Over at “Home of the Brave,” Annie calls attention to the following Las Vegas Sun story about a man who suffered a heart attack and went to the nearest ER for help:
“But even as Linda Scheinbaum — Morton’s wife of 24 years — was screaming [in the emergency room] for medical attention to save his life, the MountainView Hospital nurse was insisting on getting his Social Security number, emergency contact and insurance information.
“‘I’ll give you all the information later!” Linda Scheinbaum yelled at the clerk.
“It would be Scheinbaum’s tragic misfortune to [go] to the emergency room on the night of Nov. 4, 2005, when it was busy and hospital officials said there were no open rooms. The Scheinbaums were told to take a seat and wait — even though a delay of just minutes can make the difference between life and death during a heart attack…
“The precise timeline of the events of that desperate night is in dispute, but hospital records show that it was at least 41 minutes from the time Morton Scheinbaum arrived to the time he collapsed, blue in the face and foaming at the mouth. Only then was he rushed into the emergency room for treatment.
“And that’s where he died, his admission paperwork completed.”
There are many reasons to feel outraged when reading this story. But the tragedies of this tale are part of a larger—and just as depressing—picture in American emergency care. The staffing and overcrowding issues that Linda and Morton Scheinbaum faced three years ago are becoming the rule, rather than the exception, when it comes to emergency departments (EDs) in the United States.
Begin with the seeming villain of this tale, the pigheaded nurse who forced paperwork on the Scheinbaums in a time of crisis. Blogger Annie has some issues with the Sun’s less-than-probing characterization: “Is the ‘nurse’ cited an unlicensed admission clerk?” asks Annie. “A secretary?…or a licensed registered nurse who is obligated to perform triage and intervention to conform to state regulations and to the hospital’s accreditation agency standards?”
This is important—if the nurse in question is a registered triage
nurse, then it’s her job to prioritize patients based on the severity
of her conditions. This would make her failure to recognize Morton’s
condition all the more scandalous. Though the Sun isn’t
specific on the matter, the nurse probably wasn’t a triage nurse, since
Linda was screaming that her husband needed to see a triage nurse and
got no response.
Sadly, it really wouldn’t be surprising if MountainView didn’t have
that many registered nurses on staff. RNs are increasingly scarce in
emergency departments. In fact, the Committee on Pediatric Emergency
Medicine notes
that, “among all the supply shortages in health care professional
groups, the greatest deficiency is found within the ranks of registered
nurses.”
As I discussed in a recent post,
medicine faces a dramatic nursing shortage, and EDs are not being
spared. In fact, the supply of nurses is particularly unstable in
high-stress practice settings like emergency rooms, which see an annual
nurse turnover rate of more than 30 percent.
This is a big problem: as the Committee puts it, “experienced ED
nurses are truly the backbone of emergency care.” When nurses leave too
quickly, it’s harder to accumulate experience—and the intuitive
knowledge that would lead a nurse to realize that Morton Scheinbaum
needed immediate aid, just by looking at him.
As I argued in my earlier post, America’s nursing shortage can be
solved by encouraging: innovative partnership programs across nursing
schools, providing higher pay for nursing faculty and clinical nurses
who work in high-stress situations, and—perhaps most
importantly—improving working conditions for nurses through better
benefits and greater voice in hospital decisions.
But EDs face a number of other issues which have little to do with
staffing. Every day, millions of Americans put up with the same long
wait time that doomed Morton Scheinbaum to an early grave. In fact, an
August report
from the Centers for Disease Control (CDC) found that average ED wait
time was about 56 minutes in 2006, up from 38 minutes in 1997—even
longer than what the Scheinbaums experienced in Nevada.
These long waits aren’t due to testy nurses. As Maggie wrote in a recent post,
the real issue is that more people are visiting EDs—even as the number
of emergency departments in the U.S. is decreasing. Between 1996 and
2006 ED visits jumped more than 32 percent, hitting 118 million two
years ago. Yet from 1993-2003, the U.S. saw a 17 percent decline in
hospital beds and a 9 percent decline in hospitals with EDs. There’s no
more straightforward way to illustrate these trends than the graph
below, pulled from a 2006 New England Journal of Medicine article by Dr. Arnold Kellerman, a professor at Emory School of Medicine.
The math here is simple: more ED visitors plus fewer facilities
equals longer wait times. The key word is “overcrowding.” For Morton
Scheinbaum, this meant that there were no beds available to him when he
needed care. Even in cities like New York City, which boasts an
embarrassment of hospitals, ED overcrowding has become a major concern:
69 percent of NYC doctors say
they’ve personally experienced an ED patient suffering harm because
there was no hospital bed available; 28 percent said a patient died as
a result.
So what’s driving Americans’ great migration to emergency rooms?
“The likely cause is there are just fewer and fewer primary care
physicians,” Dr. Stephen Pitts of Emory University told the San Francisco Chronicle
last month. “If you were to get the flu and your doctor says, ‘Sure,
I’ll see you in two weeks,’ you may not be able to wait. It’s hard for
even insured people to get quick appointments and be seen quickly.”
As Health Beat has noted recently,
the evidence on primary care backs up Pitts’ hunch: it’s people who
have insurance—and thus already have, at least in theory, access to
doctors—who are making up a greater share of ED visits than in the
past. Over the years, America has seen primary care physicians who must
take on more patients. As generalist doctors have become less
accessible to insured Americans, they’re substituting doctor’s
appointments for non-emergency care with visits to the ED.
When so many patients use emergency physicians as primary care
physicians the people who actually need emergency care may wind up
taking a backseat to everyone else: At MountView hospital, one of the
bed that could have gone to Morton was already taken by a patient who
was constipated.
With such increases in ED visits, why do we have fewer EDs, when in
fact we need more? Emergency rooms just aren’t very lucrative for
hospitals. Indeed, hospitals often lose money on emergency care.
This is in large part because, whether or not they are insured, all
American citizens have a legal right to emergency care under the
Emergency Medical Treatment and Labor Act (EMTALA) of 1986.
EMTALA is a noble idea, but there’s a big problem: it’s an unfunded
mandate. The federal government orders medical professionals to provide
care for everyone, while never instituting a mechanism to compensate
them for delivering that care. And that care gets pretty pricey.
The American College of Emergency Physicians estimates that EMTALA
requirements cost emergency care professionals more than $425 million
annually; the growing ranks of America’s uninsured, who also tend to
use EDs as doctors’ offices, add
another $1 billion in uncompensated care to emergency physician
services. All in all, according to the Centers for Medicare &
Medicaid Services, fifty-five percent of emergency care in the U.S.
goes uncompensated.
Such generosity also eats up time: American College of Emergency
Physicians reports that one-third of emergency physicians provide more
than 30-hours of EMTALA-related care a week—which leaves less care for
other insured patients who could cross-subsidize EMTALA care. With
little in the way of financial support to help them navigate a sea of
new patients, 500 hospitals and more than 1,000 EDs have closed over
the past ten years.
It would be wrong to argue that emergency departments should turn
away more people in order to save money. The answer is to rebalance the
U.S. health care system so patients don’t feel that EDs are their best
resort for medical attention. That means expanding health coverage for
Americans and making sure that those with insurance have better access
to primary care physicians. The “medical home” model, centered on
collaborative, coordinated care, could go a long way in helping
patients feel like they had more options for everyday care.
What happened to the Scheinbaums was tragic. Unfortunately, so long
as emergency care in the U.S. continues to be under-staffed,
under-funded, and over-crowded, these stories will become more common.
I agree with you that these sorts of events are utterly predictable from the way things are going.
I’d like to echo your comment about experienced RNs being the backbone of ER care. At least in pediatrics, there’s been quite an effort to find some test or screen that will reliably identify very sick children and separate them from the not-so-sick. This research has consistently shown that the very best predictor of a child being seriously ill is an experienced person (which often means an ER RN) saying: “this kid is sick,” and jumping the child to the head of the triage line. It takes years to acquire that skill.
I think whether ED’s generate profits or losses for hospitals depends on accounting conventions. For example, if I go to an ED and am then sent down the hall for an MRI, it’s the Radiology Department that captures the revenue for the MRI, not the ED. If I’m admitted as an inpatient, other hospital departments book the revenue for my care with the ED probably only credited for the cost of an ED visit assuming it is paid by either me or my insurer. For many hospitals, half of their inpatient cases come through the ED. What happens to hospital inpatient case loads, occupancy rates and finances in general after they close their ED? Can they sustain their business model? If so, how?
Regarding overcrowding, there is no reason why hospitals can’t place primary care clinics either within their facility or very nearby. A triage nurse could then redirect non-emergency cases to the primary care clinic thereby freeing up resources so true emergencies can be treated on a more timely basis. Under the circumstances, it would not be unreasonable to expect non-emergency cases to wait for a couple of hours or more to be seen. After all, it’s not an emergency, and they are showing up for treatment without an appointment. Conversely, if the PCP’s staffing the clinic are not busy, they can always go over to the ED to help out if needed.
The problem is that, as triage nurses, we are not “qualified” to send someone away from the emergency department, even if it’s down the hall to a PCP’s office. EMTALA says that it has to be a mid-level (NP, PA) or physician that determines whether a patient has an “emergent medical condition”. Of course, by the time that is done, they are already taking up a valuable and scarce bed.
Katrina-
It does seem that a triage nurse should be able to send a patient to a PCP in the hospital. . . I can see why you might not want to send him
home until a doctor or NP has had a chance to check him out thoroughly (triage nurses are very busy and have to work quickly) but as long as he’s
still in the hospital he should be safe.. .
We need to do a better job of letting everyone work to the top of their training.
What you are describing is a symptom of the problem. I don’t think it’s fair to characterize the nurse as “pigheaded” or “testy.” That nurse is accountable to her employer, not the patient. That is the crux of the problem, we do not have a patient-centered healthcare system.
This opens up the debate about moral obligations, absolutely she had a moral obligation to Morton. Well…what do we do about this conundrum?
Additionally, these issues are not exclusive to the emergency room. We had the same experiences when my husband was an admitted patient, an inpatient for many months…I watched him suffocate, my sister and I pleaded, demanded, begged and asked for help and were told the nurse had to “finish her paperwork.” I can cite several examples.
I’m glad these stories are getting out there and being told to a wide audience, but it’s not a situation that’s only occuring in the ER. Hospitals are dangerous. They’re understaffed due in part because they don’t have or don’t want to spend the money to put an adequate number of nurses on duty. Now we’ve come full circle…Money Driven Medicine.
Barry–you’re absolutely correct about downstream revenue effect. I once had this debate with bean-counters who looked at my cost-center as losing money, even though I was bringing sick patients into the institution for radiologists to scan, pathologists to interpret their lab studies, and surgeons to operate on them. Thankfully, the group I deal with now thinks of the institution as a single, global entity.
Thanks so much for the mention, Niko. Your commenters understand the complexity of the problem, too.
One thing that can help address this is to have physicians and nurses come together in self-governed professional practice organizations and directly contract their professional services instead of working as employees. It is imperative that these two professions take back their respective profession’s autonomy in practice and be able to much more effectively advocate for patients. They must also be reimbursed for maintaing professional THERAPEUTIC patient relationships which involve oft time-consuming patient teaching, coaching, counseling and ongoing health symptom and disease management support. This is where these over-worked professionals are not reimbursed in any way.
This is a very astute and well written article, but I don’t get the dig at EMTALA. Before EMTALA we still had the same mass of uninsured patients but they were passed around like a hot potato until they ended up at a charity hospital with a mandate for care of the indigent. Those hospitals were failing at an inevitably high rate and would just have spilled over to the affluent hospitals, which the insured patients would then run away from because of ER crowding and other quality issues and then those hospitals would go under. It is a process that has been very evident in the city I trained in.
Therefore I think the primary care crisis and the mass of uninsured patients are clearly the problem, not EMTALA. In fact, you could argue that the crisis would be much worse without EMTALA as the economic burden was so very concentrated prior to the law that our “safety net” network of charity hospitals was rapidly disappearing. At least now it is spread a little more evenly, allowing the poor hospitals to tread water longer.
Chris has it right when he says it takes an experienced ER nurse to know when a kid is truly sick.
The ER where I worked before going into teaching has had nearly 100% turnover since I left because of the poor working conditions. More and more nurses are evaluated on their “productivity” (how many patients they can get in and out of rooms in an hour) rather than on the quality of their care.
At an ENA Leadership and Learning Conference in Boston, 2007, I asked a panel of EMTALA experts from JACHO, CMS, and other government agencies just what it meant by a “medical screening exam.” I was told that an RN could indeed perform one, in triage, but had to be trained by the facility in how to do so.
Problem is, because so many ERs practice “defensive medicine”, they don’t want to screen the cut fingers, sniffles, and such out. They want to test, test, test to make sure they cover every base before they discharge a patient, running up huge bills even if they don’t diagnose a problem.
Fast track’s and urgent cares help, some. But the ER is the only portal of access for the uninsured or underinsured. So that’s another thing that fills up the ER waiting room.
Hospitals try to improve things by building bigger ERs. Those become more crowded than ever when the word gets out, because staffing is not increased to cover the beds.
Administration at my last ER job insisted we not keep people in the waiting room. We had to put them on stretchers in the hall (with no privacy screens). It was not uncommon to have upwards of 10 patients in “hall beds”. These beds were considered part of the department, but were not staffed. So we often had to be responsible for as many as 7 patients per nurse.
While supposedly the hall beds were for “quick in and out” patients, in practice some were just as sick as roomed patients. Worse, the nurses were so busy with patients in rooms, they would not pick up charts to assess the “easy” hall patients, who would sit there for an hour or more before leaving very angry, never having been seen by an ER physician (who didn’t see patients until assessed by the nursing staff).
My vocal objection to this was met with the response, “this is what the hospital CEO wants.”
What a sad case. I agree with Maggie, it sounds like an ED clerk and therefore Maggie is again correct– one could drive a truck thru the process errors of this particular case.
But her analysis of why we are now seeing an acute spike in ED waits has missed the actual culprit this time.
It is the ED’s ‘back door’; if you can’t get the patients out the back door, you can’t bring them in the front.
So look at the boarder problem if you want to find your explanation of this problem.
The data is VERY VERY clear
Sorry Niko, not Maggie
Also Niko, while I agree with you that we need more primary care (though to some degree we have more primary care if you include MLPs in the numbers), your statement “The math here is simple: more ED visitors plus fewer facilities equals longer wait times” is simply not true. Your analysis is really one of those: “true”, “true” and “unrelated” points.
For longer ED waits are not as a result of either fewer EDs. For fewer EDs is not the same thing as fewer ED beds, nor does fewer EDs say anything about the length of stay of a patient in those same ED beds. And while higher ED volumes is a cause (though a small one), higher volume says nothing about changes in the acuity mix of the patients presenting to EDs, etc…
And while uncompensated care is a significant issue for EDs, it is not the current explanation for increasing ED lengths of stay nor waits… This entire blog posting/analysis seems to miss the non-linear reason why EDs are so expensive in the first place.
Remember, the thing that makes ANY system expensive is how much non-performing assets it must subsidize (and I am not referring to the uninsured when I say ‘non-performing assets’). EDs are very expensive (vs. say primary care offices) because they subsidize non-productive hours (nighttime/weekend/holidays) in way primary care offices and urgent care centers do not. For Emergency Departments operate 24 hours a day/7 days a week while primary care practices only operate during ‘normal business hours’ (no insult intended to those readers of this blog who do keep Saturday office hours).
Even if there were no uninsured, EDs would still be very expensive for this reason.
To illustrate my point: patient arrivals to EDs in the US follow highly predictable patterns: they begin arriving in large numbers around 9 am, thereafter volume spikes tremendously till about 1pm, arrivals tapers down a little for a few hours and then re-spike at 5-6pm until they slowly drop around 10-11pm until ‘falling off a cliff’ around 2 am. This pattern is the same for almost every ED in the United States (almost every ED in the world)
This means that the hours from 2am to 9am can be VERY slow in an ED depending on that ED’s volume. To give you some sense of how significant this is, an ED with a annual patient volume of 24,000 patient/year can have ‘dead time’ arrival data of 0.2 patient arrivals/hour.
Understand an ED with a volume of 30,000/year is considered a large volume ED by national standards: only 1/3 of all EDs in the country see this kind of volume.
Keeping doctors/nurses and equipment sitting around but inactive (which would be the case in a low volume ED after 10pm) means the hours it is busy needs to subsidize the hours it is slow—it is incredibly expensive to subsidize 1/3 of your costs (and remember, in order to get people to work nights/weekends/holidays you need to pay them a premium).
This is why we are seeing a trend nationally to decrease the number of EDs and increase each EDs volume—it is making their slow times less slow and therefore making the ED more efficient at night. I can’t say I have run the data for equipment-med costs/depreciation but if you just take staffing charges, volumes needs to be around 45,000-50,000+ to make the overnights efficient (it is tough to give a precise number because each EDs productivity is different and there are volume ‘sweet spots’)
We can certainly build more EDs if we want as a society (say closer to our homes, etc…), but all we will be doing is making more EDs we already have even less efficient during their slow times and overall costs to society will definitely go up as a result.
Diverting patients from current EDs does the same thing (though using less of something is always cheaper than using more of the same thing, whether that thing is an ED visit or a primary care office visit). It is simple math.
The person that asked for SS number and insurance information was most certainly a clerk. Nurses are not responsible for that sort of thing in ERs. There are far to few of them to waste time getting that sort of info.
Niko, The doctor who wrote the NEJM article is Arthur, not Arnold, Kellerman. Interesting to note that Dr. Kellerman was also the author of a series of breakthrough articles that linked gun ownership to higher mortality in communities.
Came across your blog and thought you might be interested in this release. It’s 11-years’ worth of data showing the effectiveness of tension-free vaginal tape (TVT) in minimally invasive treatment of stress urinary incontinence (SUI) in women. The cure rate was found to be 90% objective and 97% subjective. This is major good news for all American women suffering from SUI. Check out the press release at http://www.medicalnewstoday.com/articles/120718.php.
Many thanks,
Alec Drozdowski