Wow. I’m not even sure where to start.
There is an article in Slate today regarding emergency room care. “Waiting Doom: How Hospitals are Killing E.R. Patients” was written by Dr. Zachary F. Meisel and Dr. Jesse M. Pines. They are emergency department physicians in Pennsylvania. (h/t to Robyn at An Interior Life)
This post is a response to their article. Before you continue, please read their article in full, as I will be quoting from it and it is important that the quotes are taken in context. It is linked above.
The article begins by summarizing the case of Esmin Green, the poor woman who collapsed in a psychiatric ER receiving no help for an hour. As we know, by then it was too late. The authors noted the autopsy showed she had suffered a pulmonary embolism.
They also equate sitting in a waiting room chair for 24 hours as being “roughly the same time as a trip from New York to Tanzania”, meaning, if I understand it correctly, the risk of pulmonary embolism would be equal. As written:
“But what’s largely missing from this story is the likely cause of Green’s pulmonary embolism. The answer lies in a far more systematic and widespread danger in hospital care: E.R. waits. Why was Green sitting and waiting while blood pooled in her legs?”
I am confused. Did she sit the entire 24 hours? Did she not get up and walk to, say, the bathroom, or to grab a magazine or get a drink of water? Was she fed during that 24 hours? Didn’t she have to move to eat?
The fact that she had to wait so long for an admission is inexcusable. The fact that no one came to her assistance is nauseatingly horrific. To say that the “likely cause” of her PE was blood pooling because she was sitting in a chair in a psych ER waiting room (as opposed to what, her hospital room/day room?) is ingenious.
I am aware that my impression of emergency care comes from my working in smaller community EDs. I’ve never worked in an inner-city ED, so my perceptions may be skewed. But my jaw dropped when I read this: “…hospitals have incentives to keep their E.R. patients waiting.”
What? I’ll return to that in a minute.
The authors do a great job of describing the hazards of boarding patients in emergency departments – it is concise description of why it happens and why it can be dangerous. I have no issues with this, in fact I agree with them.
Let’s get back to those hospital “incentives” regarding ER boarding. The authors state:
What hospital would promote such a practice? Potentially, those that profit more from boarding, particularly in poorer communities with high numbers of uninsured and Medicaid patients.
The authors believe that because the ER patients are likely poorer, the hospital leaves beds open for direct admits and transfers instead, as this patient population is more likely to be insured. Ergo:
Do the math: If you fill your hospital with the direct and transfer admissions and maroon the E.R. patients for long periods, you make more money….In effect, then, E.R. boarding allows hospitals to insulate themselves from the burgeoning needs of the poor.
Or, if they keep the ER full, then the average non-emergent patient will get up and leave, saving the hospital money. This has not been my experience.
Rich, poor, old, young, drug-seeker, homeless, insured or not (and we see everything, albeit at a less intense level than an inner-city hospital) if there is a bed in the hospital you get it – and you don’t wait in line.
The hospitals that I have worked in don’t want AMAs or left-without-being-seen patients, it’s a sign (usually) that something went wrong. In fact, they are constantly working to lower our door-to-disposition time and still maintain a high standard of care.
In all fairness, the authors point out other reasons a hospital will keep patients in the ER. Noting there are often strict nurse/patient ratios for the floors:
Sometimes the nursing ratio in the E.R. can be as high as 8-to-1. That’s unacceptable in inpatient units, but just stack ’em in the E.R. hallways and suddenly it’s OK.
I have experienced this, and usually it’s because there are not enough nurses on the floors to take the new patients. Or the nurse upstairs is overwhelmed and needs more time, thinking the next shift is better equipped to admit the patient:
So you tell the E.R. nurse that the bed isn’t ready yet. This practice of “bed-hiding” is more common than you think.
Having not worked the floors in 17 years, it’s hard to address this. Sometimes, knowing a patient is going to be admitted, the hospital will staff UP for the next shift and the patient is held until then. Even so, it’s 2-3 hours at most.
I came away from this article with mixed feelings.
On the one hand I have a hard time believing that hospitals are intentionally making people wait in ERs, hoping they will leave, or are actually “cherry picking” who gets a regular bed and who stays in the ER, or that it’s a conscious decision to deny care to the poor.
On the other hand, long ER waits are a fact and there are ways to increase the turn-over in emergency departments, so that patients can be seen in a timely manner. It’s good for everyone, patients, doctors and nurses.
There is nothing wrong with making the case for decreasing ER wait times. While I find their conclusions regarding the intentions of hospitals dubious, I agree that decreasing wait times makes for better care.
But, blaming the death of Ms. Green, an ambulatory patient who had already been evaluated for admission, by stating it was “likely” she died of a PE due to blood pooling because she was sitting in an ER waiting room is speculation at best.
The horror isn’t that she had to wait.
The horror is that no one cared enough to help.