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Logjams in ERs strain hospitals


One or two days a week, three-quarters of the emergency rooms in Baltimore and the surrounding five counties are too full to accept more patients. They have put themselves on "yellow alert," forcing ambulances to travel farther. Dispatchers at the Maryland Institute for Emergency Medical Services Systems describe the alerts as increasingly common at the 24 hospitals that the medical service monitors.

Such crowding exists across the country. Yet patients in Maryland have an advantage over those in many other places where there is no regional command center.

Nationally, the logjam is severe, potentially endangering patients who must wait too long for care. "Everybody thinks that if they call 911, it's going to be fine. But we have a national crisis in emergency care," says Dr. Brent Eastman, a San Diego trauma surgeon who worked on a sweeping report released Wednesday by the Institute of Medicine, an arm of the National Academy of Sciences that advises on ways to improve health.

Another report released last week by the Baltimore Health Department found that yellow alerts at city hospitals increased by 165 percent from 2002 to 2005.

The strain results from complex factors, driven by economics and demographics, that have been brought into the open by the national report.

One reason for the crunch is that emergency room use has gone up. The city Health Department found that over the three-year period, patient visits to Baltimore hospitals grew from 552,000 to 611,000, an 11 percent rise. For increasing numbers of people, especially the poor, the emergency room serves as their only doctor. With little or no insurance coverage, many people rely on the emergency room for everything from sprains to chest pains.

Patients who could be treated by a primary care doctor tend to clog emergency rooms, says Dr. Joshua M. Sharfstein, Baltimore's health commissioner.

"The emergency system is paying for care for the uninsured," he says, "and it is paying for it in the most expensive place, the emergency room." He says state and federal support for care for the uninsured is "seriously deficient."

Sharfstein and others emphasize that the problem must be viewed in the context of the wider health care system, which has seen national hospital occupancy rates rise from an average of 70 percent in the 1980s to 80 percent to 85 percent. "Hospitals have to operate at a much higher occupancy rate than they used to," for improved efficiency, says Dr. James Schuelen, chief administrative officer of emergency medicine at Johns Hopkins Hospital. "That means that patients must wait for beds to become available, and many of them wait in the emergency department."

Technology has also played a role in slowing "throughput," the movement of patients from the emergency room to other parts of the hospital. With the proliferation of tests, such as magnetic resonance imaging, many patients end up staying longer, says Dr. Bill Frohma, chief of the emergency department at Union Memorial Hospital.

Other systemic changes contribute to the backup. As hospitals try to lower costs by reducing the length of stays, inpatients are typically sicker than they were a decade or two ago, giving hospitals less flexibility when space is needed for new arrivals, says Nancy Fiedler, spokeswoman for the Maryland Hospital Association.

She and others note that affordable mental health treatment is scarce, meaning that psychiatric patients get stalled in emergency rooms.

Another problem is a shortage of surgeons and other specialists, according to the Institute of Medicine report.

Dr. Thomas R. Russell, executive director of the American College of Surgeons, says its research shows that surgeons are becoming more reluctant to perform on-call emergency services and are given discounts on liability coverage if they limit or stop performing them altogether.

Russell also points out that the number of specialists being trained to work in emergency departments is not increasing along with the caseload. "When a doctor finishes school, they often go on to fellowships in ... specializations, so they don't feel they have the training to work in the ER. We have a real issue with attracting and keeping young doctors on the ER roster," he says.

Dr. Leigh Vinocur, an emergency physician at Baltimore's Sinai Hospital and a spokeswoman for the American College of Emergency Physicians, says the lack of specialists is a greater problem nationally than in the Baltimore region partly because of its teaching hospitals.

Eastman, the San Diego surgeon, praises Maryland because, unlike many regions, it has a command center. "Maryland does that beautifully," says Eastman, who is chief medical officer of Scripps Health, a group of San Diego hospitals.

Twenty-four hours a day, in a small dark room on the third floor of a brick building on Pratt Street in Baltimore, five men and women sit before banks of computer screens, juggling lives.

They are dispatchers for the Maryland Institute for Emergency Medical Services Systems, a state agency that oversees ambulance traffic for most of Maryland.

Command center chief Andrew J. Pilarski says the current ER situation is the tightest he has seen in his 34 years at the center. "You may have almost all hospitals but a handful on yellow alert," he says. "That's when the real crisis comes."

But Pilarski and others say there's no evidence that such backups have endangered patients' lives, in part because of the regional system and because hospitals are near each other.

Hospitals in Maryland are also taking a range of steps to free up emergency-room space. In February, Johns Hopkins started using a new triage system to improve throughput. Schuelen says the strategy has lowered the average time that ambulances wait to discharge patients. Like all hospitals contacted for this article, Hopkins did not release specifics.

Last month, the University of Maryland Medical Center began using a centralized computer system to track the minute-to-minute status of all its 550 beds. "Already we are getting a better idea of where patients are," says Dr. Timothy J. Babineau, the center's chief medical officer. "Before, we didn't have a complete view of the whole place."

Pamela W. Barclay, deputy director of the Maryland Health Care Commission, a state agency that regulates hospital capacity, says that since 2001 three-quarters of the 24 hospitals in the Baltimore region have renovated or expanded their emergency rooms or plan to do so.

Those that have remodeled their emergency rooms include the University of Maryland Medical Center and Northwest Hospital Center in Randallstown, both in 2002.

In Baltimore County, about 250 calls are made daily for ambulance service, according to Joseph Brown, the county Fire Department's director of emergency medical services.

Fire Station 56, on Nicodemus Road, was having a lull Friday. The six paramedics and EMTs on call filled the time between phone calls joking and cooking chicken and french fries in the small kitchen.

The serenity was broken when the phone rang and Hank Meyers picked it up. Meyers, who has spent 13 years as a paramedic for Baltimore County, was joined by Ron Blizzard, an emergency medical technician who came to the department two weeks ago. They rushed to an ambulance.

With the siren blaring, Blizzard steered the speeding ambulance down residential streets. The men leaped out when they reached their destination, an office building, and retrieved a gurney from the back of the ambulance. They returned five minutes later wheeling a female patient.

Nearly unconscious and suffering from high blood-sugar levels, the woman told the crew she was diabetic and forgot to take her prescribed insulin before leaving for work that morning. Her co-workers called 911 in the afternoon when they noticed that she was struggling to hold up her head.

Once the patient was secured in the ambulance, the team hooked her to an oxygen tank and inserted an IV in her arm. Blizzard then returned to the driver's seat while Meyers stayed in the back, checking the patient's vital signs and filling out forms. They called Northwest Hospital Center, where they planned to take the patient.

"One of the things we do is to notify the hospital when we have a Level 2 patient, which means that they're not dying but it's above a scraped knee," says Meyers as he pulled out the radio.

Northwest was not on yellow alert, so the emergency room was not crowded. There was no wait in the lot, and it took only 15 minutes for the crew to hand the patient over to the emergency department. Two more ambulances arrived.

"The chart nurse has to determine who has priority and who gets a bed first," Meyers explains. "Is it the patient we brought in, or a walk-in? Even though they come in the ambulance, sometimes they have to contend with patients already in the wait room who may be having chest pains and cardiac problems."

Northwest Hospital says the woman whom Blizzard and Meyers had taken to the emergency department checked out later that afternoon against medical advice.

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