ER Wait Time Problems Widespread

June 28, 2007 — -- John H. Stroger Jr. Hospital of Cook County in Chicago bears little resemblance to County General Hospital -- its fictional counterpart in the television series "ER."

Instead, a waiting patient may be reminded of the show "24," because patients can sometimes wait a full day to receive treatment, according to attending physician Dr. Robert Saqueton.

"Real emergencies are lost in the shuffle," Saqueton said.

Furthermore, he added, doctors need to see too many patients to have the type of relationship that the fictional doctors have with patients on "ER."

This problem and its consequences, which many hospitals face, were brought home to many when Edith Rodriguez died waiting to be treated on the floor of Los Angeles' Martin Luther King Jr. Harbor Hospital last month.

But while critics have pointed to poor fiscal responsibility in the case of Stroger, or poor patient care in the case of King Harbor, a look at emergency rooms around the nation shows that wait times -- and their health consequences -- are increasing everywhere.

The problem isn't confined to hospitals that serve mostly the uninsured. Wait times of several hours also occur at places like Hoag Hospital in Orange County, Calif., according to Carla Schneider, a registered nurse and director of the emergency care unit there.

"It does get frustrating," she said. "People deserve better care."

On Friday, June 22, nearly a year after the Institute of Medicine issued three reports chronicling a rise in numbers of emergency patients and a decline in the number of emergency facilities nationwide, the House Committee on Oversight and Government Reform listened to testimony from five physicians in a hearing titled "The Government's Response to the Nation's Emergency Room Crisis."

"It's clearly a national problem," said Dr. Ramon Johnson, a member of the board of directors of the American College of Emergency Physicians (ACEP), who was among the doctors who testified.

Johnson, who lives in a wealthier part of Southern California, said his area still lacks hospital beds.

"Even in the affluent communities, if they haven't built any new hospitals, we're seeing the same problems they're seeing in the urban areas," he said.

While many people may be aware of emergency department wait times, they don't know the potential harm, Johnson said.

Other emergency physicians share his apprehension.

"The real concern is you sit out in the waiting room with some vague back ache, and you could be sitting on a heart attack or a leaking aneurysm," said Dr. Peter Viccellio, clinical director of the emergency department at SUNY Stonybrook.

While emergency physicians disagree about some of the specific causes of ER overcrowding, among the leading culprits many point to is a practice known as "boarding."

Boarding occurs when a patient who has been treated in the ER is kept there afterward because of a lack of available inpatient beds elsewhere in the hospital. The ER can fill up with patients, resulting in what Viccellio describes as "a phone booth."

In a poll of emergency physicians in New York, New Jersey and Connecticut conducted by ACEP this past February, just under 65 percent of physicians said they had personal experience with a patient being harmed by boarding -- and 23 percent said they had personal experience with a patient dying because of it.

Doctors attribute the lack of hospital beds to cutbacks in hospital budgets. Many blame it on the growth of managed care in the 1990s, where hospitals were forced to cut costs wherever possible.

The current situation in emergency departments, Viccellio said, is like an airline loading its planes with exactly enough fuel to reach its destination -- without accounting for possible landing delays or weather detours.

Viccellio has alleviated the situation somewhat in his own hospital by having inpatient departments each take a few extra patients in order to get some patients out of the emergency department.

In addition to boarding, some doctors attribute the problem of wait times to closing emergency rooms and an aging population that is living longer than ever before.

"Across the nation, ERs are still closing," said Ferdinando Mirarchi, chairman of the department of emergency medicine at Hamot Medical Center in Erie, Pa. "Patients crowd the existing facilities. Patients are getting older and thus have more complex problems that require attention."

Last Option May Be Only Option

For better or worse, most emergency physicians agree that the emergency department, once a last resort, has become a primary care option for many.

Dr. Paul Pepe, chair of emergency medicine at UT Southwestern Medical Center, said that a patient who injures her knee playing tennis may choose to go to an emergency department because she will be taken care of faster.

While it may take days to get an appointment with a primary care physician, Pepe explained, followed by another wait to get X-rays and other treatments, an emergency department can diagnose and treat the problem within hours. That's even with factoring in wait times.

"We've become victims of our own success in that regard," said Pepe.

"We can get tests done…within the space of a few hours, even though we have more patients than we can handle," said Dr. Gabe Kelen, chair of emergency medicine at Johns Hopkins Hospital. "Patients themselves have now come to realize they are better off coming to the emergency department."

For some, though, the emergency room is the only option.

With the passage of the Emergency Medical Treatment and Active Labor Act in 1986, patients were guaranteed treatment at an emergency department regardless of their ability to pay. For those who could not afford a primary care physician, the emergency department filled that need.

"The global solution is better access to primary care -- most patients in ERs don't need to be there," said Dr. Antonio Dajer, acting chief of emergency medicine at New York Downtown Hospital.

But even many insured patients lack a primary care physician and go to hospitals only when something is wrong, said Johnson. And that presents a problem as well.

"It makes it much more difficult to have comprehensive records for patients," he said, leading to emergency physicians being unaware of a patients' history before they came to the emergency room.

No Harm, No Foul?

"People don't really see this as harming patients," said Kelen. "So long as people don't need it and it's OK to wait, there's no sense of urgency."

He explained that crowded emergency departments can't follow the strict guidelines for care set out for them -- guidelines that are in place to ensure the safety of patients.

Kelen isn't alone in his complaints.

The Institute of Medicine made 60 recommendations a year ago that "garnered widespread attention from the media and health care professionals," wrote Eric Berger and Mary McKenna in a recent article in the journal Annals of Emergency Medicine.

"One fact is clear," they continued, "few of the [Institute of Medicine] recommendations contained within [the] reports have yet been acted upon."

As Dr. Howard Blumstein, medical director of the emergency department at Wake Forest University School of Medicine explained, the problem will only get worse without action.

"Incidents like the one in L.A. will become more frequent," he predicted. "Patients with heart attacks and strokes and other conditions that need to be treated rapidly will see their care delayed."