ERs face a new urgency
Those folks who slice a finger chopping vegetables, come home from work to a feverish baby or break a bone in a weekend football game have, at last count, just over 4,000 emergency departments scattered across the country from which they can seek care.
But they had better have plenty of time.
As emergency room visits in the United States have ticked steadily upward, reaching 119.2 million annually, waiting for treatment has become a central feature of emergency-department care.
Patients spend an average of 3.3 hours to be seen, treated and discharged, according to a 2006 report by the federal Centers for Disease Control and Prevention. Last June, a 49-year-old woman died on the waiting room floor of a New York hospital ER -- one of the almost 400,000 patients who, the CDC found, had waited 24 hours or more to be treated in a hospital emergency room. In Arizona, where hospital emergency rooms are most crowded, patients wait just less than five hours on average for care in an ER.
Many people would rather stitch themselves up, splint their own fracture or endure a fussy baby through the night than brave that wait -- not to mention many ER staffs’ seeming indifference to their less-then-life-threatening affliction.
Instead, a growing number appear to be voting with their feet. Those walk-in patients are fueling the growth of a kind of healthcare provider now making a comeback -- the urgent care center -- and at some hospitals, a flurry of efforts to improve the ER experience.
The Urgent Care Assn. of America, a trade organization that did not exist until 2004, last year counted a total of 8,000 urgent care centers around the country. For patients with illness or injury that is not life-threatening but can’t wait for an appointment with a primary care doctor, these hybrids are a growing alternative to hospital emergency departments.
In the absence of a single standard, the Urgent Care Assn. is currently drafting a list of criteria that would let consumers know what to expect from an urgent care center. Such centers now vary widely: Most keep evening and weekend hours, although few are open 24/7; many are heavily staffed by physician assistants, with at least one physician on site or on call; most have X-ray machines and rudimentary lab facilities, though centers separate from a full-service hospital lack the sophisticated blood chemistry tests, MRIs and CT scans that ER docs use to diagnose and treat serious illness. Urgent care center staff can generally detect and set a simple fracture, administer breathing treatments and write prescriptions to treat sprains, allergic reactions and infections. But if you walk into one with signs of stroke or heart attack, or are about to give birth, they’ll call 911 faster than you can say “triage.”
About 15% of these centers are affiliated with existing hospitals -- either as satellite facilities or as on-site clinics near the hospital ER that can handle non-emergency walk-in cases. Though one in four urgent care practices serves an urban population, most -- 55% -- are in the suburbs, where affluent and privately insured patients are often reluctant to spend hours in an ER’s waiting room.
“The motivation is money, and clearly the finances are there,” said Dr. Sandra Schneider, an emergency-department physician at the University of Rochester Medical Center in New York and a vice president of the American College of Emergency Physicians. Many private insurers, keen to keep costs down, also are encouraging patients to use urgent care as an alternative to an ER visit.
Plan in advance
The rapid rise of urgent care centers, and the fact that they are largely undefined and unregulated by state hospital and medical boards, means that they place some important responsibilities on patients, Schneider said. Patients must not only make the crucial decision of what level of care they are likely to need; they would also do well to check, in advance of a potential need, the credentials, capabilities and staffing policies of an urgent-care clinic they might use.
“As it is now, anybody who has an MD or license to practice could put up a sign and say ‘I’m an urgent-care doctor,’ ” Schneider said. “If you’re having a heart attack, you really want an emergency physician there, because that’s what they’re trained to do.”
But hospitals too have responded to the growing chorus of patient complaints. In recent years, Schneider said, many have established “fast track” procedures that funnel patients who need non-emergency care to a staff of physician’s assistants operating under the supervision of emergency doctors.
Others, including the San Gabriel Valley Medical Center, a 274-bed, acute-care hospital, have taken to advertising their promise of rapid ER care on buses and billboards, and have beefed up staffing and streamlined procedures and practices across the hospital to deliver on that promise.
Dr. W. Richard Bukata, medical director of San Gabriel Valley Medical Center’s emergency department, has been a key driver of that initiative. Speaking of the emergency medicine profession, Bukata said: “I’m afraid we don’t have a very good reputation when it comes to respecting peoples’ time.” As urgent care centers have burgeoned throughout Southern California -- and as traditional emergency rooms have closed -- people have come to recognize they can take their influenza and their cuts and lacerations elsewhere, he said, and that “has put more pressure” on emergency departments to shape up.
At San Gabriel Valley Medical Center, monthly ER meetings convene the heads of nursing, labs, radiology, information technology and housekeeping with hospital executives to check flow charts, look for bottlenecks and find ways to move patients through the ER more quickly.
“We’re not the Department of Motor Vehicles,” said Bukata, whose department last month saw patients, on average, within 34 minutes. “We don’t blame them for going elsewhere. But our resources are so much better, and we want to see them all.”
But those ER resources, though necessary for diagnosing and treating heart attacks, strokes, abdominal blockages and life-threatening injuries, are not always necessary for the afflictions that patients take to urgent care centers, and they come at a very high cost. For patients, that can mean a bill, or a co-pay, much higher than at an urgent care center.
“For eight out of 10 problems seen in a hospital emergency department, we’re able to treat them every bit as well, and our fees are probably one-quarter of what they would be in an hospital emergency department,” said Dr. Richard Foullon, the medical director of the Verdugo Hills Urgent Care Medical Group, which sees walk-in patients seven days a week, spread over 85 hours. “This is a tremendous money saver for the patient.”
Foullon, who practiced emergency medicine for 24 years, says that in establishing his urgent care facility, he sought to turn the practices he had seen in hospitals on their heads. He had walls painted warm colors, made sure parking was easy and close to his entrances, and instructed staff to call each patient 48 hours after a visit to make sure he or she had understood discharge instructions and was following them. He said he once considered having no waiting room, but decided “that was a little overzealous.”
In choosing physicians to staff his urgent care clinic, Foullon found that emergency physicians, who tended to rely heavily on expensive and time-consuming labs and tests, were not always as fast at diagnosing and treating as internal medicine or family practitioners. “In medical school, we learned that 80[%] to 90% of diagnoses should be able to be made on history and examination alone,” he said. Though his facility can do X-rays and most major lab tests, Foullon added, having more done increases patients’ costs and wait times.
Problems either way
Those trends may do little to stem a growing crisis in emergency medicine. In recent years, public officials and the medical establishment have bemoaned a growing shortage of ER physicians and on-call specialists; the cost of caring for uninsured patients who turn to emergency departments for treatment; and a shortage of hospital beds to which acutely ill or injured ER patients can be admitted.
The last of these factors, in particular, has been a major factor in increasing ER wait times. But siphoning off the patients who have less-dire medical problems -- and private insurance -- will do little to reduce crowding and the related crisis in ER care, experts said.
In fact, as these patients leave, hospital ERs, which under federal law must treat all comers, insured or not, will be left with the patients who are the biggest drain on their resources -- the poorest, the sickest and those most likely to spend hours or days “boarding” in the emergency department waiting for a bed to open elsewhere in the hospital.
“If we only took care of the patients who needed to come into the hospital, we would close down,” said Bukata, of San Gabriel Valley Medical Center. “The people who keep us open are these bread and butter cases who go home -- the 80% of patients who come into the emergency department who are not admitted. It’s those patients who allow ERs to sustain themselves.”
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