When Will Emergency Rooms Go Back to Being Emergency Rooms?

The University of Chicago hospital made headlines this week when it was criticized by the American College of Emergency Physicians for a plan that tries to get non-emergency patients out of its emergency room.

I’ve been fortunate to have only made one visit to the University of Chicago emergency room in the five years I’ve lived in Hyde Park. My youngest daughter Sophie was the reason for the visit. What had seemed like a run-of-the-mill kid’s illness had taken a turn for the worse. She had become extremely lethargic. She wouldn’t eat or drink and she had been vomiting, so we figured she was likely dehydrated. I took her to the University of Chicago emergency room at about 9 a.m. on a Sunday morning.

My visit started like most other visits to emergency rooms. When we arrived, there must have been 30 people in the waiting room. All of them were African-American. I filled out some paperwork and waited for the triage nurse to call my name to hear Sophie’s symptoms. At least half an hour passed and nothing had happened. I’m not usually very aggressive, but Sophie was looking worse and worse. So I went to the triage nurse and tried to do anything I could to see a doctor. I started by describing a set of symptoms that sounded like meningitis, even though she didn’t have all those symptoms. The nurse seemed unmoved. I then told her I had a son who died of meningitis. That definitely got her attention; but when she asked when he had died, and I said five years ago, she was much less impressed.

I guess she originally thought I meant he had died yesterday of meningitis. I told her that Sophie had become nonresponsive (and Sophie complied, staring off into space absently). I told her I was a professor at the university. I told her I would get my pediatrician on the phone. I’m not sure which of these strategies actually worked (I think it was being a professor), but within 10 minutes I was in to see a doctor. It turned out Sophie was badly dehydrated. They put an IV in her and she sprung to life. Our visit still took four to five hours. As we left, I was shocked to see that most of the people sitting in the waiting room when I arrived were still in the exact same spot, not yet having seen a doctor.

I don’t know the full history of emergency rooms, but I can’t imagine that the folks who designed them ever imagined they would turn out the way they have: a place where patients with no health care go to first wait six hours and then get routine care.

It is a system that makes no sense. If you read the description of what the University of Chicago hospital is trying to accomplish with its Urban Health Initiative that is being criticized, it does make sense.

Or you can do what my grandfather did and just avoid emergency rooms altogether. My grandfather was a doctor who practiced into his 80’s. I heard the following story from my father, so who knows what part of it is true, but this is how the story goes.

One day, while at home, my 80-something grandfather realized that he was likely having a stroke. He called in a prescription to the drugstore around the corner for some clot-busting drugs and sent my grandmother to the pharmacy to pick up the drugs. He crawled upstairs and got into bed. When my grandma got home, he took the drugs and just waited to see whether or not he would die. It turned out that he lived, with no noticeable side effects, which makes me wonder how true the story really is. One facet that I know is true, however, is that a man who spent 60 years of his life practicing medicine would do anything in his power to stay out of the hospital.


Edwin Steussy

After two episodes of arriving at an Emergency Room to find exactly the same situation (both cases were potentially life-threatening), we've hit on always calling 911 for an ambulance. With the ambulance service, you get qualified people looking at you immediately and they will handle the triage to get you to a doctor.

Regarding the comment from Mike, I don't think he has had the pleasure of having a loved one horribly ill and withering in front of you, while nurses routinely ignore your presence. You need to get their attention any way you can. I worked at a hospital for five years in the 80's and have three doctors in my family - I know it does not have to be this way.

MS

Of course, everyone in the ER thinks that their problem is an emergency -- including you and your daughter. For many (40 percent according to the link you posted) it turns out not to be an emergency -- also including you and your daughter.

I don't get it. You probably have enough money. Don't you have a family doctor? Or a doctor you know who you could call? Or were you trying to save a few bucks?

And I'm with #2, using your influences to help yourself and only yourself make you sound like a prima donna.

aaron

@Mike

He mentioned that she wouldn't eat or drink, was vomiting, and that she was getting worse. I think he took the proper action going there as he had no way of knowing the actual root cause of the problem, if making her drink when she didn't want too was dangerous or the routine illness was something more serious.

Now he did override the judgment of the triage nurse by giving her false info which isn't proper, but honestly given a parent with a sick child you're going to have to expect that. It's obvious from this article that the emergency room is being used by a lot of people who should go elsewhere. What isn't obvious is if the triage performed its proper function. For instance if the triage nurse was initially correct in thinking his daughter could wait longer and if the other people were able to stand waiting longer for treatment.

It seems that there's two kinds of people who go to the emergency room, those with a medical emergency, and those who want quick and convenient treatment. If you can redirect the second group to alternate institutions than you've removed a lot of the problem.

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JoseAngelCMS

It's stupid to call an Emergency Room one, when doctors are not ready to attend in case of an emergency. Doctors never appear and nurses are never ready to look at the people with any type of emergencies. The first thing they ask is for them to fill in a set of paperwork, when there are some patients who's emergency doesn't allow them to write.
My sister is studying at Babson College and a friend of hers had to go to the hospital; she was not being able to breathe properly due to an asthma attack. My sister took her to the Emergency Room, and when they arrived they were told to fill out some paperwork, which my sister did for her, and even though the nurses saw how bad my sister's friend was, they did nothing until my sister filled out all the paperwork. Fortunately, the help arrived before it was too late.
The Emergency Rooms are called Emergency Rooms because they are supposed to treat any type of emergencies. There are some people, who in the case of an emergency just don't have the time to fill out the paperwork or anything, and they shouldn't be forced to fill them, losing so much time, therefore reducing their chances of survival.

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Chad Albert

The key to clearing out the emergency departments is actually pretty simple, but nobody wants to take the steps needed to do so. The modern emergency department is the catch basin for the health care system. If you don't need emergency services, you should be referred to another provider. Period. And this should be done without regard to insurance. If you have insurance that will pay for an ER visit when you could be seen by your primary care care MD, you should be bounced just like the uninsured or medicaid patients. Also, more time and money needs to be spent training paramedics to do field triage to determine whether or not you will be transported to an ED, or an alternate treatment facility. Currently, most (I'd hazard a guess to around 95%) of ambulance agencies are required, either by law or protocol, to transport to an emergency department.

Al Dugan

Couple things here.....A hospital near us has a split emergency room. If a child comes in, they are sent to the pediatric ER right down the hall. It has a pleasant enough atmosphere and the attention given the children appears to be more timely.

Illnesses are not diagnosed as they are on TV. Time will go by.

I have been a patient in emergency rooms several times int helast two years. And I once spent an entire day (yes an entire 24-hour day) in one. But there care was great! I got better, and time moves on.

I think a lot of it is trust. We don't trust the doctors and nurses to know what they are doing. We think they are ignoring us, but yet they could not function without ignoring us. Trust the folks in the ER to know what they are doing. I have been there 5 times in 2 years, and I'm alive typing this and have absolutely recovered.

Speed

An elderly lady I help was sick. I got an immediate appointment with her primary care physician who decided she (the patient) needed to be hospitalized. "Take her to the emergency room. They'll admit her." And they did.

The ER has become the way into the hospital for all but routine elective admissions. And for many it is the way into the health care system.

RT

MS,

If their PCP is anything like mine or any other PCP I've had, then they would have just told them to take her to an ER or an Urgent Care facility. My doctor does not have the ability to give IV fuilds, which is what his daughter needed. It doesn't matter how much money you have, the ER is still used for Emergencies, which he had. Usually ER visits with insurance is most costly than just visiting a doctor. And if your situation is not deemed an emergency by the health insurance company, they can decline payment.

However, ERs cannot turn away care, even to someone who has an unpaid medical bill. Uninsured go, get care, and may or may not pay.

Lisa

People get seriously ill on the weekends or at night or other times. This is the primary reason I've had to go to the E.R. Primary care physicians are only available during normal office hours and they are usually booked weeks in advance.

Sometimes something is wrong and it is bad enough that you are scared. You need a doctor to help you find out what it is. It isn't a planned thing and NOBODY wants to spend hours and hours and hours in an E.R. trying to get help. But what is the alternative?

Frank

at # 22, i don't know too many people who can afford health care that willing go to the emergency room to "save money". For me, the ER fee is at least 4 times the fee i have to pay for a general practitioner. This means i only go to the ER for emergencies, and if it can wait, i make an appointment. When your kids are involved, you usually err on the side of caution.

Kevin H

Emergency rooms will only go back to being emergency rooms when we do one of two things

1) Pass a law, (and get physicians to agree) that anyone who doesn't have insurance cannot recieve treatment in an emergency room.

OR

2) Provide a mechanism where >95% of the population can afford routine care.

My vote would be for 2, and that probably means some form of state subsidized plan.

Oddly enough, simply moving people out of the emergency room and into more acceptable settings will also save lives and money. Inefficiencies = potential savings.

Tom

It is grossly false to say that everyone in the ER thinks that their problem is an emergency. Many uninsured people use ERs as clinics and expect long waits. That's not Levitt's fault; it's a problem with the system.

Levitt could not triage everyone in the room. His daughter was very, very sick. Unless it was obvious that someone else was even sicker, he had to act on with what he knew, and do what ever he could to take care of his daughter.

Social justice is a Good Thing. But when your kid's life is in danger, you can't be getting all squishy about first-come-first-served. Or whether some people think you're a prima donna.

C R

Lots of interesting feedback on hospitals and ERs. I've had too much experience recently and agree on the severity matching the time waited. (BTW--we have excellent health coverage but did have emergencies.)

One Sun morning my husband was in excrutiating pain from a kidney stone that had cropped up overnight. I recommended we go to the hospital nearer us without a trauma unit. We got in right away--clearly a good choice for a non-trauma. (We have a pretty good test case there as his sister was in the hospital with a trauma unit also with a kidney stone--very weird coincidence--but a good test case. And their brother is an ER surgeon in the hospital with trauma so that's a "pretty good string" if such things worked but still we did better in the non-trauma area.)

A year ago our 2 year old son was admitted with a severe allergic reaction. We were taken without even being seated--they knew right away.
Five months later we came in after a car accident and were again taken right away. Our son didn't seem injured and he was fine. It took longer for me to be seen, even though I had a minor to medium injury.
A few months later our son developed swelling in the lips. I didn't think it was allergy but called the doctor. As it was the evening, they said take him to the ER just to be sure. We waited a long time and it was "hoof and mouth" disease.

Three for three I'd say.

So on top of the good suggestions above, I say go to a non-trauma hospital if you're not a trauma. (Or a place with a good Pediatric ER if that's relevant.)

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Don

Where I live, the major healthcare organization has hospitals with emergency rooms as well as smaller clinics for non-emergency care. The instant care clinics can provide any kind of care that you need at night and on weekends when your primary care physician may be unavailable either because they're too busy or it's after hours. I don't know how it is for everyone else, but for me it seems like my kids always have problems Friday night, so we've got the whole weekend to wait until the family doctor is available, so we end up most often going to the instant care clinic. The way our insurance works, a visit to the instant care clinic is the same as a regular office visit, so you're not paying higher emergency room copays. Then if you need to see a specialist, the instant care clinic will give you a referral that will get you into the specialist right away, instead of having to wait a month if you called the specialist first.

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Tarak

Having been a physician and worked in Emergency rooms. I think what people (general public) see as emergencies differs from what truly is a medical emergency emergency.

I do think ER's can do a better job of triage. For example a nurse can take the vital signs as soon as you register to immediately identify people who are hemodynamically unstable or in respiratory distress.

Majority of the cases that come to ER's and especially in cities is non-emergency. I would say from my experience about 75-80% are non-emergencies. So you have all these non-emergencies filling up beds in the ER.For exapmle if the ER has 20 beds. Most ER's will always leave a bed or two open in case of an emergent trauma or for a cardiopulmonary arrest (CODE BED). The other beds are filled up by non-emergent cases. Most cases, even extremely simple cases take afew hours in ER because ER's have to practice defensive medicine. They have to order a lot of labs and diagnostics because of the possible legal liability. Very rarely will you go to an ER and not get a blood test or an X-ray. Another factor is that if there are not enough nurses even, if you have the beds you can't bring patients back and use the rooms.

Your daughter probably had moderate dehdration and would have been fine if she was seen 4 or 5 hours later. I know it would have caused you a lot of discomfort. I'm not saying that the other people already being treated are more sick than your daughter but they have used up the available resouces and the ER would have to use the resouces that they have in reserve to treat your daughter. People have to realize that true emergencies are acute trauma to the chest, head, abdomen..., Myocardial Infarctions, Strokes, Gastrointestinal Bleeds, respiratory failure... The biggest complaint that I see is from people who think a sprained ankle, broken foot, hand, laceration is an emergency. Yes some conditions may cause pain but in reality if there are limited resouces they can wait a few hours before they get stabilized.

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aaron

@JoseAngelCMS

Well I think if someone came in in obvious and immediate peril they'd be able to skip the paperwork and get immediate treatment. There's obviously some conditions triage nurses will miss but on average I'm guessing someone told to fill out paperwork isn't someone who's about to fall over dead.

Hmmmmm

Wow. Some of these comments are unbelievable. Last I checked Stephen was an economist not a doctor. He has also had a bad experience with a child's illness in the past. You better believe if that was me I would be doing everything humanly possible to get my child seen pronto.

It is easy to say, she was just dehydrated, but exactly how was he supposed to know that?

With two kids and general family mishaps, we have been to the emergency room many times.

Our priority for determining this route is:
Any severe bleeding? Yes. 18 month old taken and ends up with stitches

Any wild pain or discomfort? Yes. Once a kidney stone was being passed and my husband was in so much pain that the other people waiting in the ER asked for him to be allowed to go first. Needed IV fluids

Is everything else closed? Yes. Christmas Day snowstorm, ear infection leading to busted eardrum. ER trip.

Fever and sick on the weekends? No. Check with Urgent Care. Get scrip and start kids on Anti-biotics ASAP.

Everything else is at the mercy of regular Dr. visits.

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Fool on the Hill

If you have a point in noting that everyone in the waiting room was African-American, it was lost on me, particularly because according to the census, 100% of people living in the University of Chicago Medical Center's ZIP (60637) are African American.

lobosolo

it only took you four hours ? wait til we get more socialized medicine and those four hours will seem like the good old days...
have you ever noticed that people who have health benefits from the the tax payers will run to the emergency room for everything, while people who work and have no insurance will crawl to work and push through the pain....

Alex

There's a rather large population of people who have their healthcare paid for in their own facilities and that belong to a purely American institution--the Armed forces and their families.

It would probably be an interesting study to compare folks on military health care (not the troops, but their families) to the norm (if such hasn't been done already). I was a military brat--and while we did have waits in the ER, it was never for too long. (Undoubtedly because routine healthcare was taken care of, since it was free.)

I was shocked when I graduated out of the system and had to deal with civilian health care--it seems almost barbaric at times. My parents still can't believe how much I pay yearly, even as a healthy person with good insurance.