Crowded emergency rooms can be annoying, infuriating, scary and (if you saw the brilliant documentary, The Waiting Room, about the emergency department at Highland Hospital in Oakland, Calif.) heartbreaking. Now add this to the list: Deadly

A new report published online in the Annals of Emergency Medicine found that “patients admitted to the hospital from the emergency department during periods of high crowding died more often than similar patients admitted to the same hospital when the emergency department was less crowded.”

A crowded ER, it turns out, was also associated with longer hospital stays and slightly higher costs, the study found.

Why might this be? The authors suggest a few reasons:

ED crowding may reduce access through prolonged waiting times or through increased time to care as a result of longer ambulance transport after diversion…A large literature has demonstrated the negative effect of ED crowding on throughput, including delays in the treatment of myocardial infarction, pneumonia, and painful conditions. Finally, output focuses on the transfer or discharge of patients from the ED. A common barrier to output is high inpatient occupancy, resulting in patients boarding in the ED while waiting for an available hospital bed. Prolonged boarding times may delay definitive testing and increase short-term mortality, length of stay, and associated costs. Continuity of care in the ED may be compromised by frequent nursing and physician shift changes, and ED priority on evaluating new patients may divert attention from ongoing care of boarded patients.

Here’s more from the news release:

“ER crowding is dangerous,” said lead study author Benjamin Sun, MD, MPP, of Oregon Health & Science University in Portland. “We looked at nearly a million admissions through emergency departments across California, a large number of patients. Crowding was associated with 5 percent greater odds of inpatient death.”

Researchers analyzed 995,379 emergency department visits resulting in admission to 187 hospitals. Daily ambulance diversion – the practice of closing an ER to ambulances because it is too crowded to accept new patients – was the measure of emergency department crowding. Admission to the hospital from the ER on days with prolonged ambulance diversion (a median of 7 hours) – or high emergency department crowding – was associated with 5 percent increased odds of dying in the hospital compared to admissions on days with low ambulance diversion (a median of 0 hours).

Patients who were admitted on days with high emergency department crowding had 0.8 percent longer hospital stays and 1 percent increased costs per admission. Periods of high emergency department crowding were associated with 300 excess inpatient deaths, 6,200 hospital days and $17 million in costs.

“Emergency department crowding is likely to become worse in the future because of the volume, complexity and acuity of emergency patients,” said Dr. Sun. “Policymakers should address ER crowding as an important public health priority.”

The study was supported by the Agency for Healthcare Research and Quality and the Emergency Medicine Foundation.

To read the article at its source, please Click Here.

DENVER – Frequent visitors to emergency departments come in mainly for valid reasons that usually are related to acute illness, mental illness, pain, or substance abuse, results of seven new studies show.

These so-called frequent flyers are a heterogeneous group of patients who typically are frequent users of emergency services for a year or less and have been mischaracterized as abusers of the health care system, speakers suggested in a press conference at the annual meeting of the American College of Emergency Physicians (ACEP).

Frequent flyers were significantly more likely than other emergency department visitors to be insured by Medicare or Medicaid; be chronically ill; have a pain diagnosis, mental illness, or substance abuse problem; and visit multiple hospitals for care. If admitted, they also were significantly more likely to be readmitted within 30 days, the studies found.

Better use of electronic health records, with information shared among hospitals in a region, could help identify frequent flyers so that individualized care plans might be created for each patient, reducing emergency department use, said Dr. Andrew Sama, president of ACEP. He is chairman of emergency medicine at North Shore University Hospital in New Hyde Park, N.Y., and Long Island Jewish Medical Center in Manhasset, N.Y., and chief of emergency medicine at Huntington (N.Y.) Hospital.

New federal policies that will reduce reimbursements to hospitals for patients readmitted within 30 days of discharge, implemented as of October 2012, amount to a blanket penalty for a nuanced problem and could end up harming some frequent flyers, said Dr. Robert E. O’Connor, professor and chair of emergency medicine at the University of Virginia, Charlottesville.

“While I think we could probably drive down the 30-day readmission rate through a variety of techniques that improve home health care, there’s going to be some irreducible percentage – it will never go to zero. I think that’s what these studies all say: There is a subsegment of the population that is not going to proceed in the usual manner of recovery from whatever illness they have, but will have complications that are unforeseen and unpreventable, and that’s when they end up back in the emergency department,” Dr. O’Connor said in an interview.

The studies included data from four states:

Virginia: Repeat users accounted for 20% of visitors and 40% of visits to Dr. O’Connor’s emergency department in a 6-month period. These patients were more likely than single-visit patients to be African American, indigent, and chronically ill, and to live close to the hospital and be covered by public insurance. Patients who made greater than nine visits were more likely to be on Medicare and to have psychiatric comorbidities.

Notably, the likelihood of admission was similar among single-visit patients, “low-repeat users” who made 2-3 visits, and “moderate-repeat users” who made 4-9 visits (14%-15% admitted from each subgroup). The admission rate was lower among the high-repeat users (10 or more visits), who were hospitalized 5% of the time. The lack of a significant difference in admission rates for all but the high-repeat users suggests that admissions were necessary and justifiable for low-repeat or moderate-repeat users, the investigators concluded.

High-repeat users who were admitted had significantly shorter stays than did non-repeat users (4 vs. 6 days). All repeat-user subgroups were significantly more likely to be readmitted within 30 days (26%-68%) compared with non-repeat users (7%), the retrospective study found.

Physicians should not assume that repeat users come in for the same problem on each visit, he cautioned. “If you start assuming that this is the same reason they came in last week, you will miss something at some point,” he said.

“My message to colleagues is to create individualized treatment plans for each frequent user. One of the investigators from Wisconsin told me that the extremely high users who were repeatedly admitted were 39 patients. You could come up with 39 treatment plans,” Dr. O’Connor said.

Better outpatient services for people with mental health, pain, or substance abuse problems also would help, such as increasing clinic hours to cover nights, weekends, and holidays, he added.

While that would be nice, it’s also an expensive strategy, Dr. Sama commented.

If health reform goes as planned and is successful, 38-40 million Americans without insurance will get coverage, which will increase emergency department use. If primary care coverage also expands for these patients as planned, “we may see a flattening or decrease in urgent visits,” Dr. Sama said in an interview.

He urged emergency physicians to develop comprehensive plans to identify frequent flyers “and then work with your organizations or community resources that are available to add social workers, care coordinators, and home care specialists to begin to focus on plans to do at-home, proactive, in-the-community assessments of these patients to lower the number of frequent users, which we hope will decrease hospital utilization, save money, and make the system better,” he said.

Wisconsin: Efforts to characterize frequent flyers have produced conflicting results because of great variance in this population. Amanda G. Polsinelli, a medical student at the University of Wisconsin, Madison, and her associates reviewed data on 779 patients who made emergency visits to their institution at least seven times in any year between 2008 and 2011. They differentiated frequent flyers (who were admitted less than 10% of the time) from “hot spotters” (who were admitted more than 50% of the time).

Most of the 779 patients were frequent users of the emergency department for 1 year only (77%), and 5% were frequent visitors in each of the 4 years of the study. Frequent flyers were younger (mean age, 38 years) and accounted for only 2% of admissions among all patients in the study; hot spotters (mean age, 48 years) accounted for 60% of admissions. Frequent flyers had a lower triage acuity and stayed in the hospital for 3 days on average, compared with 4 days for hot spotters.

Strategies for addressing frequent emergency department users should accommodate differences in these subgroups to be most effective, the investigators suggested.

California: Four studies were done by investigators with the University of California (UC), San Diego. The studies retrospectively analyzed data on 925,719 patients seen in more than 2 million emergency department visits between 2008 and 2010 in all 18 nonmilitary acute-care hospitals in the San Diego region. The data were drawn from the California Office of Statewide Health Planning and Development.

The 97% of patients who were “occasional users” (defined as one to five visits to emergency departments in 12 consecutive months) accounted for 79% of all visits. The 3% of patients who were “frequent users” (6-20 visits in 12 months) were seen in 16% of visits, and the less than 1% of patients who were “superusers” (more than 20 visits in a year) made up 5% of emergency department visits, Edward M. Castillo, Ph.D., and associates reported.

As a whole, the subgroups of frequent users accounted for a large and disproportionate share of emergency visits, reported Dr. Castillo of UC San Diego.

Respiratory and abdominal symptoms were the leading problems in each subgroup. The superusers were more likely to have Medi-Cal (California’s Medicaid program) (35%) compared with occasional users (18%) and frequent users (29%); they also were more likely to be self-paying patients (22%) compared with occasional or frequent users (14% each).

Patients with a “pain diagnosis” were 14 times more likely to be frequent users compared with occasional users. Patients with heart failure were seven times more likely to be frequent users, and patients on Medicare or Medi-Cal were five times more likely to be frequent users compared with occasional users.

A separate analysis of the data by Dr. Gary M. Vilke, professor of clinical medicine at UC San Diego, and his associates found that 8% of patients had at least four visits to emergency departments, accounting for 34% of all visits. Among these frequent users, 59% came for reasons unrelated to pain, 36% occasionally visited emergency departments due to pain, and 6% frequently gave pain as the reason for the visit.

Pain-related visits were defined as those with a primary diagnosis of pain, migraine, abdominal symptoms, head and neck symptoms, and other disorders of the back.

The “frequent-pain” users were younger, less likely to be admitted, and more likely to have a mental disorder and be dependent on or abusing drugs or alcohol compared with “non-pain” users and “occasional-pain” users. A total of 24% of frequent-pain users visited more than five hospitals during the study period, compared with 2% of non-pain users and 4% of occasional-pain users.

A third analysis of the data by Jesse J. Brennan and his associates revealed that, among patients with more than four emergency visits in 12 months, 81% were seen for nonpsychiatric reasons, 16% came in occasionally for psychiatric-related reasons, and 3% visited frequently for psychiatric reasons. “Frequent psychiatric users” were younger, more often male, and more likely to be admitted to an inpatient service and to leave against medical advice compared with nonpsychiatric or occasional-psychiatric users, according to Mr. Brennan, who is a statistician at UC San Diego, and his colleagues. Both occasional-psychiatric and frequent-psychiatric users were significantly more likely to visit more than five hospitals (8% and 27%, respectively) compared with nonpsychiatric users (2%). The difference between occasional- and frequent-psychiatric users also was statistically significant.

The fourth California analysis defined frequent users as patients who visited emergency departments 6-20 times during 12 consecutive months and superusers as those making at least 21 visits. Seventy percent of frequent users and 97% of superusers were seen in multiple hospitals. If individual hospitals used only their own data, they would fail to identify 33% of 28,569 frequent users and 66% of 1,661 superusers compared with using community-wide shared data to identify patients, the investigators calculated.

Part of the aim of the UC San Diego studies is to develop a regional system for identifying frequent users, Dr. Castillo said.

Dr. O’Connor noted that such a system would be valued in Virginia. “If we could have access to simple things – medications, diagnoses, and imaging studies that were done elsewhere – it would be much more efficient. We could save a ton of money and resources,” he said.

Massachusetts: Investigators at Massachusetts General Hospital and Beth Israel Deaconess Medical Center, both in Boston, hypothesized that frequent emergency department users would be more likely to visit due to nonemergent conditions that might be amenable to timely primary care, but their review of 65,149 patients who made emergency visits in 2010 could not clearly support that supposition.

Analysis showed that 2% of the patients were frequent visitors (making at least five visits), accounting for 12% of 91,198 visits. Frequent visitors were more likely to be older men insured by Medicare, Medicaid, and/or welfare compared with non-frequent users, S.W. Liu and associates reported.

Fewer visits by frequent users were classified as nonemergent compared with visits by non-frequent users (20% vs. 22%), but there were no significant differences between subgroups in diagnoses that might be addressed in a primary care setting.

After controlling for the effects of other factors, frequent users were 10% less likely to be admitted compared with non-frequent users, 39% more likely to come to the emergency department for a reason related to mental health, twice as likely to visit for reasons related to drugs, and four times as likely to visit for reasons related to alcohol.

General, nontargeted approaches to reducing frequent visits to emergency departments may not be productive, they concluded, and strategies that focus on managing mental health and substance abuse might be more helpful.

Dr. Sama, Dr. O’Connor, and Dr. Castilla reported having no financial disclosures. Disclosures for the other investigators were not available.

To read the article at its source, please Click Here.

Fact or fiction, emergency room nurses are having their moment in the spotlight as people tune in to watch the drama of their jobs unfold on television.

One thing is for certain, emergency nursing is different than any other kind.

“We treat all different age groups, from neonates to geriatrics,” said Larry Hamm, president of the Houston chapter of the Emergency Nurses Association.

“And we have to know all body systems and illnesses, from a heart attack to a stubbed toe.”

According to the U.S. Bureau of Labor Statistics, the median annual wage of registered nurses in May 2010 was $64,690. Emergency room RNs had an average salary of $68,610.

Overall employment of registered nurses is expected to increase by 26 percent between 2010 and 2020, faster than the average for all occupations.

Nurses are in demand; emergency room nurses even more so.

“The average age of nurses is rising, and as a result, nurses are retiring or finding other health-care opportunities away from the bedside,” said Michelle Henderson, RN, director of emergency services at Tomball Regional Medical Center.

“Emergency nursing is a specialty area that requires nurses with skills in customer service, critical thinking, time management and technical skills.”

Henderson said it’s an exciting specialty, because no two days, patients or shifts are ever the same.

Best suited for this career are people who can tolerate long work shifts, usually 12 hours at a time; and shift work that includes nights, weekends and holidays.

Hamm said ER nurses must be energetic in order to keep up with the fast pace; analytical in order to absorb what’s going on and anticipate changes; organized in order to effectively multi-task; and composed in order to work effectively with physicians, patients and families.

If this sounds like you, here’s how to get started.

Henderson said there are multiple educational paths for nurses, ranging from associate degrees to master’s degrees. Additional training specific to emergency departments includes basic life support, advanced cardiac life support, pediatric emergencies and trauma.

The way to get this additional training varies. Some hospitals provide internships, while others offer bridge programs to train nurses who want to switch from one specialty to another.

Hamm said one should earn an RN degree, then work a year or so in the nursing industry before transitioning to emergency medicine.

Once in the emergency department, Hamm said, a preceptor/mentor will “hold your hand until you are comfortable functioning as an ER nurse, and are familiar with that hospital’s policies and procedures.”

Hamm knows of what he speaks.

He worked in banking for several years until the industry collapsed, and jobs were hard to come by.

But he noticed many job postings for nurses, so he went back to school for a nursing degree. Hamm’s first nursing job was in intensive care.

“Working in the ER is a totally different mind set,” said Hamm, who works in the ER at St. Luke’s in the Texas Medical Center. “You concentrate on saving life and limb before sending patients somewhere else for continued care.”

To read the article at its source, please Click Here.

New research suggests that doctors are doing a better job of treating — and saving — emergency room patients whose injuries fall between mild and severe.

Between 2000 and 2009, the overall death rate for patients with moderate injuries who were treated in Pennsylvania hospitals fell almost 30 percent, from 7.2 percent in 2000-2001 to 5.7 percent in 2008-2009.

The findings, which appear in the August issue of the Archives of Surgery, don’t directly prove that better medical care boosted survival rates in these patients. Nor does the study indicate exactly what the hospitals might be doing better.

Still, the result “suggests that the quality of trauma care is improving substantially over time,” said study author Dr. Laurent Glance, vice chair for research in the department of anesthesiology at the University of Rochester School of Medicine, in New York. “It is likely that many incremental changes in medical care involving care of these critically ill patients in the intensive care unit and in the operating room are responsible for these improved outcomes.”

While much attention in the United States has focused on medical errors in recent years, the study authors noted that great strides have been made in the field of medicine in terms of helping people stay alive. Death rates from heart attacks and heart failure in particular have fallen markedly over the past decade or two.

In the new study, Glance and his colleagues sought insight into whether medicine is also doing a better job of treating patients who are admitted to emergency rooms with injuries.

The researchers examined the medical records of nearly 209,000 patients who were treated for trauma in 28 Pennsylvania hospitals.

Of the patients, 61 percent to 64 percent were male, and the percentages of patients with mild, moderate and severe injuries were roughly equal, at about a third. Blunt trauma and car accidents were the most common causes of trauma, followed by gunshots, low falls, pedestrian injuries and stabbings.

The mortality rates for people with mild and severe injuries didn’t change much during the study period, but those with moderate injuries were much less likely to die by 2009. The improvement remained even after the researchers adjusted their statistics so they wouldn’t be thrown off by high or low numbers of certain kinds of patients.

Certain kinds of complications became more rare, too, affecting 8 percent of patients in 2000-2001 and 6.4 percent of patients in 2008-2009.

What’s happening?

Dr. Matthew Ryan, an assistant professor of emergency medicine at the University of Florida, said several factors may be responsible for helping people survive trauma. For one, he said, emergency medicine doctors are better trained, and there are more standards about the care they should provide. Also, he said, trauma centers are more prepared to deal immediately with patients in dire condition.

Why didn’t mortality rates change for the mildly and severely injured? “We do not possess [the] skills, technology or aptitude to alter the outcome of patients who are mortally injured and beyond the care of our present state of the art,” he said. “The least severely injured are just that, and the odds of a fatality should remain at a baseline of near zero, or highly improbable.”

There are caveats, however, he said. The study looked at trauma centers, not other hospitals whose staffs may have less experience and training. However, he said, the overall good news is that “your trauma centers are well-equipped to help if you are acutely injured. Research and training over the years have prepared specialists to handle critically injured patients, and we are continually improving.”

To read the article at its source, please Click Here.

Doctors may be able diagnose a heart attack in one hour using a new test approach that could save time, money and crowding in hospital emergency rooms, researchers said.

Using more-sensitive screening technology to detect changes in cardiac troponin, a substance in the blood tested for evidence of heart attack, and inputting the data into an algorithm, doctors were able to determine whether a heart attack had occurred in 77 percent of patients within an hour of arriving at the hospital with chest pain, according to research published in the Archives of Internal Medicine.

About 10 percent of all emergency room consultations are for patients with heart attack symptoms, the researchers said. Limitations in older tools used to read troponin can delay heart attack diagnosis for as long as six hours and contribute to overcrowding in the emergency room, the authors said.

“There’s a bit more work to be done to show, that in a prospective fashion, by employing these algorithms you have good clinical results,” Kristin Newby, professor of medicine in the Division of Cardiology at Duke University Medical Center in Durham, North Carolina, and author of an accompanying editorial, said in an interview. “This kind of work sets the stage for that and ultimately helps move things forward.”

The more-sensitive blood tests aren’t available now in clinical practice in the U.S., Newby said. Basel, Switzerland- based Roche Holding AG, a sponsor of the study, donated the blood assay used in the research. Rising troponin levels are a marker of a heart attack. With conventional tests it can take three to four hours before doctors can detect an increase in troponin levels.

Test Results

The study published yesterday was also supported by Abbott Laboratories, Siemens AG, the Swiss Heart Foundation, the Swiss National Science Foundation and the University Hospital Basel.

The researchers looked at 872 patients who went to the hospital with chest pains. They used 436 patients’ troponin levels to develop the algorithm and validated the results in the remaining people.

Heart attack was diagnosed in 17 percent of all the patients. After using the algorithm, 259 people were classified as not having a heart attack, 76 were confirmed as having a heart attack and 101 were put in an observational zone within one hour of arriving at the hospital.
They found 30-day survival was almost 100 percent in those ruled out as having a heart attack, 99 percent in those in the observational group and 95 percent in the heart attack group.

Newby said the real opportunity for using an algorithm like this would be if it could be incorporated into electronic health records or hand-held devices to make it easier for doctors to remember all the information they need.

“These assays are incredibly sensitive. We’re still in some ways looking for how to implement them effectively,” she said. “This is a big step forward in understanding how to employ them in what can be a very confusing environment, to tease out heart attacks from many other things.”

To read the full article at its source, please Click Here.

Health researchers have long suspected that “cleaning and greening” overgrown, vacant lots does a neighborhood good, now they have gathered mounting — and solid evidence — that transforming nuisance properties pays off in health dividends.

For more than a decade, Philadelphia has paid the Pennsylvania Horticultural Society to rehabilitate neighborhood nuisance lots. The group now cares for about 8,000 rehabilitated properties.

“We see children walk down the middle of the street because it’s too dangerous to walk down by a vacant lot that’s heavily weeded,” said society director Bob Grossmann. “It’s a convenient place for drug dealers to stash their drugs and weapons, when the lot is cleaned and kept mowed, there’s no place to do that.”

Grossmann said clearing vermin and piled-up debris reveals a lot’s potential to local property developers and neighbors, like Andre Mears. This fall, the society cleared a lot across from the 66-year-old home near Temple University in Eastern North Philadelphia.

“The ones that aren’t cleaned up, they have been eyesores,” Mears said. “People had the tendency to just throw trash. You are going to see trash and tires and what have you, I think there is a respect for when it’s maintained.”

Grossmann rejects the idea that the society is an “outside” group that swoops into a neighborhood to fix things without community buy in.
“I get maybe six calls a day from people asking me to come out and do the lot adjacent to their house,” Grossmann said. “We take great care to talk to neighborhood residents when we do our work, many of our contractors are residents from that neighborhood.”

To read the full article, please Click Here.

Visits to emergency departments increased 60 percent faster than population growth over an 8-year period, and occupancy – or crowding – grew even more rapidly, mostly due to diagnostic tests and treatment intensity, according to a study published online yesterday in Annals of Emergency Medicine (“National Trends in Emergency Department Occupancy, 2001-2008: Impact of Inpatient Admissions Versus Emergency Department Practice Intensity”)

“We were surprised that ordering blood tests and administering IV fluids, along with other aspects of patient care, contributed more to crowding than advanced imaging,” said lead study author Stephen Pitts, MD, MPH, of the Department of Emergency Medicine at Emory University in Atlanta, Ga. “A rapidly rising tide of older, sicker patients combined with a an increasingly interventionist practice style is putting enormous pressure on a shrinking supply of emergency departments. This has ominous implications for patient safety and access to emergency care in the U.S.”

Researchers analyzed patient data for emergency department visits from 2001 through 2008. ER visits increased by 1.9 percent per year. Mean occupancy – or crowding – grew by 3.1 percent per year. Visits during traditional office hours increased significantly more than visits after hours. Visits for Medicare patients and adults age 45 to 64 grew faster than any other group. Non-urgent use of the emergency department exerted little or no impact on crowding.

“Ironically, it is possible that innovations intended to speed patients through the ER – such as authorizing the early ordering of blood work and x-rays at triage – may be bogging down patient flow instead,” said Dr. Pitts.

Advanced imaging – often blamed for delays in emergency departments as well as growth in costs – grew by 140 percent over the study period. However, researchers found that the net impact of advanced imaging on crowding was smaller than that of several other throughput factors, including clinical procedures.

According to study co-author Jesse M. Pines, MD, MBA, of the Departments of Emergency Medicine and Health Policy at George Washington University in Washington, DC, “We have to consider the study’s findings in the context of the wider health care debate in this country. Lengthy work-ups in the emergency department are not always a bad thing if they prevent a costly hospitalization. The problem is that more and more demands are being placed on emergency departments and the mood in the health policy community is to shrink emergency departments, not grow them. While everyone would agree that preventing emergencies is ideal, policies designed to pinch off an already overwhelmed emergency care system are not.”

Annals of Emergency Medicine is the peer-reviewed scientific journal for the American College of Emergency Physicians, the national medical society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research, and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies.

People aged 19 to 25 with public insurance were more likely than their uninsured counterparts to have had an emergency room visit in the past 12 months, according to a report (pdf) by the Centers for Disease Control and Prevention’s National Center for Health Statistics.

The NCHS report, “Health Care Access and Utilization Among Young Adults Aged 19–25: Early Release of Estimates From the National Health Interview Survey, January–September 2011,” provided estimates of young adults’ healthcare utilization.

Some of the key findings for patients aged 19 to 25 include:

• Of people with public coverage, 35.9 percent had an ER visit in the past 12 months compared with 25.1 percent of uninsured people and 18.3 percent of people with private insurance.

• Women (27.4 percent) were more likely to have had an ER visit in the past 12 months than men (19 percent).

• Twenty-nine percent of poor respondents visited the ER in the past 12 months compared with 19.9 percent of people who were not poor. Poor people were defined as having an income less than the poverty threshold set by the U.S. Census Bureau. “Not poor” people were defined as having an income 200 percent or more of the poverty threshold.

Too small to fail. That could be the battle cry of a little emergency department on the high plains of South Dakota, which is struggling to keep its doors open in the tiny city of Martin, the only town in the entire county. In many ways, it is no different from scores of others across the country, as emergency departments that provide care for the underserved fall victim to high costs and low revenue.

It is not that the emergency room, as the ED is invariably called at Bennett County Hospital, doesn’t have a high enough patient load. It is that it is too high, or rather, that the compensation for care is too low. “What happens is that everyone shows up at our door,” said Dale McDonnell, a lifelong resident and longtime member of the Bennett County Hospital board, which oversees the hospital, its ED, and its adjoining nursing home.
Some 200 patients per month are served by the ED, but many are covered by Medicare or Medicaid. Complicating matters, treatment for the local Sioux is almost free under provisions of a nearly 150-year-old federal treaty; the Indian Health Service pays only when the ED visit is a true emergency, Mr. McDonnell explained. “It is not surprising that they [enrolled tribal members] expect this. And we don’t disagree that they have this coming to them,” he said.

Medical clinics supported by the Indian Health Service, which are more than an hour’s drive away, put these facilities out of reach for some Native Americans because of distance, time pressure, or the need for highway transportation.

In fact, when it comes to providing care for Native Americans, which comprise about half of Martin’s 1,100 population, only one point is in contention. Board members believe the Indian Health Service ought to be paying a large share of the expense, but that isn’t occurring, and neither is adequate reimbursement from the Centers for Medicaid and Medicare Services, according to news accounts. The ED’s Medicaid patients, for example, are paid by a different, DRG-based formula than are some other rural hospitals in the state, which means Martin’s ED is paid about half of what other EDs are for the same patients.

And in a classic Catch 22, the 12-bed hospital is seen as among the most “access critical” on a list of critical access facilities in the state. Theoretically, this would make it top-priority for distress-targeted funding aimed at helping shore up such emergency care. But, in fact, this special status has only made it seem more difficult to navigate the bureaucracy, Mr. McDonnell said.

Still, Mr. McDonnell is cautiously optimistic. For one thing, the governor’s office is now taking note, and offering some newfound support. For another, the hospital is the town hub and its biggest employer, meaning the close-knit community is committed to saving its three ambulances and ED. In a place where the badlands meet the sand hills, “we are all survivors, and nothing dies easily out here,” Mr. McDonnell said.

But EDs are dying, and with chilling regularity, as results of a recent study show. Renee Hsia, MD, MSc, the lead author, said the 27 percent decline over the past two decades documented by her and two co-investigators, Arthur Kellermann, MD, MPH, and Yu-Chen Shen, PhD, indicate that low-profit margins are one marker of EDs susceptible to closure, and so is being a safety net hospital. For-profit status and keen market competition are associated with closings as well, she said. (JAMA 2011;305[19]:1978.)

“These aren’t necessarily earth-shattering results in the sense that most people would predict this from our market-driven approach to health care,” said Dr. Hsia, an assistant professor of emergency medicine at the University of California at San Francisco and an emergency physician at San Francisco General Hospital. “But interestingly, after the study was published, there were a lot of people who were surprised that there isn’t some kind of more rational system to decide who gets care — or who gets an emergency department — and who does not.”

The study excluded rural EDs, like the one in Martin, because rural facilities get critical-access funds, noted Dr. Kellermann, the director of RAND Health at the RAND Corp. in Santa Monica, CA. Even so, “emergency room care is a huge issue for rural America,” said Alan Morgan, the chief executive officer of the National Rural Health Association. “There is an ongoing struggle to keep access to this care in America.”

Perhaps nowhere has there been more evidence of this struggle than in California, where agricultural communities are grappling with the same financial pressures as urban centers. This past year, Dr. Hsia and other colleagues from UCSF looked at California EDs, and found, unsurprisingly, that minorities and Medicaid patients were at higher risk of losing their EDs than other groups (Ann Emerg Med; in press).

For the past decade, California has been losing EDs almost routinely. But this is not a West Coast phenomenon or limited to pockets of high immigration. New York City’s St. Vincent’s Hospital in the affluent West Village succumbed to similar financial stress, as did Lenox Hill, which has been characterized as “the boutique hospital of choice for Upper Eastsiders.” It was taken over by North Shore-Long Island Jewish Health System. (New York, October 25, 2010; see FastLinks.)

In fact, St. Vincent’s may have been one of those that showed up in the survey from the American Hospital Association, which Dr. Hsia and her colleagues used to analyze the years 1990 to 2009, when EDs declined from 2,446 to 1,779.

The results of this nationwide study provide a reality check for those who thought the shake-out of EDs was winnowing down, Dr. Hsia said. “I think this offers information that tells us something has to change, and I think that’s important because we do have the ability to change,” she added. Such a shift will take more health care activism and legislative support for financially challenged emergency care. “But I think the momentum is there,” Dr. Hsia said.

In contrast, Sandra Schneider, MD, the immediate past president of the American College of Emergency Physicians, conceded that her attitude is more one of pessimism. “I have to say I am a little bit doom and gloom,” she said, but added that “it has been said that challenges mean opportunities, and that is one of those things that really is true, after all.”
The medical home, which has been promoted as one solution, simply will not provide an answer for many people who need urgent care. It is not, as the charming moniker would suggest, a place where health care consumers can seek care whenever they need it, she said. Instead, it refers to coordinated care, in which their various health care experiences and contacts with providers can be collected and monitored, not fall through the cracks, as has been the case at times. This is unlikely to lighten the load to EDs, said Dr. Schneider, a professor and the chair emeritus of emergency medicine at the University of Rochester in New York.
“Given that the idea of a medical home is just a concept at this point, and we don’t know how it will be operationalized, it’s hard to predict,” Dr. Hsia agreed.

In addition, the burden some legislators believe is being placed on their coffers due to over-reliance on EDs has meant some states are looking at barring payments from Medicaid or Medicare for certain ED visits. Dr. Schneider noted that this idea seems to be gaining traction in Washington State, where Medicaid may be curtailed for ED care if the state passes a proposed law. This seems destined to worsen the situation for at-risk EDs.
Currently, the Washington State Hospital Association is soliciting support to put a stop the effort. “The Washington State Health Care Authority plans to stop paying for all emergency department visits for Medicaid patients when [it] deems those visits ‘not medically necessary’ in the ER,” the association warned on its website (See FastLinks.)

In response, the association is promoting an alternative, and developed a plan with the Washington State ACEP chapter and the Washington State Medical Association. An online petition asks website visitors to join in asking the Washington legislature “to enact a physician-developed plan to reduce emergency visits that will save millions of dollars and still protect patient safety and access to quality care.”

It is presumed that if Washington begins to decline publicly funded care like Medicaid payments to EDs, other states will follow suit. Already there are rumblings in some parts of the country, such as the South and Midwest, that plans with “decline of payment” options make fiscal sense.
When a team of health researchers from the University of Kansas looked at money-losing health care facilities in that state, it found that focus groups of nurses, physicians, administrators, and community leaders in each of 10 places had similar concerns. The overwhelming majority identified aging populations, growing poverty, and declining rates of insured patients as a problem. (Kansas J Med 2009;2[3]:62.)

The uninsured and poor are increasingly blamed for patient overflow in EDs, Dr. Schneider said. And with good cause. A study at her institution, however, showed that ED use, even in the daytime, is often not by those who lack insurance or have no access to primary care.

Patients in the waiting area at her medical center’s ED were surveyed by a colleague, Michael Kamali, MD; he and emergency medicine colleagues found that most of the 400 patients they questioned did, in fact, have physicians, but they could not get in to see them in a timely way. In fact, some of the primary care doctors presumably had advised their patients to go to the ED. (Ann Emerg Med 2011;58[4]:S234.)

In some ways, it only echoes what Rochester researchers found more than 35 years ago. “A subject of particular concern is the type of problems that people bring to the ER because it is evident that, contrary to its traditional function as a facility for urgent medical needs, substantial numbers of people now use the ER for treatment of routine, nonurgent problems,” the investigators wrote in a 1975 study. They noted that a third to a majority of the visits even then were for “problems that might more readily be treated at an outpatient clinic or private doctor’s office.” (Med Care 1975;13[12]:1033.)

Anecdotal accounts encompass stories of patients who prefer using the ED to their own physicians for reasons other than availability. They include a woman who wanted an emergency physician with whom she felt special rapport to become her primary care provider and a man who reported he kept getting ointment and pain pills for an infected knee during office visits, but was ultimately diagnosed in the ED as requiring surgery.
Dr. Schneider noted that one innovation to help answer such need is the freestanding emergency medical center, which has shown success in Texas. The concept was put into practice by Tim Seay, MD, an entrepreneurial emergency physician and a founder of the Greater Houston Emergency Physicians in Houston, which staffs EDs.
Another development cited by Dr. Schneider is paramedics in North Carolina and Texas who make the modern equivalent of the house call of yesteryear by stopping by to check on patients with chronic illnesses, sparing them a trip to the physician office that they need but might not make, which would typically result in an ambulance call. The paramedics stay in touch with the physicians in the program, providing them updates on these patients, and taking instructions when a situation arises in which they need guidance. This means fewer emergency calls for elderly people who need medical care but who have a difficult time getting out to access it, she said.

The answer to the current crisis is likely, at least in part, to come from the profession itself, in the form of “outside-the box” ideas, Dr. Schneider said. When something survives, she said, it is usually because the people involved in it say, ‘OK, how can we make this work?’”

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