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President George W. Bush no doubt antagonized a few emergency medicine professionals with a statement he once made when asked what to do about the estimated 47 million Americans who have no health insurance.
"I mean, people have access to health care in America," Bush told reporters. "After all, you just go to an emergency room."
Trouble is, millions of uninsured individuals are doing just that. By federal law, hospital EDs must provide care to all patients, regardless of their ability to pay. Ever-higher numbers of the uninsured and the underinsured are entering EDs for non-emergency care.
That fact, coupled with workforce shortages and geographic maldistribution of healthcare workers, has placed America's emergency medical system in alarming straits. Nearly every hospital in the nation suffers from chronic ED overcrowding, and hundreds of thousands of ambulance patients each year are diverted to secondary facilities.
Has the problem reached a crisis level? "Absolutely," said Jesse Pines, MD, MPH, MSCE, assistant professor of emergency medicine at the University of Pennsylvania School of Medicine, Philadelphia.
Proposed solutions include everything from increasing the size of EDs to enticing more medical students into emergency medicine to scheduling surgeries in a more uniform way so more hospital beds are available each day.
ED overcrowding "is a multifaceted problem that requires a multifaceted approach to solve it," Bill Bell, general counsel for the Florida Hospital Association (FHA), told ADVANCE. "No one silver bullet will fix the problem." ED 'Boarding'
EDs served 3.6 million more people in 2006 than in the prior year, according to the 2008 edition of the American Hospital Association's Annual Survey of Hospitals. ED visits totaled 118.4 million in 2006.
"One in every three people per year comes to the ED," Pines said. "To stay competitive, hospitals need to operate at a very high occupancy to maximize their profits. But when a hospital is full, patients in the ED must wait for long periods of time. We call it ED 'boarding.' When you're boarding admitted patients in the ED, you can't really evaluate that high a volume of new patients, so they sit in the ED waiting room."
Boarding, in turn, creates ambulance diversions. In 2003, an average of one ambulance per minute was diverted because hospital EDs could not receive additional ambulance patients, according to the CDC. An estimated 501,000 ambulance cases were diverted during that year, and an estimated 45 percent of EDs reported diverting ambulances at some point during the year.
"A delay in one area can have inadvertent consequences in other areas you didn't even think about," Bell explained. "The nursing shortage forces hospitals to close down inpatient beds because there are not enough nurses to staff them. That means more patients back up in the ER, which then backs up ambulances outside the ER, which then keeps those ambulances from going out and picking up new patients." Older Patients
The aging of America is further straining the emergency care system.
"Contributing to the rise in ED visits is the increased use of hospital services by baby boomers recently turning 60, an age when use of healthcare services begins to increase dramatically," the AHA hospital survey report states. Providers like Pines would readily concur.
"I can tell you the overall population of ED patients we're seeing is getting older," he said. "They are more critically ill. They require more complex care coordination, including more diagnostic testing. They are coming in with complications from chemotherapy. They are transplant patients. The overall burden of complexity of care is increasing, adding to overcrowding. You can figure out how to treat a sprained ankle, but a transplant patient with a fever requires more complex care coordination."
Additionally, nursing home patients spending long periods in EDs can become "de-conditioned" to the hectic environment "and that may make their overall outcomes worse," he added.
Florida's large retiree population is a major cause of its ED overcrowding, though far from the only one.
"We have an aging population that uses healthcare more than younger people do; so even if our population were stagnant, the fact that it's getting older means you need more healthcare services," Bell said. "But our population is not stagnant either; we have a growing population. Our tourist population and our non-citizen population are each growing, and we have fewer ERs today than 10 years ago. That equals overcrowding. Throw in a shortage of specialists, which delays the process of patients being seen and moving them out, so they wait longer in ERs, and you have a broad problem."
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