Hospitals say there are no quick fixes to long lines in emergency rooms


Joyce Gazzara went to the emergency room with severe stomach pain on a recent Friday afternoon, hoping to get quick treatment. But the 64-year-old suffered for 12 hours in the waiting room at Munroe Regional Medical Center, before she managed to squeeze through the bottleneck of ER doors.

“We were watching the clock,” said her daughter, Kathy Roman. “I could have flown her to New Jersey and back.”

While Roman’s mother squirmed in pain, other patients with headaches, colds and rashes expressed their sympathy.

“I don’t know where the clog in the system is,” Roman said. “How do they determine who’s really sick …? It was so frustrating to watch my mom, and no one could help us. She needed attention.”

Gazzara was eventually admitted to the hospital for surgery.

Unfortunately, there are thousands of stories like hers.

The issue of overcrowded emergency rooms is a national problem, and health-care providers know it results in lower quality of patient care. Yet finding a solution has not been easy, since a host of factors feed into the problem.

The number of ER visits among the four local hospital emergency departments went up 18 percent between 2002 and 2006, reflecting not only the area’s aging population, but also its growth.

To make matters worse, roughly a quarter of the patients in 2006 were uninsured.

Dr. Art Osberg, medical director of Emergency Services at Ocala Regional Medical Center, has been practicing emergency medicine for more than two decades, and he has witnessed a new trend.

Roughly half of the patients who visited Marion emergency rooms in 2006 had minor, non-urgent medical problems, which could have been addressed in urgent care clinics or doctor’s offices.

But many uninsured and underinsured patients cannot afford to go to an urgent care clinic or a doctor’s office, and they know they will receive care at an emergency room.

The federal Emergency Medical Treatment and Active Labor Act of 1986 requires emergency departments to screen all patients and stabilize them if necessary, regardless of their ability to pay. Yet, the government has not allocated any specific funding to carry out this mission.

“We are truly honored to be the safety net for the society,” said Dr. Frank Biondolillo, the medical director of Emergency Services at Munroe Regional.

But this honor and responsibility brings along its own set of problems.

More than 80 percent of hospitals recently surveyed by TeleTracking Technologies and the American College of Emergency Physicians said that overcrowding of emergency departments is one of their top concerns.

Directors of the four emergency rooms in Marion County expressed the same concern in a recent presentation at the Public Policy Institute of Marion County.

Since the beginning of the year, local emergency departments have had to go on divert mode and let ambulances know that they were filled to capacity.

“Almost every room gets filled with patients. Nurses get overwhelmed. Staff is overwhelmed,” Osberg said.

In 2006, the four local emergency departments – at Munroe Regional, Ocala Regional, West Marion and TimberRidge – logged more than 1,000 divert hours.

Part of the problem, locally and nationally, is the fact that inpatient hospital beds are not readily available to patients admitted to the hospital through the emergency department.

Many times, this is due to shortage in staff, especially nurses. Sometimes the specialty beds needed for complicated cases are not available.

Biondolillo compared the emergency room to a revolving door, where “the front door is always open, but the back door into the hospital is usually slammed shut.”

More than 22,000 patients, like Gazzara, were held an average of 7 hours and 10 minutes each to get an inpatient bed after being admitted at one of the emergency departments in Marion County.

Meanwhile, as many as 10,000 patients left the emergency rooms without receiving any treatment because the wait was too long.

“The ED [emergency department] is a place to begin, not a place to end. We do a great job in ruling out life threats. But there comes a time that we have to pass the baton to the next person,” Biondolillo said.

Unfortunately, that next person, who is either a primary care doctor or a specialist, is becoming harder to access.

There is a local and national shortage of primary care doctors, which affects even those with commercial health insurance.

There has been a dramatic change in the mindset of today’s physicians, said Osberg. “Medicine has changed from being available all the time. … People, including doctors, want to live a better lifestyle.”

The threat of frivolous malpractice lawsuits also may have discouraged many physicians from getting involved with the high-risk environment of emergency rooms, experts say.

There’s also a shortage of specialists like ophthalmologists and hand and wrist surgeons. Most times, these patients have to be referred to another county for proper care.

Due to lack of financial incentive, many specialists don’t collaborate with emergency departments. Some would rather have regular office hours instead of being on call at odd hours.

And while EDs try to find care for these patients, they lie on ED beds. “If someone needs urgent surgery, that patient needs to stay in bed until they can get transported,” further impairing the rotation of the department’s revolving door, Biondolillo said.

“Please hire another doctor, if that’s all it takes,” said Roman. “When you see your loved one crying and begging for somebody to help them and you’re at a hospital but you can’t help them, it’s just frustrating,” she said.

But fixing ED overcrowding is not as easy as expanding emergency rooms or hiring additional staff.

“The strategy of a bigger ED may be driven by a desire to be responsive to staff, physicians and the community, who all want the hospital to ‘do something’ visible to ‘solve’ the problem of the crowded ED,” wrote Bruce Siegel, a research professor in the Department of Health Policy at George Washington University School of Public Health and Health Services, in the journal Health Affairs in 2004.

“But it may simply result in a larger reservoir behind the bottleneck of moving patients out of the ED to where they need to be.

“Hospitals must recognize that ED crowding is a hospital-wide problem, not an ED problem,” he continues.

Hospitals say they are trying.
Munroe Regional and Ocala Regional have created urgent care areas close to their emergency rooms, for low-priority emergencies, but the clinics are not open around the clock.

They have also created a sorting system, where patients are screened so the sickest get care first.

“We work closely with ancillary departments [labs and X-ray],” said Susan Atkin, director of Emergency Services at Ocala Regional. “We’re trying to figure out where the delays are happening. We’re constantly trying to work the systems out.”

Despite the efforts, patients like Gazzara, still end up waiting for hours because they’re not having a heart attack or a stroke, yet they don’t have a minor cut on their thumb either and can’t be referred to an urgent-care clinic.

“Nurses are faced with the challenge of solving problems to get the patients seen,” said JoAnne Phillips, director of Emergency Services at West Marion Community Hospital. “We’re doing things behind the scenes to change things, and I don’t think the public understands that.”

To solve the nursing shortage problem, for example, Munroe Regional has a nurse-intern program, in hopes of retaining more nurses.

But being an ER nurse is not easy. “Sometimes they feel like they’re in a war zone,” said Vickie Sullivan, director of Emergency Services at Munroe Regional.

The hospitals have also begun to pay physicians for charitable cases. The four local hospitals paid more than $1 million to doctors to care for uninsured patients in 2006.

They paid an additional $2.6 million to specialists for on-call emergency room duty.

Yet, the struggle continues.
“My biggest frustration is walking out at night and seeing a packed waiting room,” Sullivan said. “Those are sick people sitting there that need attention. But if the beds are full in the back, we have to take the sickest first.”

“It is hard to be optimistic in short term,” said Osberg.

“The good news is that we’re getting people’s attention. The CDC [Centers for Disease Control] has recognized the problem. The whole disaster planning is giving more attention to the important role of ER,” Osberg added.

Local leaders are thinking about educating the public about the role of emergency rooms.

Maybe establishing a Federally-Qualified Health Clinic will lighten the burden, they say.

But, “until we can make health care accessible for common everyday things, ERs would be crowded. Until we have enough bed space and nurses, we’d be overwhelmed,” Atkin said.
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