Holdover In the ER

By Abigail Trafford
Tuesday, May 31, 2005

Jonelle Rowe, 64, of the District, woke up at 3 a.m. with an acute attack of colitis. Rowe, who is a physician, realized she had to go to the hospital and dialed 911. The ambulance team came "in a flash," she recalls. They gave her oxygen, started an intravenous line and took her to the emergency room.

For 13 hours she was immobile on a gurney with the safety sides up. She was vomiting and in pain. At times, she was lying in her own bloody feces. It took outside physician pull to get her admitted finally to the intensive care unit.

Rowe was what's known in medical circles as a "boarder" -- a patient who waits in the ER for a hospital bed to open up. Boarders are sick enough to need hospital care, but ER staff is usually too overwhelmed to give them much attention. Rowe was given pain medication and a barf basin, but mostly the nurses rushed by. "They don't have staff," Rowe says. "They are working as hard as they can. It's a system problem."

Boarders spotlight a gap in medical care -- and in homeland security that political leaders refuse to see. The hospital is not as visible as a bridge or a nuclear power plant, not as symbolic as the White House or the Statue of Liberty. But emergency rooms form the front line against injury and illness -- whether the attack on civilians is caused by bacterial agents or enemy agents.

Rowe's story is a familiar one to ER physicians. "It's happening all over the country, and it is driving us crazy," says Arthur L. Kellermann, chairman of emergency medicine at Emory University. Boarders can be stuck for 12, 18, 24, 36 hours in the ER, he says. "Public officials are in a state of denial. What would we do in a bioterrorism attack?" Or an outbreak of an infectious disease such as SARS?

ER physicians have to triage patients. Rowe hadn't been hit by a car. She wasn't having a heart attack. She didn't need immediate surgery. "So she's not on top of the list," explains Sheila Coin, a former nurse and neighbor who accompanied Rowe to the hospital. "On the other hand, you have someone her age, who is bleeding and in pain."

The boarder phenomenon arises because there are not enough hospital beds and nursing staff to accommodate all the patients who need to be admitted on an emergency basis. Financial incentives reward hospitals for keeping their beds full, which favors patients scheduled for elective procedures. As a result, few empty beds are available for ER patients. Besides, Medicare pays hospitals more for taking care of a patient who has elective surgery than a patient like Rowe, who has a medical emergency. So there is built-in financial resistance to admitting many patients from the ER.

Yet, boarding is hazardous to health and it increases costs. Last week at the annual meeting of the Society for Academic Emergency Medicine in New York, researchers presented a study of 50,322 patients from 120 hospitals who were admitted to the ICU from the ER over a three-year period. Boarding in the ER for more than six hours led to increased mortality in the ICU and on the medical floor, longer hospital stays and higher than expected costs.

Still, official Washington remains indifferent. Boarding is not a problem confined to the poor in the inner-city or the more than 40 million Americans without health coverage. Rowe is medical aristocracy -- a physician with comprehensive insurance and connections. She had run a neonatal intensive care unit at a university hospital in Connecticut and moved to Washington about eight years ago to work on health policy. She knows how to navigate the system. "I probably got a little preferential care," she says.

She also has family support. Her younger brother, an internist and gerontologist, rushed to her bedside, telling her: "No relative of mine is going to be in the hospital without me being there." That's what insiders think of the state of care. After a stint in the ICU, Rowe was moved to the medical floor. Her brother checked her chart, monitored her vital signs. After she was discharged, he cared for her in her apartment.

Rowe has recovered. As she says: "Nobody killed me." But the experience has left her shaken.

Health care is crumbling. Education, status, health coverage--none of it matters in a crisis. "If it can happen to me," Rowe points out, "it's going to happen to all of us." ยท

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