State of emergency

It's becoming a real emergency.

The Centers for Disease Control and Prevention released new statistics that confirmed what most hospitals already knew: Emergency room visits are increasing at a rapid pace. When these statistics are coupled with other factors, such as fewer hospitals offering emergency services and looming staffing shortages, experts are increasingly concerned.

According to the new CDC estimates, visits to hospital emergency departments increased to an all-time high of 136 million in 2009, and this represents almost a 10% increase from the 2008 figure of 123.8 million.

“If you ask if I'm optimistic in the long run, I'd have to say I'm not,” said Dr. Robert Wears, a patient-safety advocate and an emergency medicine physician and professor at the University of Florida at Jacksonville. “The population is going up, the population is getting older and the intensity of care that's needed is going up, but the real kicker is the number of nurses is going down. This looks like a perfect storm to me.”

Wears, who is on the board of the Emergency Medicine Patient Safety Foundation, said the best solution seems to be “eat right, get plenty of sleep and exercise, and wear your seat belt, because the outlook doesn't look good unless we resolve these problems.”

With fewer hospitals offering emergency care, “the degree of busyness is going up,” said Dr. Robert Shesser, an active member of the American College of Emergency Physicians and chairman of the department of emergency medicine at the George Washington University School of Public Health and Health Services in Washington. “Crowding compromises safety, and it certainly compromises satisfaction,” Shesser said. “Hospitals aren't hotels. They can't say, ‘You have to be out by 11 or we'll charge your credit card.'”

The most common reasons for visiting an ER, according to the CDC data, included stomach and abdominal pain (9.6 million); fever (7.4 million); chest pain (7.2 million); cough (4.7 million); headache (4 million); shortness of breath (3.7 million); and back symptoms (3.7 million).

The expected sources of payment for those visits were private insurance, 39%; Medicaid or State Children's Health Insurance Program, 29%; Medicare, 17%; and no insurance, 19%. (Numbers are higher than 100% because some patients had multiple sources of payment.)

“One big misconception is that ER crowding is a result of people without insurance using emergency services inappropriately,” Shesser said. “Utilization is pretty broad across society.”

Both Shesser and Wears said part of the increase is a result of the modern demand for instant service. Despite the crowds and wait times, “EDs offer convenience,” Wears said, as well as an immediate diagnosis and treatment.

Urgent-care centers, where minor problems are treated during off hours when most doctors' offices are closed, are seen as ER alternatives and a solution to ER crowding, but it may not be working. American Hospital Association statistics are hard to interpret because more hospitals participated in the survey in 2008 than in 2009, so a smaller number of hospitals offered urgent care but a bigger percentage. In 2008, 974 (23.3%) of the 4,186 community hospitals surveyed offered urgent care. In 2009, 960 (23.5%) of 4,086 institutions surveyed had urgent care.

St. Francis Medical Center in Cape Girardeau, Mo., has seen a 3.1% increase in emergency department volume for fiscal 2011 (which ended June 30), with 35,000 visits. Marilyn Curtis, vice president of professional services at the 258-bed hospital, said a 7% increase was projected for fiscal 2012. Officials now believe that number could be even higher.

St. Francis has a seen a “very slight decrease” in the number of patients seeking convenient care in the ER since it opened three urgent-care centers, Curtis said in an e-mail. “The danger of using the emergency room as a primary-care resource is that while patients receive excellent care, it offers no continuity or preventive care.”

In February, St. Francis opened a $12 million emergency and trauma center that added 30,000 square feet to the existing 11,600-square-foot facility. Curtis said physician and staff suggestions were incorporated into the design to improve patient flow, patient safety and staff efficiency.

In Seattle, a grand opening ceremony was held Oct. 22 for the new emergency department at 247-bed Virginia Mason Medical Center, with the first patients expected Nov. 2. Virginia Mason trimmed the number of treatment rooms to 17 from 22 in the old facility, emphasizing efficiency in the design. An adjacent unit was built to handle less-acute patients designed to reduce delays for patients with more emergent problems.

Hospitals also are testing less capital-intensive approaches to the problem.

At four Seton Healthcare Family hospitals in and around Austin, Texas, the SetonER.com website allows patients with minor emergencies to pay a $4.99 fee and designate their arrival time at the emergency department. If these patients are not seen within 15 minutes of arriving, the fee is refunded.

Another way to ease crowding is to even out the number of elective surgeries across the week, Shesser and Wears said. Patients start arriving for elective surgery Sunday night and institutions get filled between Monday and Wednesday. Then the census rapidly drops because people avoid elective surgery on weekends. “There is a seven-day demand being handled by a five-day system,” Wears said. “Crowding in the ED reflects an overall lack of function.”