State of emer­gency

ER vis­its up as short­ages in ser­vices, staffing loom

Modern Healthcare - - THE WEEK IN HEALTHCARE - An­dis Robeznieks

It’s be­com­ing a real emer­gency. The Cen­ters for Dis­ease Con­trol and Pre­ven­tion re­leased new sta­tis­tics that con­firmed what most hos­pi­tals al­ready knew: Emer­gency room vis­its are in­creas­ing at a rapid pace. When these sta­tis­tics are cou­pled with other fac­tors, such as fewer hos­pi­tals of­fer­ing emer­gency ser­vices and loom­ing staffing short­ages, ex­perts are in­creas­ingly con­cerned.

Ac­cord­ing to the new CDC es­ti­mates, vis­its to hos­pi­tal emer­gency de­part­ments in­creased to an all-time high of 136 mil­lion in 2009, and this rep­re­sents al­most a 10% in­crease from the 2008 fig­ure of 123.8 mil­lion.

“If you ask if I’m op­ti­mistic in the long run, I’d have to say I’m not,” said Dr. Robert Wears, a pa­tient-safety ad­vo­cate and an emer­gency medicine physi­cian and pro­fes­sor at the Univer­sity of Florida at Jack­sonville. “The pop­u­la­tion is go­ing up, the pop­u­la­tion is get­ting older and the in­ten­sity of care that’s needed is go­ing up, but the real kicker is the num­ber of nurses is go­ing down. This looks like a per­fect storm to me.”

Wears, who is on the board of the Emer­gency Medicine Pa­tient Safety Foun­da­tion, said the best so­lu­tion seems to be “eat right, get plenty of sleep and ex­er­cise, and wear your seat belt, be­cause the out­look doesn’t look good un­less we re­solve these prob­lems.”

With fewer hos­pi­tals of­fer­ing emer­gency care, “the de­gree of busy­ness is go­ing up,” said Dr. Robert Shesser, an ac­tive mem­ber of the Amer­i­can Col­lege of Emer­gency Physi­cians and chair­man of the depart­ment of emer­gency medicine at the Ge­orge Washington Univer­sity School of Pub­lic Health and Health Ser­vices in Washington. “Crowd­ing com­pro­mises safety, and it cer­tainly com­pro­mises sat­is­fac­tion,” Shesser said. “Hos­pi­tals aren’t ho­tels. They can’t say, ‘You have to be out by 11 or we’ll charge your credit card.’”

The most com­mon rea­sons for vis­it­ing an ER, ac­cord­ing to the CDC data, in­cluded stom­ach and ab­dom­i­nal pain (9.6 mil­lion); fever (7.4 mil­lion); chest pain (7.2 mil­lion); cough (4.7 mil­lion); headache (4 mil­lion); short­ness of breath (3.7 mil­lion); and back symp­toms (3.7 mil­lion).

The ex­pected sources of pay­ment for those vis­its were pri­vate in­sur­ance, 39%; Med­i­caid or State Chil­dren’s Health In­sur­ance Pro­gram, 29%; Medi­care, 17%; and no in­sur­ance, 19%. (Numbers are higher than 100% be­cause some pa­tients had mul­ti­ple sources of pay­ment.)

“One big mis­con­cep­tion is that ER crowd­ing is a re­sult of peo­ple with­out in­sur­ance us­ing emer­gency ser­vices in­ap­pro­pri­ately,” Shesser said. “Uti­liza­tion is pretty broad across so­ci­ety.”

Both Shesser and Wears said part of the in­crease is a re­sult of the modern de­mand for in­stant ser­vice. De­spite the crowds and wait times, “EDs of­fer con­ve­nience,” Wears said, as well as an im­me­di­ate di­ag­no­sis and treat­ment.

Ur­gent-care cen­ters, where mi­nor prob­lems are treated dur­ing off hours when most doc­tors’ of­fices are closed, are seen as ER al­ter­na­tives and a so­lu­tion to ER crowd­ing, but it may not be work­ing. Amer­i­can Hos­pi­tal As­so­ci­a­tion sta­tis­tics are hard to in­ter­pret be­cause more hos­pi­tals par­tic­i­pated in the sur­vey in 2008 than in 2009, so a smaller num­ber of hos­pi­tals of­fered ur­gent care but a big­ger per­cent­age. In 2008, 974 (23.3%) of the 4,186 com­mu­nity hos­pi­tals sur­veyed of­fered ur­gent care. In 2009, 960 (23.5%) of 4,086 in­sti­tu­tions sur­veyed had ur­gent care.

St. Fran­cis Med­i­cal Cen­ter in Cape Gi­rardeau, Mo., has seen a 3.1% in­crease in emer­gency depart­ment vol­ume for fis­cal 2011 (which ended June 30), with 35,000 vis­its. Mar­i­lyn Cur­tis, vice pres­i­dent of pro­fes­sional ser­vices at the 258-bed hos­pi­tal, said a 7% in­crease was pro­jected for fis­cal 2012. Of­fi­cials now be­lieve that num­ber could be even higher.

St. Fran­cis has a seen a “ very slight de­crease” in the num­ber of pa­tients seek­ing con­ve­nient care in the ER since it opened three ur­gent-care cen­ters, Cur­tis said in an e-mail. “The dan­ger of us­ing the emer­gency room as a pri­mary-care re­source is that while pa­tients re­ceive ex­cel­lent care, it of­fers no con­ti­nu­ity or pre­ven­tive care.”

In Fe­bru­ary, St. Fran­cis opened a $12 mil­lion emer­gency and trauma cen­ter that added 30,000 square feet to the ex­ist­ing 11,600square-foot fa­cil­ity. Cur­tis said physi­cian and staff sug­ges­tions were in­cor­po­rated into the de­sign to im­prove pa­tient flow, pa­tient safety and staff ef­fi­ciency.

In Seat­tle, a grand open­ing cer­e­mony was held Oct. 22 for the new emer­gency depart­ment at 247-bed Vir­ginia Ma­son Med­i­cal Cen­ter, with the first pa­tients ex­pected Nov. 2. Vir­ginia Ma­son trimmed the num­ber of treat­ment rooms to 17 from 22 in the old fa­cil­ity, em­pha­siz­ing ef­fi­ciency in the de­sign. An ad­ja­cent unit was built to han­dle less-acute pa­tients de­signed to re­duce de­lays for pa­tients with more emer­gent prob­lems.

Hos­pi­tals also are test­ing less cap­i­tal-in­ten­sive ap­proaches to the prob­lem.

At four Se­ton Health­care Fam­ily hos­pi­tals in and around Austin, Texas, the Se­ web­site al­lows pa­tients with mi­nor emer­gen­cies to pay a $4.99 fee and des­ig­nate their ar­rival time at the emer­gency depart­ment. If these pa­tients are not seen within 15 min­utes of ar­riv­ing, the fee is re­funded.

An­other way to ease crowd­ing is to even out the num­ber of elec­tive surg­eries across the week, Shesser and Wears said. Pa­tients start ar­riv­ing for elec­tive surgery Sun­day night and in­sti­tu­tions get filled be­tween Mon­day and Wed­nes­day. Then the cen­sus rapidly drops be­cause peo­ple avoid elec­tive surgery on week­ends. “There is a seven-day de­mand be­ing han­dled by a five-day sys­tem,” Wears said. “Crowd­ing in the ED re­flects an over­all lack of func­tion.”

St. Fran­cis opened three ur­gent-care cen­ters and an emer­gency and trauma cen­ter that adds 30,000 square feet to its fa­cil­ity.

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