Danger at the Emergency Room

Indebted, Overcrowded, and Understaffed ERs

Even on a Thursday afternoon, in an affluent suburb of Los Angeles, the 15-bed emergency room at Encino-Tarzana Regional Medical Center is packed. While more than two dozen people sit in the waiting room, inside every bed is filled, corridors are clogged with stretchers and equipment, and sick and injured patients are waiting to be examined by a doctor.

The scene is chaotic. One bed holds a wailing 6-year-old girl who knocked out a front tooth in a playground accident, while a frightened middle-aged woman in another bed is vomiting after having had a seizure. Nearby, a young mother cradles her sickly, feverish newborn. In the hallway, two beefy paramedics wait for a gurney to become available so they can transfer a dazed elderly woman who suffered a fall, and then leave for their next emergency call.

Behind the nurse's station sit an elderly man and his wife who have been in a fender bender. Her forehead and lip are badly cut and her chin and blouse are covered with blood. "Having them wait in chairs, instead of lying down in a bed, isn't ideal, but we need to monitor her head injury and there's just no other place to put them," says G. Scott Brewster, MD, one of the two ER doctors on duty. He orders a CT scan to check for possible brain damage.

But an hour will pass before the scanner is available and a nurse can escort the patient to the hospital's imaging center.

"Hospitals like ours are trying to be as efficient as possible, but the overcrowding keeps getting worse," says Dr. Brewster. The numbers bear him out: Between 1993 and 2003, the annual number of emergency department visits increased 26 percent, from 90.3 million to 113.9 million, according to the Centers for Disease Control and Prevention (CDC), in Atlanta. This growth is driven in part by the increasing numbers of older Americans, who tend to have chronic medical conditions that take more time to diagnose and treat, and by the nation's swelling ranks of uninsured, which now top 45 million.

But the real problem is that during this same period, the number of hospital emergency departments decreased by about 14 percent, leaving the nation's remaining 4,000 ERs to serve a larger volume of patients than ever before.

The Dire Results of ER Shutdowns

ERs are also being strained on other fronts: Entire hospitals have been closing down, too, creating a scarcity of inpatient beds to which ER patients can be admitted, while a dire nursing shortage means that available beds sometimes remain empty because there isn't adequate staff to care for patients. The result is risky bottlenecks in the ER, where patients can end up stranded for up to 48 hours waiting to be moved upstairs.

Furthermore, even as medical costs skyrocket, almost half the care that emergency rooms provide never gets reimbursed. A federal law requires emergency departments to treat everyone who comes through their doors regardless of ability to pay. Known as the Emergency Medical Treatment and Active Labor Act (EMTALA), the 1986 legislation banned patient "dumping," a practice by which uninsured patients were stabilized at one hospital and then shuttled to another for follow-up care.

According to a 2003 American Medical Association study, ERs lost $4.2 billion a year in revenues by providing care mandated by EMTALA, leaving many facilities drowning in a sea of red ink. And because some ERs perform services they were never designed to, such as delivering primary medical care, they are feeling the burden.

In California, which is often a bellwether for the nation, one ER after another is being shut down because of financial losses accrued by emergency departments. Private hospitals, which are in business to make a profit, can no longer afford to finance their perpetually money-losing emergency rooms, and a reported nine in the state have closed in 2004 alone. In Los Angeles County, only 75 ERs now serve nearly 10 million residents, down from 94 facilities for 9 million people a decade ago.

Since 1992, hundreds of emergency departments across the country have shut down at hospitals that were closed or financially ailing. These closures create a domino effect, because when one ER closes its doors, it puts greater pressures on those that remain open. The situation is also a concern in rural areas, where small community hospitals typically aren't equipped to deal with medical catastrophes and 12 percent of emergency rooms have closed over the past decade. In fact, a 2005 University of Pennsylvania study revealed that nearly 50 million Americans do not have access to a trauma center within an hour's transportation -- by either ambulance or helicopter.

When you factor in the challenges of finding available beds at already overcrowded urban trauma centers, transferring a critical patient from a small hospital to a high-level facility can be delayed by up to eight hours.

Ultimately, everyone suffers, not just people in outlying areas or the poor and uninsured. Being affluent or having excellent health coverage won't help if the nearest emergency rooms are filled to capacity when your husband wakes up in the middle of the night with chest pain, or your daughter has an asthma attack. "This crisis hits everyone in all classes equally," says Joel Geiderman, MD, cochair of the emergency department at Cedars-Sinai Medical Center, in Los Angeles.

Who's to Blame for ER Problems?

Contrary to popular belief, ERs aren't being overrun by the poor and uninsured seeking treatment for everyday ailments. In fact, a 2004 University of California, San Francisco, study revealed that 85 percent of emergency room visits were made by people who had some form of health insurance, and about half the visits are by people in chronically poor health, suffering from such conditions as asthma, diabetes, or heart disease. "It's a huge misconception that people come to the ER with minor ailments -- the majority of patients have complaints that are very serious," Dr. Geiderman says. According to the latest CDC figures, the leading cause of ER visits -- 6.7 percent -- involves potentially grave symptoms such as stomach pain, cramps, and spasms, while chest pains and related symptoms were the second most common, reported 5 percent of the time.

The overcrowding and subsequent closures are particularly worrisome for any critically ill patient headed to an ER by ambulance. Dispatchers, who are plugged into a computerized network of local emergency rooms, are routinely forced to reroute ambulances as one ER after another turns them away because it is filled to capacity. At the height of flu season in 2004, 911-receiving hospitals in Los Angeles were closed to ambulances 36 percent of the time; even world-class institutions, such as Johns Hopkins Hospital, in Baltimore, must divert ambulance patients one-third of the time. These diversions occur even when lives hang in the balance. During the critical "golden hour" after an accident or medical emergency, such as a stroke or heart attack, wasted minutes driving to an ER farther away might mean the difference between a full recovery and permanent disability -- or between life and death.

Once paramedics arrive at an overloaded ER, they also have to wait longer to unload patients, which means they are unavailable for other ambulance calls, triggering a chain reaction of possibly life-threatening delays. In fact, the equivalent of two ambulances are out of service every day in Los Angeles, because paramedics are waiting in the ER for an available gurney, according to Los Angeles Fire Department data.

Overcrowding not only delays care but also increases risks of medical errors, contributes to employee burnout, and erodes morale, which can make it difficult to retain competent professionals. "Emergency departments are being asked to function at peak capacity 365 days a year, which is like flying a plane 24-7 without doing any maintenance," says Robert E. Suter, DO, an emergency physician in Houston and president of the American College of Emergency Physicians. "You can't function at overcapacity on a continual basis and not expect errors to occur."

The Inadequate ER's Effect on the Patient

Tragically, but not surprisingly, these errors too often harm patients. One morning in March 2004, Julie Koleszar's 22-month-old daughter, Charlotte, woke up with a stomach virus, vomiting several times. Koleszar called her pediatrician, who told her to go to the ER if her toddler's symptoms persisted. As the day wore on, Charlotte couldn't keep anything down. Worried that her child was getting dehydrated, the 40-year-old Fallbrook, California, mother of three called the nearby ER to verify that they treated children and ferried her daughter there at about 4:30 p.m.

But the toddler languished in the waiting room until 6 p.m. "As I watched the clock, Charlotte was getting worse and worse -- even vomiting blood," Koleszar recalls. The little girl was finally given some tests, but another 45 minutes elapsed before a doctor came into the exam room. Three hours had passed from the time Charlotte arrived before she was given intravenous fluids. Her electrolyte levels were dangerously low. She was severely dehydrated, beginning to turn blue and gasping for breath. Nurses frantically inserted an oxygen tube to aid the child's breathing, but it turned out not to be put in correctly, thereby depriving her of oxygen for almost another hour. "The doctor finally told me, 'Your daughter is very sick and we're not equipped to handle sick kids,' " Koleszar says. "I was horrified -- I thought I was in a safe place." An emergency physician team was summoned from a nearby children's hospital, but by then it was too late. Charlotte died shortly before 11 p.m. from severe dehydration.

State investigators later determined that two of the three nurses who attended to Charlotte had not taken required courses in emergency pediatric care and that hospital staff had failed to monitor her vital signs properly. Had Charlotte been correctly triaged and immediately cared for, her condition likely would not have deteriorated so drastically. More mistakes like this may happen if the crisis plaguing emergency departments isn't remedied. "ER overcrowding is like the canary in the coal mine," says J. Brian Hancock, MD, an emergency physician in Saginaw, Michigan, and the immediate past president of the American College of Emergency Physicians, "because it is signaling the entire healthcare safety net is at risk."

When EMTALA was passed nearly 20 years ago, it required ERs to care for everyone, insured or not. Congress made no provisions for how the extra services mandated by the law would be paid for. To make matters worse, insurance companies and HMOs often deny coverage or refuse to pay the full freight when their members visit the emergency room because of muddled distinctions their plans make between "emergency" and "urgent" care. When reimbursements aren't made, the facilities often must absorb the loss. This financial crunch threatens the round-the-clock care we've come to count on in times of crisis. If an extraordinary medical emergency were to hit -- such as a bioterrorist attack, a natural disaster, or even a particularly contagious and virulent flu outbreak -- it could overwhelm the emergency-care system, and hundreds of thousands might die needlessly. "If we are ever faced with a situation where we have a surge of critically ill patients and inadequate resources to deal with them," Dr. Hancock says, "the network will break down."

How Can You Help Solve the ER Crisis?

The good news is that there are ways to ease the ER crisis, as the city of Houston proved. By 2001, Texas trauma centers, which are specialized ERs equipped to deal with patients with life-threatening emergencies such as gunshot wounds or cerebral hemorrhages and other serious head injuries, were losing more than $200 million a year. Financially squeezed hospitals closed some centers and the remaining ones were so overloaded that they were forced to divert patients to other trauma centers 30 percent of the time. This triggered life-threatening delays of up to eight hours and resulted in perhaps hundreds of needless deaths and permanent disabilities. "The system was in meltdown," says Guy L. Clifton, MD, a neurosurgeon at the University of Texas Health Science Center at Houston.

But the city's doctors banded together with community groups, business leaders, and hospital administrators to form Save Our ERs, a coalition organized to increase public awareness and enlist support for legislative action to beef up Houston's trauma care system. The group raised $750,000, hired experienced lobbyists and, in 2003, persuaded Texas lawmakers to pass a bill that could earmark as much as $180 million a year for the state's ER network. "The money stabilized the trauma problem in Houston for the moment," says Dr. Clifton, who chairs the still-active coalition, "but it will take a national mandate to solve the underlying problems that plague the system."

The American College of Emergency Physicians is spearheading an effort to do just that. There are no easy fixes, but pumping more money into emergency departments and reimbursing them for all the services they provide would be a good start. On September 27, thousands of emergency physicians, nurses, patients, and concerned consumers are rallying at the U.S. Capitol, in Washington, D.C., to draw attention to the growing crisis. They plan to lobby lawmakers to pass legislation that will recognize the care ERs provide as an essential community service and therefore allocate appropriate funding. The proposed bill also provides incentives for hospitals to move patients from ER beds to inpatient beds.

"Emergency physicians are can-do problem solvers," says Dr. Hancock. "But we can't do this alone. We need the public's help." To voice your support for initiatives that would safeguard your family's access to quality emergency care, join Ladies' Home Journal's petition drive, and add your support to the Access to Emergency Medical Services Act. Visit www.lhj.com/petition. We will bring the petition before Congress on your behalf and urge our government to protect emergency medical services.

How to Protect Yourself Today

How does your ER rate? Not all emergency departments are created equal. Be sure to research your nearest options before you have a medical crisis

• Get a Recommendation Ask your primary doctor at which hospital she has admitting privileges, and where she would go if she needed treatment.

• Weigh Your Best -- Not Just Your Closest -- Options  In a medical catastrophe, such as a car accident or possible stroke, every second counts and you should certainly head immediately to the nearest ER. But in other instances -- you have twisted an ankle or your child has a raging fever, for example -- "taking the few extra minutes to travel to the ER of your choice may get you better, faster care," says Kevin J. Soden, MD, a former ER physician and coauthor of Special Treatment: How to Get the Same High-Quality Health Care Your Doctor Gets.

• Inquire About the Services  Call the community relations department of nearby hospitals to find out which ones staff their own 24/7 lab and radiology technicians for X-rays, CT scans and MRIs. Waiting for these professionals to be called in late at night or on weekends can cause potentially deadly delays. Also ask whether the supervising ER doctors are board certified. These physicians typically undergo four years of training in emergency medicine to learn to distinguish influenza from meningitis, heartburn from a heart attack or stomach cramps from the rupture of an ectopic pregnancy. Moonlighting internists may not have the same diagnostic skills as ER specialists.

• Know Where the Nearest Pediatric ER Is Many emergency departments aren't adequately prepared to handle a sudden pediatric illness or injury. Children under age 6 can't really articulate what's wrong, their symptoms are often subtler than those of older patients with the same condition, and they need to be treated with special equipment designed to suit their small size, explains Steven E. Krug, MD, the head of pediatric emergency medicine at Children's Memorial Hospital, in Chicago. Pediatric ERs can better diagnose and treat the 30 million children who seek emergency care every year. If you do end up at the local community hospital, however, make sure a pediatrician is called in to evaluate your child.

How to Get the Best Care in an Emergency

• Call an Ambulance In a life-threatening situation, don't drive to the ER yourself. Calling 911 allows paramedics to begin interventions as quickly as possible. Have someone alert your primary doctor that you're on the way to the ER.
• Don't Minimize Your Symptoms to the Triage Nurse Otherwise, you may find yourself at the back of the line, as patients are prioritized according to the severity of their symptoms. Be candid about your personal health information (such as whether you smoke, have high blood pressure or diabetes, or take prescription or over-the-counter remedies). And be sure to repeat everything you told the nurse to the ER doctor. Don't assume he has read the nurse's notes.
• Use the ER Only When You Have To Establish an emergency action plan with your primary care physician, pediatrician, and any specialist(s) you or your family members routinely see for a chronic condition. Find out how to reach your doctor after regular business hours. At this number, you should be able to talk to a doctor or nurse who can give you advice and tell you whether the medical problem requires an ER visit. Set up a phone tree so family can be reached quickly.

• During off-hours, an urgent care center can treat minor ills -- for instance, bacterial infections, ankle sprains, cuts that require stitches. These clinics are not prepared to treat serious illnesses, particularly in the elderly and in children. Moreover, free-standing clinics are not regulated and the quality of care can vary greatly, cautions Dr. Geiderman. Check them out carefully beforehand; ask your doctor, neighbors, and friends about their experiences. Find out whether your insurance will cover visits.

Originally published in Ladies' Home Journal magazine, October 2005.