The New Health Dialogue

Overcrowding in emergency rooms and departments costs lives.  A 2009 Government Accountability Office report found that “emergent” ER patients – those who need treatment in 1-14 minutes – faced an average wait time of 37 minutes. Patients have to wait longer than recommended over 50% of the time.  One in four hospitals even diverted ambulances to other emergency departments at least once in 2006.  In New York City, periods of ambulance diversion increased the heart attack mortality rate by 47%.

This blog has covered the issue a number of times, looking at ambulance diversion, emergency care state grades, the multiple reasons behind ER crowding, ER “super users,”  and more.  But we were given a stark reminder of the delays plaguing many emergency departments across the country when we read Dr. John Maa’s article “The Waits That Matter” in this month’s New England Journal of Medicine.

In his piece, Maa describes the story of his 69-year-old mother with mild heart disease.  After feeling slightly short of breath and noticing an irregular heart beat one morning, she had her husband drive her to the local hospital – “one of the most highly regarded academic medical centers on the West Coast.”  At the ER, she waited an hour to be seen, eventually being diagnosed with rapid atrial fibrillation and admitted into the hospital.  She receives an IV for anticoagulation drugs and is scheduled for an electrical cardioversion procedure the following day.

However, no inpatient bed is available, and Maa’s mother is kept in the ER overnight, forcing her to deal with the noise and bright hallway lights.  She doesn’t get much sleep on the narrow bed, but is finally given a place in the hospital the next morning, shortly before noon.

Unfortunately, the cardiologist informs her that due to the delayed admission, it wouldn’t be possible to complete her procedures before the end of the workday.  She is scheduled for a Monday procedure.  Meanwhile, she remains in the hospital and continues receiving drugs.

The next day, she suffers a massive stroke.  She is rushed to surgery, but complications arise during the procedure resulting in internal bleeding.  Due to the anticoagulants in her system, the rapid intracranial bleeding leads to her death.

It’s hard to say for certain what effect the delays had on the eventual outcome, but it probably didn’t help. 

Many people might look at the story as evidence that more hospital beds are needed, and just as many will debate whether or not that is true.  More important is how hospitals are filling the existing beds.  Often, hospitals and doctors make the choice to allocate beds to patients receiving elective procedures, which net a higher profit.  While this allows us to claim shorter wait times for electives in comparison to national health care systems like Britain and Canada, the trade-off is not always worth it.  As Maa pointedly remarks, “A lengthy wait for elective surgery can be irritating, but it is rarely deadly.”

There are other key factors, especially a lack of access to primary care doctors.  A look at New York hospitals shows that only 20% of ER patients need ER-specific care. Meanwhile, communities with long wait times for clinic or doctor’s office appointments – where that non-ER-specific care should be delivered – find their emergency rooms the most crowded.  By improving access to primary care doctors, we can considerably reduce the number of unnecessary ER patients.

In addition, poor management of chronic disease and inefficient patient flow can play a role.  Some hospitals with a high percentage of uninsured patients restrict the number of beds available to emergency care patients to save money.  And as Maa’s story tragically illustrates, many specialists don’t want to work on weekends or after-hours.

To help fix the problem of overcrowding, Maa suggests we “invert the current paradigm of incentives and reimbursement” to prioritize those with emergency and urgent conditions.  It’s a common sense proposal, but one that would certainly take a dramatic shift in how our health care system operates.

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Maa M.D., John. The Waits That Matter. The New England Journal of Medicine. June 16 2011. 364:2279-2281. http://www.nejm.org/doi/full/10.1056/NEJMp1101882