Everyone is just one wrong step away from requiring emergency care. No one likes to go to the emergency room (ER), but we are all glad the services are there when we need them. From 1995 through 2010, annual visits to ERs swelled from 97 million to 130 million, an increase of 34 percent. During the same period, the total number of ERs dropped by 11 percent countrywide. In this environment, ER overcrowding and drawn-out wait times are becoming the norm and represent an obstacle for the future of healthcare delivery.
ER Wait Times at a Glance
- From 2003 through 2009, the mean wait time in U.S. emergency departments (EDs) increased 25 percent, from 46.5 minutes to 58.1 minutes.
- Wait time is, on average, about 17 minutes longer in ERs that report boarding.
- Longer wait times are associated with an urban area (62.4 minutes), verses non-urban areas (40.0 minutes).
- The worst place to go to the ER is Washington, D.C. — it has the nation’s longest wait times to be seen (52 minutes), sent home (182 minutes), and transferred to an inpatient facility (217 minutes).
- You are seen by a doctor fastest in Wyoming (15 minutes).
How Did We Get Here?
The first emergency rooms, developed in the 1960s, were little more than rooms where a hospital’s doctors took turns treating patients with traumatic, emergent conditions, such as accident victims. By 1980, emergency rooms were the backbone of our national healthcare safety net. After a few well-publicized incidences of “patient dumping,” Congress passed the 1986 Emergency Medical Treatment & Labor Act (EMTALA) that required emergency rooms to examine and, if necessary, treat to stabilize anyone who asks for their help, regardless of their ability to pay associated fees. The result? For the ensuing 28 years, ERs saw an influx of patients and became the primary care physicians of the uninsured and underinsured.
The EMTALA made many ERs unprofitable as they took on more and more uncompensated cases. According to the United States Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC), 1 in 5 patients treated in the ER have no clear method to pay their medical expenses and about half of all ER services go uncompensated. As a result, the number of hospitals offering ER care declined 11 percent between 1995 and 2010. A 2011 study concluded that urban and suburban areas lost close to 25 percent of their ERs between 1990 and 2009.
Hospitals Struggle to Respond
When ER departments try to reduce overcrowding on their own, they often fail. Systemic problems — such as too few free inpatient beds, a lack of communication/collaboration between hospital departments, and a lack of primary care and ER physicians — require complex solutions, and hospitals often struggle to coordinate the necessary stakeholders. With coordination being such a large problem, enterprise software such as referralMD can often make the difference with patients being able to see find the correct doctor. Instead of using the fax machine or referral pads to manage hand-offs, we recommend that you join a city-wide communication network that will speed up the process dramatically and lower costs.
Unlike other hospital departments, the ER is not set up for ongoing care. The mission of the ER is to stabilize patients and admit them to the hospital — something that is less straightforward than it sounds. The ER relies largely on the cooperation and capacity of other departments to move patients along, which can be a problem when something as simple as transferring a patient to an inpatient bed can involve the coordinated efforts of 10 members of staff and several departments.
A lack of inpatient beds leads to “boarding” — holding patients in the ER until a bed opens up. In some extreme cases, a patient can wait for days while they await admittance to the hospital. Boarding forces patients to endure what should be private in full public view. When overcrowding gets to dangerous levels and there are no inpatient beds available, acutely ill patients in ambulances are diverted to other, sometimes far-flung, hospitals.
A shortage of physicians further complicates the problem. According to the Congressional Research Service, ER doctors handle 28 percent of acute care cases and 11 percent of outpatient care. However, only about 4 percent of physicians practice emergency medicine, leaving many ER doctors overworked and spread thin.
What Role Does the ACA Play?
Once again, the ground is shifting for ERs with the implementation of the ACA in 2014. While it is too early to tell exactly how the ACA will affect ERs, surveys by the American Academy of Emergency Room Physicians found about half of respondents expected increases in patients and overcrowding under the ACA. In the first 6 months of ACA implementation, levels of overcrowding increased slightly for 36 percent of respondents and significantly for 28 percent. This increase is likely multifactorial, but a lack of primary care options and familiarity with the ER for primary care are the driving factors.
The ACA is expected to attenuate impact of uncompensated care as much as 17 percent for uninsured people who go on Medicaid and by 39 percent for uninsured people who move to the private insurance market. There is hope that reductions in uncompensated care will cull the pace of ER closings, but it is unlikely to result in more ERs opening up to fill the already large void.
What Is Being Done?
Recently, a number of organizations have led the charge against ER overcrowding. The American College of Emergency Physicians encourages chapters to affect policy change at the local and state level. Chapters in Washington, West Virginia and Puerto Rico have hosted meetings to bring overcrowding issues to the attention of state and local policy makers.
Hospitals in Colorado are using new software to create a landscape of real-time patient load at participating hospitals in order to minimize diversion times. In addition, hospital systems all over the country are implementing sophisticated electronic medical records (EMR) systems that streamline intake, workflow and minimize time spent reading and writing patient charts. The University of California-San Diego Health System is currently running a telemedicine pilot program that brings on-call physicians into the ER remotely to see patients when overcrowding occurs.
Other ERs have adopted policies to limit care of patients who should be seeing a primary care physician. For example, in an attempt to decrease the influx of pain management patients coming to ERs for narcotic medications, ERs in Maine give only two-day emergency refill prescriptions.
How Can We Fix the Problem?
The first, and most obvious step is reversing the trend of diminishing hospital capacity. With more beds, there will be less “boarding” and more opportunities for primary care outside of the ER.
Second, we need to find more ways to decrease the percentage of patients coming into the ER for non-emergent problems, which is currently around 12.1 percent. This would direct efforts toward caring for only patients with actual emergencies. Increasing access, capacity and awareness of a primary care safety net would divert these patients to a more appropriate venue for care. The implementation of the ACA and the subsequent increase in insured Americans is an opportunity to change people’s attitude about the ER back to “for emergencies only.”
Expanding and investing in public health initiatives and awareness may also reduce the burden on our nation’s ERs. Many visits to the ER result from a long list of adverse health events that may be preventable. Regular primary care, in addition to chronic disease management, could mitigate the need for ER visits related to hypertension, diabetes, obesity and maternal care. Initiatives related to lifestyle such as smoking or sexually transmitted infections could also decrease ER use. Public health policies such as car safety and drunk driving also reduce the number of traumas seen in ERs.
Utilizing additional non-physician staff can help solve the problem of not having enough ER physicians. Expanding the use of licensed vocational nurses, nurse practitioners and physician assistants will reduce the amount of time the doctors on call will have to spend with each patient
Finally, emerging information technology creates efficiencies at the individual ER level. ERs with high-quality, functional EMRs are shown to have shorter overall stays.
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Emily Newhook