July 24, 2008, 2:45 pm

Waiting Doom – A Response to the Article in Slate

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.

13 Comments

  • ArkieRN
    ArkieRN

    July 25, 2008 at 3:34 am

    People need to get over the idea that they are always waiting for a bed – a lot of the time they are waiting for a NURSE. If there’s a bed available but no nurse, how are you better off in it than in a waiting room?

    Hospitals have closed off whole wards due to lack of nurses. They can’t magically make one appear.

    And overburdening an existing nurse just makes it more dangerous for the patients she’s already looking after. If you were the administrators would you want one patient at risk or ten? Yeah, I thought so.

    Having said that, at some times (flu and pneumonia seasons mostly) there simply aren’t ANY empty beds. An ER patient has to wait until someone has been discharged and the bed has been cleaned. Sometimes there’s even a waiting list for the beds as they become available.


  • ERMurse
    ERMurse

    July 25, 2008 at 8:22 am

    Kim, I have to disagree with your point about hospitals not holding beds for direct admits while leaving many in the ED and sometimes using that to discourage the ED use via LWBS.

    Several hospitals I know of do exactly that. I doubt my experience is unique. They contract beds to certain health plans. An example, recently while trying to get an acute MI transfered from a community hospital where I work to a hospital that does the majority of the Heart Caths in the area we were turned down supposedly because there were no beds and they were holding ED patients. When we found out a short time later that the patient was a member of a prepaid plan – Kaiser in this case, we contacted Kaiser and a short time later were contacted by the origional hospital that turned us down and given a bed. They admitted they hold beds that are contracted to Kaiser because they do their Heart Caths for them.

    Another example – I wrote a post on a Large Academic Medical Center with an ED LWBS rate of 21 percent. I know from inside info that while they hold patients in that ED for up to 2 days they keep beds open upstairs for their capitated patients who need to be transfered in from other facilites. They also do not do anything serious to address their LWBS rate so they can encourage the mostly uninsured walk-ins to use the other hospitals in the community. Here is that post http://ermurse.blogspot.com/2008/01/and-winner-of-lwbs-sweepsakes-is.html


  • Jen
    Jen

    July 25, 2008 at 9:30 am

    Just a question about what you mean in the second section, last sentence: “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” Do you mean “ingenious” (clever, brilliant, inventive?) or “disingenious” (inept, dumb, incompetent, ignorant, stupid)? I sense the latter, but since the article gave you mixed feelings, I’m not sure where you are going there. [defs. from http://www.answers.com]


  • Eva
    Eva

    July 25, 2008 at 11:11 am

    “There are two competing sources for inpatient beds. The first source is patients who come in through direct and transfer admissions. They are more likely to come with private insurance and need procedural care, both of which maximize profits … 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.”

    That was a good point, except the fact that it can only apply to the United States (and other places that don’t have free health care,) (if in fact it truly happens). In Canada, where ER visits are free, in my experience as a patient and volunteer, always have a several hour wait, are full, crowded, with people laying in stretchers in the halls around the ER because there is no room for them, and people standing in the waiting area because there are no more chairs.

    The reason for that certainly isn’t because the hospital is picking and choosing who gets a bed and who doesn’t.


  • healthcaretoday.com
    healthcaretoday.com

    July 25, 2008 at 11:49 am

    Waiting Doom – A Response to the Article in Slate…

    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. This po…


  • RNTed
    RNTed

    July 25, 2008 at 11:59 am

    Actually, Jen, I think the word is supposed to be “disingenuous” – hypocritically ingenuous, i.e. – pretending to a naivete that does not exist.

    Just my $0.02


  • Kim
    Kim

    July 25, 2008 at 8:48 pm

    Ahem. I have changed the word in question! : D

    Nothing like making a major gaff in a post! LOL!

    Very embarrassing! : )


  • […] broke the news about the same thing on Thursday. Kim at Emergiblog and David Catron at Health Care BS have already posted excellent rants on the topic. Now it’s […]


  • Allie
    Allie

    July 27, 2008 at 9:04 pm

    I’ve worked in a large inner-city ER. And I’ve also worked in the patient placement department (for the same hospital.) Maybe I’m naive about the politics of it all, but I can’t believe any hospital would pick and choose who gets what bed outside the realm of patient acuity. I have seen patients wait in the ER for more than fourteen hours because the hospital was full but, in that rare case, we get them a hospital bed (not an ER stretcher) and initiate floor orders in the ER.

    I will admit that, on both the ER and patient placement sides, I have seen floor nurses “hide” beds before. This could be a constant struggle that we could usually handle on our own but that sometimes we had to get the house supervisor to look into. And by that I mean they would literally go up to the floor to see if the bed was occupied or not. If not, then we got the bed we wanted and, lo and behold, the floor nurse got another patient.


  • Jen
    Jen

    July 27, 2008 at 9:07 pm

    Thanks RNTed, you’re right.


  • Jen
    Jen

    July 27, 2008 at 9:23 pm

    Eva said “In Canada, where ER visits are free, in my experience as a patient and volunteer, always have a several hour wait, are full, crowded, with people laying in stretchers in the halls around the ER because there is no room for them, and people standing in the waiting area because there are no more chairs.

    The reason for that certainly isn’t because the hospital is picking and choosing who gets a bed and who doesn’t.”

    You’re right Eva, the example doesn’t work for Canada. Here the pressure is on the system to save money by shutting down beds (which really means not staffing enough nurses to cover hospital capacity) on the inpatient side. Get people out faster (e.g.: shorter stays post op), try not to let them in if they don’t really need it/another solution can be found (e.g.: long waits in the ER, referals to clinics). But they are picking and choosing who gets a bed and where. Daily hospitals have bed meetings or online computer systems to determine how many patients of what sort of acquity are coming and going so the ER and ICU know who can go to inpatient wards. ERs shut down when the hospital is at capacity. I haven’t heard about that happening recently, but it used to happen frequently in Calgary in the 90’s that there were so many nurses laid off and beds closed by the health region that hospitals just didn’t accept ambulances. They were re-routed to other hospitals.

    Remember too that the ER visits here aren’t actually free. They seem free because no money changes hands, but everyone paid their taxes, the hospitals get their money from the region who gets it from the government who get it from the taxes. The docs and the hospitals are billing the government for specific treatment for every patient they see.


  • Jen
    Jen

    July 29, 2008 at 4:20 am

    Here’s a good & related blog post by a great ER resident about how Canadian hospitals (specialists) are picking and choosing, and why things get backed up here.

    http://drcouz.blogspot.com/2008/07/i-just-really-need-to-know.html


  • Ethan
    Ethan

    August 6, 2008 at 11:29 am

    Ughh… This sounds like another one of those lawsuits against McDonald’s for making people fat. Sure, it does, but you have a choice to go there or not. And I see your point. The woman didn’t have to sit there for twenty-four hours. She probably couldn’t. I know I couldn’t. I’d have to move around a bit or something. And all these kinds of stories make me depressed about the future. Oh well. Let’s all just move to some obscure yet rich country like Andorra. I heard they had the highest life expectancy. 😛


About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

Continue reading »

Find Me On...
Twitter     Technorati

Subscribe to Emergiblog

Office of the National Nurse

Zippy Was Here


Healthcare Blogger Code of Ethics

  • Perspective
  • Confidentiality
  • Disclosure
  • Reliability
  • Courtesy

medbloggercode.com