Our Ailing ERs

The Baltimore Sun

There's no denying the emergency room at University of Maryland Medical Center is a busy place. On a recent morning, the beds that circle the nurse's station are quickly filling up. Plenty of seats are taken in the waiting room. There isn't time to close for repainting, so the painters applying a periwinkle blue to the corridors must dodge doctors and nurses at work.

The waits are long and will get longer as the lunch rush begins. And nearly every day the hospital must tell state emergency services officials that the place is full and ambulances will have to take patients somewhere else.

The story is the same at most emergency rooms in Maryland - and throughout the country. And the problem of emergency room crowding grows by the day.

Who is jamming up these emergency departments? Listen to the political rhetoric and you'll hear it's all those uninsured - 47 million and counting. But a new study - and conversations with experts in the field - suggests uninsured patients nationally make up a small portion of those who use the emergency room for their medical problems, big and small. It's just 15 percent, according to a recent study.

The fastest-growing group of ER users turns out to be middle-class patients with insurance, people who usually get their health care from primary care physicians. Their share of visits jumped from 52.4 percent in the late 1990s to 59 percent in 2003-2004, according to a recent study in the Annals of Emergency Medicine.

"We felt there would be much more political will behind solving the emergency room crowding problem if everyone understood that ... [the increase is] not poor, homeless and uninsured. These are mainstream Americans," said Dr. Ellen J. Weber, an emergency room physician at the University of California, San Francisco Medical Center and lead author of the study. "It's eventually going to affect you."

The emergency room, considered the health care option of last resort for the uninsured, has been transformed in the last decade. Between 1996 and 2003, annual emergency room visits in the United States rose from 90.3 million to 113.9 million, according to Weber's study, an increase of 26 percent. In Maryland last year, there were 2.4 million visits to emergency rooms, a number rising about 3 percent annually - that's an additional 90,000-plus visits each year.

There are many reasons why people use the emergency room, though a main one seems to be convenience. It is open 24 hours a day, 365 days a year - no appointment necessary. It's a place many come when they don't want to wait the several days it will take to see their doctor. And it's where everything from blood work to X-rays to treatment can be done in a compact amount of time, under one roof.

"The world is so busy. They just don't have time to be sick," said Jim Scheulen, chief administrative officer for Johns Hopkins Emergency Medicine. "It almost seems to reflect an overall societal change that's calling for everything to be instantaneous. They want a complete assessment and they want it relatively quickly and they want to move on."

"Typically you've got both spouses working," said Peter J. Cunningham, senior fellow at the Washington-based Center for Studying Health System Change. "It's not always easy for them to get off work and see the doctors. Sometimes it's just easier to go to the emergency room than to see their doctor."

That wasn't what the emergency room was supposed to be. But doctors say it has become a place where people know they can go for episodic care - often for emergencies, some of them life-threatening, many others not.

Primary care doctors have become increasingly reliant on the emergency room. When busy practices don't allow them to see all the patients who need to be seen, they send the overflow to the ER. When patients experience chest pains, the doctor sends them to the ER. When patients require tests beyond those that can be done in a doctor's office, to the ER they go.

"Who shows up here? Anybody who thinks they've got a problem - that's the definition of an emergency," said Dr. Brian J. Browne, chief of emergency medicine at the University of Maryland Medical Center in Baltimore. "It's your perception of the issue, not necessarily mine. ... I don't mind. It's my job."

Improvements in technology and in treatment have also led to the increased use of ERs. "There are a lot of things we need to treat in hospitals," Weber said.

Take stroke. Fifteen years ago, it didn't change anything if you had a stroke and didn't see a doctor for three days, she said. Now, lives can be vastly altered if a stroke victim gets to the hospital quickly.

Sometimes the uninsured will come in with minor problems - only because they cannot pay and have nowhere else to go. Much of the national conversation about the uninsured in recent months has been among Democratic presidential hopefuls talking about universal health coverage in the U.S. One of the underlying assumptions has been that if there were fewer uninsured, more people would have doctors and fewer people would end up in the ER. It turns out to be a false assumption, experts say, because the insured are using the ER at record rates.

"The question is, 'What are the solutions?' and, frankly, reducing the number of uninsured, while that's something that will have a lot of benefits to a lot of people, it's not something that will reduce the burden on emergency rooms generally," Cunningham said. It may result in hospitals being reimbursed more often for the care they provide, he said, "but it's not going to relieve overcrowding."

The United Kingdom and Canada, countries with universal health care, have also seen large increases in ER visits, Weber said.

In Maryland, hospitals are private and take all patients, whether they can pay or not. But because of the unique system here, the burden of uncompensated care is spread more evenly. In other states, emergency rooms at large public hospitals in urban centers see more uninsured than others.

One reason for the nationwide backlog in emergency rooms - some say the main reason - is a shortage of inpatient hospital beds. Between one-fifth and one-quarter of those who enter the ER will be admitted to the hospital. If no beds are available, patients stay in the ER, taking up space that could be used by the next patient in line.

Money plays a role here, too. Some of those beds are occupied by elective surgery patients - paying patients, Weber said.

Hospital expansions are being built in Maryland, but those are longer-term solutions to the crowding issue - and still won't be enough to fix the system.

Some suggest that urgent care centers - which are designed to take patients without life-threatening problems and are open late - could ease the burden on emergency rooms. Jim Schulenberg, a spokesman for the Patient First chain of medical centers, said 70 percent of what is seen in the emergency room - specifically routine illness and injury - can be seen by its doctors.

Still, opening an urgent care center isn't always a panacea. A center near Washington Hospital Center in Hagerstown was supposed to relieve the load on its emergency room. The decrease in patients was small - and temporary - and soon the urgent care center was seeing tens of thousands of its own patients each year.

A similar thing happened after a Patient First opened on the campus of Johns Hopkins Bayview Medical Center in December. It sees lots of patients, Scheulen said, but the ER remains overwhelmed.

New strategies are needed. Nearly two years ago, as a pilot program, the Shady Grove Adventist Emergency Center in Germantown opened, said Pamela W. Barclay, an official with the Maryland Health Care Commission. It is a comprehensive, free-standing emergency room - open 24 hours a day, accepting ambulances and patients without insurance.

Still, doctors agree, patients are not regularly crowding emergency rooms for minor ailments or injuries.

"They're not coming in to get medication refills," Weber said. "They're not coming in to get their blood pressure checked." Nevertheless, some probably should have been treated elsewhere.

The lowest-priority patients will wait, Browne said, "but I will get to them and they know it."


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