America's Emergency Rooms in Crisis

Our ERs in Trouble

It doesn't take a lot of imagination to get good and scared: Someone could release plague bacteria into the ventilators of the concert hall downtown or SARS could break out at the airport. Maybe there's another huge earthquake. Crowds of injured pour into the ER of your local hospital and stack up like traffic in rush hour.

Even a multiple-car highway crash can create havoc in an emergency department, according to a June 2006 Institute of Medicine report, which concluded that "the nation's emergency care system is very poorly prepared to handle" megadisasters.

What's also piling up is the scientific evidence pointing to the danger of overcrowded ERs. Delay in getting proper treatment and being dispatched speedily to the intensive-care unit means patients are less likely to survive, according to a 2006 Australian study that found a 50 percent higher mortality rate in crowded facilities. Researchers at New York's Albert Einstein College of Medicine came to similar conclusions in 2007: Longer ER waits translated into longer hospital stays and more deaths. And when the American College of Emergency Physicians polled 1,500 emergency-medicine doctors about overcrowding in 2007, half said patients were harmed and 200 reported that patients had died.

A chronic shortfall of funds is one key reason for the crush, but the other shortfall -- until recently -- has been in finding strategies that truly target the crises that Americans must now expect to face. We finally have the know-how to address each of the challenges: A blueprint of the emergency room of the future is on the drawing board.

Called "Project ER One," it's a model for the next-generation ER, based on 10 years of planning with input from top national and international experts from more than 90 institutions, including nurses, hospital administrators, ex-military doctors from the U.S. armed services, and an Israeli trauma surgeon. The goal is to make ER One a national model for the emergency departments of the 21st century.

ER One is planned for the Washington Hospital Center, where victims of the 9/11 attack on the Pentagon and the anthrax scare were treated. At present the project awaits federal funding (it's expected to cost $100 million, which is less than the $137.5 million that the New York Mets just spent on pitcher Johan Santana's contract). However, some of its cutting-edge features have already been adopted by a handful of hospitals, including seven of the hospitals in the MedStar Health network, to which Washington Hospital Center belongs. In the meantime, the hospital has revamped its current emergency department space, including pilot testing some of the innovative ER One technologies for the first time.

"ER One is going to be a demonstration facility for the whole nation on how emergency departments should be designed and built going forward," says Mark S. Smith, MD, director and chairman of emergency medicine at Washington Hospital Center.

Here, how the world's smartest ER doctors are planning to remake emergency medicine for the 21st century.

Overcrowding and Misdiagnosis

Problem: Overcrowding and misdiagnosis
Solution: Digitize everything

Even in this high-tech age, the majority of hospital records are kept on paper and stored in manila folders, and in some ERs patient status is still tracked on dry-erase boards. These antiquated systems can cost lives as healthcare professionals waste precious time searching for patient information. "Health care has lagged behind other industries by about 20 years," says Dr. Smith. "Most hospitals have less sophisticated computer systems than the cashiers at the local supermarket."

The foundation of ER One is a computer software system, called Amalga, that addresses this problem. invented by Dr. Smith and Craig F. Feied, MD, a former Washington Hospital Center ER physician (both were recipients of the Ladies' Home Journal Health breakthrough award this past September), the system was acquired by Microsoft in August 2006 for nationwide marketing. Amalga will be deployed around the country at such top centers as New York-Presbyterian Hospital, the Johns Hopkins Hospital and Health system, in Baltimore, and the H. Lee Moffitt Cancer Center and Research Institute, in Tampa.

ERs with Amalga have computer screens mounted in a central location so patients' information is available at a glance. There's no more running around looking for charts. Need to see a patient's angiogram? The image comes right up on the screen, along with her whole medical record at that hospital. (Because data from all patients at MedStar hospitals is in Amalga, a clinician at one network hospital can view data on a patient at a different network facility. Eventually, experts hope, Amalga will pull data from private practitioners and other hospitals in Washington, D.C.)

"Our experience suggests the majority of a doctor's time is spent seeking information," says Dr. Feied, the former director of ER One. "But when the existing data are just a click away, it cuts the search by many orders of magnitude, allowing us to spend more time with a patient and make more accurate diagnoses." With proper diagnosis, unnecessary tests are avoided and treatment can begin faster.

Amalga also has a significant security aspect. If there is a suspicious disease outbreak -- be it anthrax, SARS, or West Nile Virus -- the system can alert doctors to a cluster of similar symptoms among people seen by facilities in the network, something individual physicians seeing different patients might not recognize on their own.

Treating patients faster also increases how many people an ER can handle -- and how long they have to wait for help. In 1995, the year before the prototype of this software was installed, the Washington Hospital Center ER handled 37,000 patients, and waits could stretch up to nine hours. Today more than 80,000 patients visit the ER annually, and 60 percent are treated and discharged from the hospital in 3.5 hours.

Deadly Contamination and Cross-Infections

Problem: Deadly contamination and cross-infections
Solution: Anti-germ warfare

Hospital-acquired infections claim more than 90,000 lives every year, according to the Centers for Disease Control and Prevention (CDC). ERs need to isolate infections and keep microbes from spreading.

Reconfigured air circulation: An estimated 50 to 70 percent of the air in today's ERs is recirculated, which can spread airborne infections. ERs typically have only a few isolation rooms, which have special circulation systems that keep a patient's germs from spreading. In ER One every treatment room will have the capacity to become an isolation room. "All you have to do is flip a switch," says Dr. Smith.

Ionic silver coatings: Planned for use on ER One's duct system and on common surfaces -- doorknobs, staircase banisters, elevator buttons, toilet seats, wall surfaces, the backs of chairs -- ionic silver coating will inhibit the growth of microbes that are spread by people's hands, adding another layer of protection against harmful agents.

Scaling Up When Disaster Strikes

Problem: Scaling up when disaster strikes
Solution: Make space and equipment flexible or portable

The biggest test of any ER is how well it ramps up to handle a pandemic, natural disaster, or terrorist attack. The following features, all in the planning stages, will enable ER One to handle 400 patients simultaneously, if needed. Right now, the Washington Hospital Center ER can handle only 110.

Flexible room sizes: Treatment rooms will be 15 to 20 percent bigger than standard and be able to be enlarged, thanks to ultra-wide hallways. This could triple -- even quadruple -- patient capacity. In conjunction with special anti-germ air circulation, these rooms would be instantly sealable to isolate patients with a dangerous communicable disease.

Modular equipment: In-ceiling electrical outlets will allow doctors to use equipment anywhere in the hospital instead of being limited to locations near wall outlets.

-- An airport-style three-lane concourse for ambulances will facilitate pickups and drop-offs and prevent traffic jams, which could cause gridlock if dozens of vehicles were attempted to be moved at the same time.

-- Equipment will be portable, letting the hospital transform atria, conference rooms and lobbies into treatment areas or temporary wards, quadrupling daily ER capacity in an instant from 250 to 1,000. Outdoor space will also be usable. A decontamination center is incorporated into the ER One design, and it can accommodate hundreds of patients. In a contamination emergency doctors could treat additional patients in outdoor tents, drawing on electricity available outside the building.

What Some Hospitals Are Doing Now

ER One is still on the drawing board, but some forward-thinking hospitals are already transforming their ERs. Improvements don't have to be made all at once.

Doubling capacity: New York Downtown Hospital, New York City
Located three blocks from ground zero, Downtown treated more than 1,200 people on 9/11. In 2006, with funding from nearby Wall Street firms, it opened a $25 million emergency center with features that include advanced patient-monitoring systems, decontamination showers, and isolation rooms, as well as gas pipes for oxygen and other equipment in the cafeteria, so it can be used as another ER. Doctors consulted with Israeli counterparts for advice on handling massive casualties.

Disaster-ready: New Hanover Regional Medical Center, Wilmington, North Carolina
Officials prioritized their disaster planning based upon what was most likely to occur: a hurricane, nuclear accident, or toxic spill. They acquired four massive tents equipped with high-pressure showers that can decontaminate 100 people an hour. They also installed isolation rooms in their ERs to prevent the spread of infections plus portable filters to convert whole wards to isolation rooms. The disaster team is trained to handle hazardous waste.

Boosting efficiency: University of Michigan Health System, Ann Arbor
Changes included dividing patients into separate tracks. One is reserved for sick patients who need a bed and possible long-term care. A second treatment fast-track handles those with minor ills that can be treated quickly. Today most of the 75,000 patients who visit the ER every year are seen in 20 to 90 minutes, down from almost two hours. The cost of these changes was negligible -- medical support personnel were simply redeployed.

Computer on wheels: The Hospital of Central Connecticut, New Britain and Southington
A greeter registers new ER patients with a portable computer. Lab data are entered immediately in the computer, which also checks patients' records before medication is prescribed. Patients now see a doctor within 60 minutes and most leave the ER in less than 90 minutes. The system cost about $450,000, but it more than paid for itself in three months because it charged for services that physicians and nurses sometimes forgot to enter.

What Can You Do to Help?

Be prepared for your community's emergency risks. Memphis, Tennessee, sits near a major earthquake fault, for instance, and Long Island, New York, is prone to flooding. And there are man-made risks, like nuclear power plants or oil refineries.

Encourage local media, government, and citizen groups to determine how prepared your region's hospitals are. Are they coordinating with state disaster-preparedness authorities? Can they handle an influx of extra patients? Do they have stockpiles of extra medical supplies, such as gloves, masks, and gowns? Extra antibiotics and antidotes to chemical agents? Backup systems for electronic records and contingency plans in case of power failure? Decontamination showers or tents, and protective gear?

Are your local hospitals conducting mandated drills -- successfully? Since Hurricane Katrina, the Joint Commission (the standard-setting and accreditation body for hospitals and healthcare organizations) requires hospitals to conduct twice-yearly disaster drills and formulate comprehensive programs for dealing with all types of hazards. See if your hospital has gotten a passing grade from the Joint Commission. If not, find out why. People in the community can compel hospital officials to do better by posing uncomfortable questions, says Brian F. Keaton, MD, clinical professor of emergency medicine at Northeastern Ohio University College of Medicine.

Check out your local health department. Progress has been made in the emergency preparedness of public health departments on state and local levels, according to a report earlier this year by the CDC. They've improved their computer programs and hired more trained personnel, plus more people are accessing key databases, and laboratories for identifying bioterrorist agents have been upgraded. To find out how your state is doing, see the report at www.bt.cdc.gov/publications/feb08phprep. What's more, Project Public Health Ready, a pilot program from the National Association of County & City Health officials, has designated 152 local health departments as "public health ready" owing to their ability to respond to emergencies. See www.naccho.org/topics/emergency to check if your area is included.

Badger your Congressional representatives to spend Homeland Security money on disaster preparedness. Increasing stockpiles of drugs and supplies could enhance security at an estimated cost of $500,000.

Originally published in Ladies' Home Journal, May 2008.