are not well equipped to handle pediatric care.

• Most children don’t receive emergency care in children’s hospitals but in general hospitals, which are less likely to have pediatric expertise, equipment, and policies in place for the care of children.

• Children make up 27 percent of all ED visits, but only 6 percent of EDs in the United States have all of the necessary supplies for pediatric emergencies.

• Many drugs and medical devices have not been adequately tested on, or dosed properly for, children.

• Disaster planning has largely overlooked the needs of children, even though they have increased vulnerability to disasters; for example, children have less fluid reserve, which leads to rapid dehydration.

Recommendations:

Create a coordinated, regionalized, accountable system.

• The emergency care system of the future should be one in which all participants (from 911 to ambulances to EDs) fully coordinate their activities and integrate communications to ensure seamless emergency and trauma services for the patient.

• Congress should enact a demonstration program ($88 million over 5 years) to encourage states to identify and test alternative strategies for achieving the vision.

• The federal government should support the development of national standards for: emergency care performance measurement; categorization of all emergency care facilities; and protocols for the treatment, triage, and transport of prehospital patients.

Create a lead agency.

• The federal government should consolidate functions related to emergency care that are currently scattered among multiple agencies into a single agency in the Department of Health and Human Services (DHHS).

End ED boarding and diversion.

• Hospitals should reduce crowding by improving hospital efficiency and patient flow, and using operational management methods and information technologies.

• The Joint Commission on the Accreditation of Healthcare Organizations should reinstate strong standards for ED boarding and diversion.

• The Centers for Medicare and Medicaid Services should develop payment and other incentives to discourage boarding and diversion.

Increase funding for emergency care.

• Congress should appropriate $50 million for hospitals that provide large amounts of uncompensated emergency and trauma care.

• Funding should be increased for the emergency medical component of preparedness — both EMS and hospital-based — especially for personal protective equipment, training, and planning.

Enhance emergency care research.

• Federal agencies should target additional research funding to prehospital emergency care services and pediatric emergency care.

• DHHS should conduct a study of the research needs and gaps in emergency care, and determine the best strategy for closing the gaps, which may include a center or institute for emergency care research.

Promote EMS work force standards.

• States should strengthen the EMS work force by: requiring national accreditation of paramedic-education programs, accepting national certification for state licensure, and adopting common EMS certification levels.

Enhance pediatric presence throughout emergency care.

• EDs and EMS agencies should have pediatric coordinators to ensure appropriate equipment, training, and services for children.

• Pediatric concerns should be explicit in disaster planning.

• Increase research to determine the appropriateness of many medical treatments, medications, and medical technologies for the care of children.

• Congress should increase funding for the federal Emergency Medical Services for Children Program to $37.5 million per year for 5 years.

Source: Future of Emergency Care report series, 2006, from the Institute of Medicine

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