The ED picture today

How bad is the emergency-department crisis, which has taken on an almost permanent status? Earlier this year, 67 percent of EDs told the American Hospital Association that they were at or over capacity. AHA spokesperson Rick Wade says that figure probably represents an increase over two years ago because managed care has been easing restrictions on enrollees to visit the ED. In addition, 80 percent of ED physicians believe their facilities couldn't handle an epidemic illness or an act of terrorism, according to another recent survey.

Here's one problem fueling the crisis: the number of uninsured Americans hit 43.6 million in 2002, a 5.8 percent increase over 2001. "This strains EDs even further, because the uninsured turn to us as a last resort," says George Molzen, an ED physician in Santa Fe, NM, and immediate past president of the American College of Emergency Physicians.

Don't obsess on the uninsured, though. Privately insured and Medicare patients accounted for almost two-thirds of the 16-percent increase in ED usage from 1996 to 2001, according to the Center for Studying Health System Change in Washington, DC. Insured patients are flocking to EDs partly because they're having a hard time getting a timely appointment with their regular doctor, the Center suggests. Once again, a systemic problem in healthcare ends up in the ED.

While visits climb, the number of EDs dropped 5 percent from 1997 to 2001, either because hospitals closed or surviving hospitals didn't want to operate these departments. Meanwhile, specialty hospitals sprout like dandelions, but only 45 percent have EDs, according to the US General Accounting Office.

More EDs would help, but the most pressing shortage may be for inpatient beds, drastically reduced during the heyday of managed care. In 2001, general acute care hospitals had 826,000 staffed beds, 101,000 shy of the count in 1990. And those remaining beds are more in demand, according to the AHA. If ED patients are admitted to the hospital, but no beds can be found, they languish in the ED for hours.

Of course, you can't operate a bed without personnel. The AHA is begging Congress to spend more on recruiting and training registered nurses to fill 126,000 vacancies that also contribute to the ED crisis. One solution is looking overseas. Norwalk (CT) Hospital has hired 46 RNs from India who will report to work in 2004.

Hospitals need physicians, too. Soaring malpractice premiums have caused many specialists to reduce or eliminate ED call. Recent revisions of the Emergency Medical Treatment and Active Labor Act could dry up the pool of on-call specialists even more. EMTALA now grants hospitals more flexibility in providing ED coverage, but ED physicians fear that hospitals will drop 24-hour coverage and let more specialists opt out. "It's going to be harder to find a neurosurgeon in the emergency department," says ED physician Michael Carius of Norwalk, CT.

Not all the news is dismal. George Molzen reports that funding for emergency preparedness from the US Department of Homeland Security is trickling down to EDs, adding to what's called a boom in expansion projects for surviving EDs. Hospitalists speed up admissions from the ED as well as hospital discharges, freeing up beds that much sooner. And some primary care physicians are more accessible. "Doctors in my community are expanding their hours and leaving slots open for same-day appointments," says Molzen.

Yet another encouraging development is the digital ED. Patient-tracking software, computerized physician order entry, and wireless computers for bedside registration and treatment move patients through EDs more swiftly and safely. Such automation has helped NorthCrest Medical Center in Springfield, TN, shave 30 minutes off the average ED visit.

However, high-tech EDs are still the exception. And even the best information system can only blunt the impact of unrelenting forces like the malpractice insurance crisis, the uninsured, and an aging population that's overwhelming the capacity of hospitals to treat it. ED physicians haven't run out of hope, but they don't expect overnight solutions, either.

Says Michael Carius: "It's like a war that never ends."

See "What will it take to solve the ER crisis?" Dec. 3, 2001.

 

Robert Lowes. Special Report: The ED picture today. Medical Economics Dec. 5, 2003;80:15.