Emergency Rooms – Troubles and Transformations

Scarcely a day passes that you don’t read something about. ERs. Today, April 25, the Los Angeles Times and USA Today have the honors.

• The L.A. Times report “ Exodus of specialists from ERs raises concerns,” says California specialists are staying away “in droves” from ERs for various reasons – more uninsured patients, language barriers, high malpractice risks, and disruption of family and private time. Lack of specialty coverage is particularly acute in community hospitals, which have no house staff to cover. And in California, specialty shortabes are mounting, as the state cuts back on Medi-Cal because of budget overruns.

• The USA Today report “More ERs move away from hospitals “ is more upbeat. It simply says hospitals and entrepreneurial doctor groups are building more free-standing ERs, often miles away from hospitals. These new facilities have more amenities but still have life saving equipment. They have no medical ward to transfer to

The new disconnected ERs offer convenience to patients and can ease overcrowding in nearby hospital ERs. Freestanding ER grew 23% from 2005 to 2006, jumping from 146 to 179, according to an American Hospital Association survey. About a dozen more are opening or are planning detached ERs in Florida, Minnesota and Texas. In Connecticut, Middlesex Hospital has two freestanding ERs miles away from its main campus, with ambulance and helicopter services for critical patients.

Answers are evolving to relieve the ER crisis, manifest by overcrowding, ambulance diversions, lengthy waiting times, delays in transfer to medical or surgical wards, and lack of specialty coverage. Some hospitals are hiring full-time specialists and more critical care and hospitalists to meet the crisis.

I interviewed the physician who headed the California Emergency Physician organization. He had a few suggestions for helping to make ER physicians more productive: have a physician at the front door doing the triage, hire a scribe to follow the ER doctor around to document the encounter, do away with some of the software programs the doctor must open and close, minimize the bureaucratic demands of the various hospital department, pay specialists to cover.

Meanwhile numbers of free-standing ERs are growing. They’re open around the clock, offer shorter wait times than hospital-based departments, and reat a variety of illnesses and problems, such as fevers, broken bones and serious cuts. The growth of stand-alone emergency departments helps “decongest” overcrowded hospital ERs. Competition among hospitals stimulates expansion in fast-owing suburbs. Among other reasons for building free-standing emergency departments are: shortening travel times for suburban or rural residents; gaining a foothold in a growing suburb; and competing with a rival hospital.

Free-standing ERs have troubles and critics. Perhaps 10% of patients need to be transferred to hospitals. A stop in a freestanding ER may delay treatment for critically ill patients. Care in free-standing facilities costs more than urgent care centers. Ambulance services are refusing to take heart attack or stroke patients to free-standing centers . Legislators are concerned freestanding centers may not have the standards of hospital ERs.

Stand-alone emergency centers are part of convenience driven care movement featuring in-store clinics, work site clinics, and doctor-owned urgent care centers. Some of the questions being asked are: Are quality, safety, and continuity of care being sacrificed on the altar of convenience? What is the role of entrepreneurial physicians in building and owning free-standing ERs? Who sets the standards for these new centers?