Emergency Rooms

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.)

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.

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.

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.

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.

We recently published an issue brief and blog posts (here, here, and Issues:

• Health Reform
• Emergency Rooms

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.

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.