ER Care, Stat!

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By Sandra G. Boodman
Special to The Washington Post
Tuesday, September 16, 2008

After two weeks of hoping her abdominal problems would improve, Sharon Dailey couldn't wait any longer. So one morning last week, she got dressed and headed to the place she'd gone when she accidentally sliced off the tip of her finger and when she broke her toe: a Northern Virginia emergency room.

Less than 10 minutes after the 68-year-old Alexandria resident arrived, a nurse ushered her into a treatment room. A few minutes later a doctor examined her, then ordered a CT scan for which she was quickly prepped.

"The care here is excellent," said Dailey, sipping ginger ale before she headed to the radiology department for her test.

Dailey's streamlined experience at the Inova HealthPlex at Franconia-Springfield differs radically from the ordeal familiar to many of the 119 million Americans who seek treatment annually in the nation's hospital emergency rooms. Their ranks have increased dramatically in recent years, federal authorities reported last month, although the number of ERs has shrunk.

HealthPlex's full-service emergency department, which can treat everything from heart attacks to finger "lacs" (ER-speak for laceration), sees close to 33,000 patients annually, nearly as many as the emergency department at Georgetown University Hospital. Unlike traditional emergency rooms, it has no inpatient beds. Patients who need hospitalization or surgery are transferred by ambulance to surrounding hospitals, most to Inova Fairfax, seven miles away.

Experts say that HealthPlex, which opened in 2001 and is designed to divert patients from the ERs Inova operates at Alexandria, Fairfax and Mount Vernon hospitals, is an innovative, patient-friendly response to one of the gravest problems facing the fraying health-care system: overcrowded ERs. A similar free-standing unit, the Shady Grove Adventist Emergency Center, opened last year in Germantown.

Packed emergency departments are "definitely a symptom of deeper problems in health care," observed Caroline Steinberg, vice president of trends analysis for the American Hospital Association. While addressing overcrowding requires multiple approaches, freestanding ERs such as the one at the HealthPlex "are a very effective strategy."

For years, blue-ribbon panels from the Institute of Medicine, as well as officials at the American College of Emergency Physicians (ACEP) and the American Hospital Association have warned about deteriorating conditions in the nation's emergency departments; a 2006 IOM report is titled "At the Breaking Point."

All agree that emergency rooms are caring for more patients who tend to be sicker than their counterparts were a decade ago. A report released last month by the Centers for Disease Control and Prevention said that the number of ER visits rose from 90 million in 1996 to 119 million in 2006; during that same period, the number of hospital emergency rooms decreased from 4,109 to 3,833. The closures include D.C. General Hospital, which was shuttered in 2001.

Increasingly, ERs are jammed with patients lining the hallways on gurneys, like planes waiting to take off at an overbooked airport. In a horrifying illustration of the problem, a 49-year-old day-care worker died three months ago on the floor of an ER waiting room in Brooklyn, N.Y. She had spent nearly 24 hours waiting for doctors to treat her and lay unattended and unconscious for an hour.

A recent ACEP survey of nearly 1,500 emergency physicians found that 13 percent said they had known a patient who died while "boarding" in the emergency room, waiting for an inpatient bed. Earlier this year, Harvard Medical School researchers who analyzed how long it took for ER patients to see a doctor, reported that 25 percent of heart attack victims waited 50 minutes or more in 2004, a delay that could prove fatal. In 1997 the average wait for a heart attack patient was eight minutes; in 2004 the average was 20 minutes.

Many emergency rooms, including some in the Washington area, are frequently gridlocked by a shortage of inpatient beds, doctors say. As a result, patients may spend as much as 48 hours boarding in the ER. Diversions, in which hospital ERs are so packed they temporarily close their doors to ambulances, sending patients farther away, are routine. These strains are compounded by an aging population that tends to use more emergency services, a dearth of primary care doctors, a chronic nursing shortage, hospitals that cling to outdated ways of doing business, the financial burden imposed by uncompensated care, and the reluctance of physician specialists to provide on-call care for which they may not be reimbursed.

"I feel like we're losing ground every year," said Jon Mark Hirshon, a past president of the Maryland chapter of ACEP and an associate professor at the University of Maryland School of Medicine. "We're dealing with a crisis on a day-to-day basis."

Patients come to the ER, said Thom Mayer, formerly the longtime chief of emergency medicine at Inova Fairfax, because it's the one place they can be sure of receiving care, even if means a long wait.

"We provide a tremendous amount of care for people with two jobs and no health insurance who may not get out of work until 11 p.m.," added Mayer, who has written several books on emergency department operations. Increasingly, Mayer added, emergency rooms are seeing patients sent by their physicians for a high-tech test such as a CT scan or MRI that needs to be performed quickly and cannot be obtained in a doctor's office.

Shorter Waiting Times

Located in a sprawling office park in Springfield, the HealthPlex ER, like its counterparts in Fairfax City and Reston, may be well known in medical circles but not among the public. HealthPlex director Rachel Mooney said that she gives tours at least once a month to physicians and administrators from across the country but that many area residents still head for a hospital ER if they need treatment.

"We can do everything here that a hospital can do from an ER perspective," said Mooney, a registered nurse who worked for a dozen years at Fairfax's 52-bed ER. Heart attack patients can go "from arriving at our door to the cath [cardiac catheterization] lab at Fairfax in 90 minutes," she said. "We've done it in 60."

A few weeks ago, the 12-bed HealthPlex, which is usually staffed by two board-certified emergency physicians and eight nurses, treated a youth with a gunshot wound; heart attack and stroke patients are common.

The average visit to the HealthPlex ER takes about 2 1/2 hours, Mooney said. Her goal is to reduce the "door to discharge" time to two hours by the end of the year. The average waiting time in a Virginia ER is nearly five hours, according to the consulting firm Press Ganey, which studies ER operations.

The maximum boarding time at the HealthPlex is four hours, said nurse Yvette Dean, the management coordinator. Patients who are transferred to Fairfax, she said, are usually able to get an inpatient bed fairly quickly.

One reason HealthPlex visits tend to be speedy is the presence of lab and radiology departments on site, both of which operate round-the-clock. Both places tend to be major bottlenecks in hospitals, Mooney said.

"There is minimal wait for lab, ultrasound and radiology here," she said, adding that the average turnaround time for an X-ray is about 10 minutes.

HealthPlex also uses a practice known as advance triage, under which tests are ordered for patients with certain ailments, such as belly pain or a sprained ankle, even before a doctor sees them.

"All the diagnostics are cooking" by the time a doctor first examines a patient, Mooney said.

HealthPlex has advantages its counterparts at major hospitals lack. Nearly 90 percent of its patients have some form of insurance. And only 10 percent are so sick they need to be admitted; Inova Fairfax admits about 30 percent of its ER patients, according to Mayer. GWU's ER chief, Robert Shesser, said the rate at his hospital is 25 percent.

"Patients with minor injuries are not the cause of crowding" in the ER, said Shesser, whose 34-bed emergency department is the city's third busiest. "It's housing the admissions that's the problem." Hospitals have become the social and medical safety net, he said, and are treating more patients with "complex medical and social issues."

Self-Inflicted Wounds

Some problems facing hospitals are self-inflicted. The IOM notes in its 2006 report that "many are the result of operational inefficiencies in the management of hospital patient flow."

Among these inefficiencies are the custom of discharging inpatients late in the day, which impedes bed turnover; the practice of scheduling most elective surgeries early in the week, which are also the days emergency departments are the busiest; and 9-to-5 scheduling for much of the staff, including housekeepers, which delays moving patients out of the ER and into a bed.

One of the most radical and successful approaches to reducing overcrowding was pioneered several years ago at Boston Medical Center, one of the nation's busiest and most-overcrowded ERs.

Called "surgical smoothing," it involves scheduling elective surgeries throughout the week, rather than concentrating them on Monday, Tuesday and Wednesday. Few hospitals have embraced the concept, which tends to be unpopular with surgeons, on whom hospitals are dependent for revenue and patients.

GWU has not adopted it, according to Shesser. Mayer said "it is being worked on" at Inova Fairfax.

Maryland's Hirshon said that another promising tactic involves boarding one or two patients on inpatient floors rather than letting them pile up in the ER. That practice, he said, keeps the pressure on other parts of the hospital to move more quickly.

But, he added, ER overcrowding is symptomatic of bigger problems in health care.

"We're the canary in the coal mines," he said. "What we don't want is to have the canary die."

© 2008 The Washington Post Company

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