Headed to the emergency room? Bring a book


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The stereotype of hospital emergency rooms crowded with patients waiting endlessly to be seen by a doctor is true, according to a new study in Tuesday’s edition of Archives of Internal Medicine. The conventional wisdom that throngs of low-income, uninsured people who use the ER as a substitute for primary care visits are to blame, however, is wrong.

First, a few statistics:

  • In 1997, the median wait time for ER patients was 22 minutes. By 2006, it was 33 minutes.
  • Per capita use of ERs was 40.5 visits per 100 people in 2006, up from 34.2 visits per 100 people a decade earlier.
  • The proportion of ER patients deemed to be suffering from a real medical emergency fell from 26.9% in 1997 to 18.3% in 2007.
  • The percentage of ER patients who lacked health insurance remained between 16% and 17% between 1997 and 2006.

These and other statistics were gleaned from data on 151,999 patient visits to emergency departments recorded in the National Hospital Ambulatory and Medical Care Survey. The survey includes four triage categories – emergent (patient should be seen within 14 minutes), urgent (15-60 minutes), semiurgent (61 minutes to two hours) and nonurgent (anywhere from two to 24 hours).


Though wait times got longer for everyone, the problem was worst for emergent patients – their median wait times increased by 4.6% per year, the study found. Waits for urgent patients grew 2.8% per year for urgent patients, 3.9% per year for semiurgent patients, and 1.6% for nonurgent patients.

Put another way, only 56.6% of emergent patients saw a doctor within the time recommended by triage staff, compared to 100% of nonurgent patients. Overall, the proportion of patients who got to a doctor within the “triage target time” fell from 80% in 2000 to 75.9% in 2006, the study found.

One theory to account for increased ER wait times is that more people who can’t afford to go to a regular doctor wind up coming to the ER instead, where federal law guarantees they’ll be treated regardless of ability to pay. The survey data corroborated this to an extent, finding that 17% of uninsured patients in the ER were classified as nonurgent, compared to only 13.9% of people who had private insurance. That works out to about 567,000 extra visits each year.

But the researchers, Dr. Leora Horwitz and Elizabeth Bradley of the Yale University School of Medicine, found that all patients – regardless of whether they had private insurance, Medicare, Medicaid, or nothing – were more likely to use the ER for nonurgent reasons. Overall, the number of patients coming to ERs with true emergencies barely budged between 1997 and 2006, but the number of total visits increased by 3.9% per year, on average.

The use of triage assessments was supposed to reduce waiting times for the most vulnerable patients by allowing ER staff to focus their attention on those most in need of treatment. Instead, the researchers found that “these patients experienced the largest percentage increases in wait time and were consistently the least likely to be seen on time.”

What gives?

The researchers conclude that poor, uninsured patients aren’t to blame. “Rather,” they write, “it appears that decreased access to primary health care for all patients and an aging population are more important contributors to the per capita increase” in ER visits.


Hospitals are also to blame, they said. ERs could be more efficient about processing patients and obtaining various tests that are used to make a diagnosis. And inpatient wards have more patients too, reducing the number of beds available for people who must be admitted from the ER. That clogs up the whole system like a rush-hour traffic jam.

The consequences are worse than just wasted time, write UC San Francisco physicians Renee Hsia and Jeffrey Tabas in an editorial accompanying the study. Evidence is piling up that crowded ERs are associated with higher rates of morbidity and mortality in hospitals. Patients have to wait longer for pain treatment and antibiotics, and when maxed-out ERs close, ambulances have to drive further to deliver their charges. Meanwhile, other patients who need ambulances have to wait longer for a pick-up.

Overcrowded ERs “must be recognized as a systemwide problem,” they wrote.

-- Karen Kaplan