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.


Caliphilosopher

"All of them were African-American."

What exactly does this have to do with your story about getting ER care? It's quite meaningless, and can easily be construed in a way that you might not want.

d

Seems like the point some comments are missing is that folks without insurance often don't have access to ANY other medical care. Walk-in clinics are good for non-emergencies, but they also cost money. Something that many without insurance also don't have. I don't think I've ever visited a walk-in clinic for something like the flu and gotten away without paying 100+.

I've had excellent health care through insurance for many years, but recently have also seen the flip side. I'd suggest that anyone who has never been without health insurance (you , too Steven, for eye-opening research!) visit Stroger Hospital in Chicago.

There are people there trying to NOT tie up emergency rooms, yet still get some medical care. The wait is approx. 8 hours, and you need to get there very early - once it gets to be mid-morning, you won't even be given a number. Go in the dead of winter, using public transport. Bring a book, and a bag lunch - you'll be there for quite some time, likely the better part of 2 days by the time you fill any prescriptions at the pharmacy.

That's the reality of healthcare for many, many people. That, or the emergency room. Where, unfortunately, the 'squeaky wheel does get the grease,' and you have to be your own best advocate for care.

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Alfred

Point 1, If patients aren't seen how does anyone know if they have a true emergency or just need routine care?

Point two, U of Chicago's recent problem stems from dending home a severely mauled child. The parents had better sense than to take U of Chicago at their word went to Cook County Hospital where it was immediately recognised that the child needed surgery at once.

point three, Th University gets a tax break as a nonprofit for services it seems not to want to deliver. Research is great, but don't take a tax break for treating the poor unless you treat the poor.

RobLL

dehydration is an emergency at any age. IVs are generally the solution (pun - funny), and take very little time to set up, and nurses time to supervise. So don't really delay those other people who are still in line.

Our local hospital is developing a monopoly on clinical medicine in our rural area, and the doctors love to pass you on to the emergency room where there are serveral hundred dollar fees due to both the hospital and the ER doctor (even if you are seen only by a nurse.. Rip Off, and poor management.

ARM

John @ 7:

"How is the fact that everyone in the ER waiting room was African-American germane to your point?"

If I had to guess, I'd say shorthand. "All of them were African-American," being a less-wordy way to say: "All of them were poor, uninsured, urban people, and many of them were there for otherwise routine medical care."

Presumably, this assumption is what allowed Mr. Levitt to feel justified in manipulating the triage nurse into allowing Sophie to "line-jump," as it were. But to substantiate that assumption for this posting, Mr. Levitt would need to have access to hospital records, which it is unlikely that they would grant him. So simply saying that the ER was filled with African-Americans (unsurprising, for the south side of Chicago) gets that point across for him.

After all, if you look at the other comments people have made, it seems to be a pretty universal understanding.

ER Doc

Here are some interesting facts from recent studies that are somewhat counterintuitive:

* People with insurance use emergency departments MORE than people who are uninsured. And it's not because there are proportionally more people with insurance than without. Recent studies have shown that people with insurance will have more ER visits per person than people without it.

* ER crowding is often due not to indigent patients seeking primary care in ERs, but it's due to patients being boarded in the ER. What does this mean? Boarding refers to the practice of keeping patients who are otherwise admitted to the hospital in the ER due to lack of inpatient beds. If you have a 15 bed ER but 5 beds are taken up by admitted patients, you've cut your capacity to see new patients by 1/3, keeping patients in the waiting room for much longer than necessary.

What can be done about this? A few things come to mind from articles that have been recently published: 1) streamline inpatient discharges. This doesn't mean kick people out of the hospital before they are ready, but it often takes many hours between the time a patient is deemed to be ready to leave the hospital and the time they actually do. This takes up bedspace that should be allocated to the sick ER patient, rather than the recuperating and ready-to-be-discharged inpatient 2) board patients in the hallway on the floor/ward where they are supposed to be admitted rather than in the ER. This has been shown to be a safe alternative, makes space for ER patients to be seen, and creates an incentive for inpatient nurses and physicians to accomplish goal #1 above.

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Karl Bielefeldt

You likely would have been seen in the same amount of time, regardless of what you said that was unrelated to the case at hand. Parents often confuse importance with urgency. Yes, your daughter's condition was a true emergency, but waiting a few minutes for the paperwork and triage obviously didn't affect the outcome, and the medical professionals knew it wouldn't. In fact, slowing down to be cautious can prevent serious mistakes. You yourself didn't truly believe time was of the essence, or you would have summoned an ambulance.

By the way, imagine if someone tried to bolster an economics argument they were making by saying they were a physician.

Kevin

Last year my daughter had the same condition - severe dehydration, and we couldn't have had a different experience. We took her to her primary care doctor, who referred us to the emergency room. We took her there and were seen almost immediately. There were no long lines - in fact even though they later told us it was a busy day I hardly saw anyone else waiting. This is in Saint Paul, MN (United Hospital if anyone cares).

Also, #2, I assume you know this and are just being intentionally rude because you can hide behind the internet, but when a person (especially a child or older person) is not able to keep anything down, severe dehydration can indeed be an emergency that "drinking water" will not solve.

Kevin

#22 Surely his child has a primary pediatrician, but surely that pediatrician's office is not open 24/7. Severe dehydration can be a very serious condition that cannot necessarily wait until the office opens Monday morning. Besides, if the condition really was severe, the pediatrician's office is probably not equipped to administer an IV and would have referred them to the emergency room anyway.

Kim Siever

The one time we had to use the ER with our children (our son swallowed a marble, which had lodged in his oesophagus and he could barely breathe), we had zero waiting time.

maxicms

If you're sitting for hours in an emergency room, then one thing's for sure, the demand for care is high and the supply is low. Obviously the doctors are not merely making you wait for no apparent reason, at least i hope so. So maybe the solution to this problem is to eliminate what seems to be a kind of monopolistic competition of health care. Since firm entry is not so difficult, more people can be attracted to the careers of being doctors since it is clearly profitable. Basically we need to get more doctors in the room to take care of these people that are in obvious need.

erdoc

When I was a 3rd year resident my 4month old developed a fever and projectile vomiting. I took her to the ER where i worked. By the time we got there, the fever was gone and we were sent home. My insurance didn't cover the visit, so I ended up paying hundreds of dollars out of pocket. An ER visit is no way to save money.
I now live in a country with socialized medicine. The care is adecuate, but the waits are tremendous. Most people i know avoid it, preferring to pay a private doctor.

sarahCMS

In response to JoseAngelCMS, the reason why hospitals require for emergency patients to fill paperwork is to prevent themselves from being sued. Since many people blame hospitals for their irresponsibility of asking whether the patient is allergic to something or whether a patient is drinking some kind of medication, etc. Therefore they make you lose time filling these papers in order to not be responsible for some kind of mistake. What I think can be some good solution is to register your information in all hospitals, therefore if you arrive to an emergency room by simply checking your name in the computer they can be able to "know" about you. But the story about the 80 year old man is truly a miracle. A fact is that if he had waited for the ambulance, he probably would have died, since they last a long time to arrive to where you are, and some other time to attend you in the emergency room.

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Kayla

I understand that you were frustrated but no need to pull the race card. So what if there were African American individuals in the ER. Are they not good enough? Be polite before you publish things like this. I do understand that people just go there because it's often times quicker than making doctor's appointments which on their behalf are selfish. Often times you are going to be treated in the order of what the team thinks is the most life threatening at the given moment. Keep in consideration they could be misinformed and we are all human and make mistakes.

Deborah

When I took my mother into a local Seattle hospital (Swedish in Ballard) because she was having problems breathing and turning purple, they allowed mothers doing pre-natal care checkups to go ahead of her.

Pre-natal patients in the emergency room. Not in labor or anything.

At a recent visit to another hospital, this time in Bellingham, my friend had sliced her hand open. It took four hours for them to have a doctor finally look at the injury, then have a nurse dab that wound sealant on.

Jordan Martin

The problem with socializing health care is that the people that need the socialized health care the most are not educated. I attend Penn and am exactly 1 block from the University of Pennsylvania Hospital. I've been there the past year twice for two reasons of differing severity. One a squirrel attack.... (darned thing jumped out of a trashcan on my back) to see if I needed rabies shots and another for a 5 hour bloody nose. Both times I believe I waited the appropriate amount of time: (although I did not think so at the time) about 4 and 2 hours respectively. Both times I waited in the waiting room with people that did not need to be there: those with coughs, those with minor aches, those who wanted to sit inside out of the cold.

It is just a fact that these problems exist and you must wait. It is good how it is, there is no need to fix it. "Fixing it" costs money, money that we do not have, nor we do not want to spend. Besides, I had a great time staring at the fish in the aquarium.......

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Dan L.

In a sample set of two EDs that I've worked in, the prioritization was simple: if it looked like a heart attack or stroke, get a doctor immediately. Otherwise, let the patient wait.

In both cases, a patient could typically expect to spend 3.5 hours in the ED per visit. This is the mean of the length of stay data discounting visits of 8 hours or more, which were almost always psychiatric patients or cardiac/stroke patients being admitted into the hospital itself.

Some psychiatric patients ended up staying more than 24 hours in a room in the ED simply waiting to be admitted to a mental health care facility.

The statistics we gathered weren't all that good; they spanned only a few days and the times were rounded off by as much as 5 minutes by hurried doctors and nurses. But for what it's worth, we found that for both these hospitals, one can expect to wait about 1 hour between registration and being put in a room (with triage falling somewhere between). The average visit was about 3.5 hours. Both hospitals devoted resources to a "fast track"/day clinic program for about 10 hours a day. The data for these weren't quite so consistent, but suggested about 1 hour of wait, 1.5 hours of care.

However, when I split the data from one of the hospitals by doctor, I found that this was actually the mean between a few doctors who were treating non-urgent patients over the same span as urgent patients and a particular doctor who would see as many as 45 patients in a single day. A typical time for one of that guy's patients was 30 minutes wait, one hour care.

In both states, there was a law requiring EDs to provide care to anyone who came, regardless of insurance status or ability to pay. At both hospitals, uninsured patients made up approximately half of all visits. I'm not qualified to decide what constitutes an emergency, but I would guess that more of half of all visits were non-emergency. They didn't let me in on all this stuff, but I'm pretty sure both EDs operated in the red.

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Anon

i haven't read all the criticisms for the plan to get non-emergency patients out of the ER, but my friend had to go to 4 different hospitals - encountering bloated ER waiting rooms and subpar hospital staff. The staff made him wait! He had sickle cell anemia and needed attention!! When they finally treated him, it was too late. He died of complications.

There has to be some sort of system that monitors people in the waiting room. Critics may say that such a system exists - but apparently it didn't the hospitals that failed to treat my friend

HildaCMS

This is most definitely an inefficient emergency room. I mean, the five hours that the other people spent in the waiting room is not acceptable considering there is an emergency to attend to. Maybe it's a bad specialization on behalf of the University of Chicago people, maybe they are just not caught out to be emergency-attending people. The fact that a nurse was immune to all the things that were told to her was a horrible thing. I mean, she was told that a kid had died from meningitis and that the daughter had the same symptoms and she still didn't care. The ER has to reorganize itself and know how to distribute its resources (as in doctors and ORs) properly in order to be able to reach an efficient working scale.

Shannon

ORs are expensive. As an uninsured person, I'll do the ol' bathroom surgery way, way before I go to the ER. I'll have to be dragged there -- not because I don't trust emotionally and physically drained doctors, but because I can't handle the ridiculous cost of routine care, let alone emergency.