U.S. Emergency Care Sytem at Breaking Point
A new study finds major problems with emergency room services in the United States.
Half a million times a year — about once every minute — an ambulance carrying a sick patient is turned away from a full emergency room and sent to another one farther away. It’s a sobering symptom of how the nation’s emergency-care system is overcrowded and overwhelmed, “at its breaking point,” concludes a major investigation by the influential Institute of Medicine.
That crisis comes from just day-to-day emergencies. Emergency rooms are far from ready to handle the mass casualties that a bird flu epidemic or terrorist strike would bring, the institute warned Wednesday in a three-volume report. “If you can barely get through the night’s 911 calls, how on earth can you handle a disaster?” asked report co-author Dr. Arthur Kellerman, Emory University’s emergency medicine chief.
That ERs are overburdened isn’t new. But the probe by the IOM, an independent scientific group that advises the government, provides an unprecedented look at the scope of the problems — and recommends urgent steps for health organizations and local and federal officials to start fixing it. Topping that list is a call for coordinating care so that ambulances don’t waste potentially lifesaving minutes wandering from hospital to hospital in search of an ER with room. The idea is to set up regionalized systems that manage the flow much like airports direct flight traffic. That also should direct patients not just to the nearest ER but to the one best equipped to treat their particular condition — making sure stroke victims go to stroke centers, for example.
While there are many reasons for these problems, the main one seems to be that the poor and uninsured often rely on ER care for ailments that would send the rest of us to a primary care physician. It’s also the case that ER/trauma care is at the high end of the spectrum for susceptability to malpractice suits and therefore their insurance costs are astronomical. Combined with the fact that a substantial portion of their patients can’t or won’t pay, this is problematic.
Well, maybe. There are certainly huge gaps in our system and the patchwork of part capitalism, part socialism may indeed be worse than either extreme. The fact that someone else pays most of our medical costs takes away any incentive to cut costs, especially when combined with a tort system that further distorts the economics.
Still, one can’t cite a study on problems in one system as proof that one system is preferable to another without demonstrating that said problems don’t exist in the alternative. Is emergency care in, say, the United Kingdom or Canada available in abundant supply without long wait times, overrunning with specialized equipment such as child-sized items, and set up in such a manner that those who need trauma or other specialized care are seldom misdirected?
Apparently, not so much. A study of the Canadian system released last month reveals that “About 85 per cent of emergency room directors working in communities of at least 10,000 people reported a lack of available beds was a major cause of overcrowding” and that “Of the emergency room directors surveyed, 62 per cent called overcrowding a major problem and half thought it posed a risk to patient well-being.” A 2003 study found that they needed major overhaul in order to respond to natural disasters and other crises. A September 2002 CTV report found all manner of problems.
Canadians know there are plenty of problems in Canada’s health care system. But if you want a close-up look at the problems, simply head to your local emergency room. In this CTV exclusive, reporter Avis Favaro found graphic evidence of the chaos in one hospital.
Credit Valley Hospital in Mississauga is just one hospital in crisis. Dr. Eric Letovsky works in the emergency room there, and while he loves his job, he hates what he sees there on a daily basis. On the day our CTV cameras stopped by, five paramedic teams clogged up the ER waiting area, trying to admit sick patients. One woman had a hip fracture, another woman had just suffered a suspected stroke. But there wasn’t a stretcher available to put the patients on.
No one was being admitted. A glance at the board of patient names shows a sea of red names — all the patients waiting for beds upstairs. But most of those patients coming in by ambulance are going to have to wait until another patient can be discharged before they’ll be given a bed. Not only is this emergency room over-capacity, but so are 80 per cent of the hospitals in nearby Toronto. “Basically every hospital from downtown west was not available,” says one of the waiting paramedics.
“This is a normal day,” says Levotsky. “This is a normal day.”
“The provincial and federal governments would like the public to think that everything is good or getting better in the health care system. And it’s really just the opposite,” he says.
A Google search for “UK Hospital Emergency Rooms ” reveals at least anecdotal evidence that they have issues as well.
These stories are all on the first page of results; none of the skipped results provide countervailing data:
Integrated security solution improves hospital security (Paramedic UK, October 2005):
Hospitals have complex security requirements and are faced with a range of threats and risks to patients, staff, expensive equipment and medicines. According a to a report by the Guardian in April 2001, violence in hospitals had become so widespread that for every NHS Trust in the UK, an average of 500 violent incidents during the year 2000.
In almost all major teaching hospitals, police presence has now become routine, especially around hotspots like A&E departments. NHS trusts are also employing their own security guards, hiring private companies to carry out round the clock patrols, using closed circuit TV cameras and alarms, and in some cases giving staff mobile phones and pagers purely for extra security. Staff accommodation has to be protected from intruders, and trusts have had to introduce tight security in maternity units because of the fear of baby snatching. Many hospitals are also plagued by thieves and vandals.
Jon Richards of Unison commented at the time: “What is important is to analyse where staff are going to encounter problems. People, who work in mental health, ambulance workers, A&E, maternity units and in the community, are all in the frontline, therefore most at risk”.
Europe diary: Belgian health (BBC, 1 June 2006)
. . . BBC Europe editor Mark Mardell praises Belgian health care, after his son was rushed to hospital . . .
The hospital is super clean, quiet and calm, in a way that British wards rarely are.
I was rather a fan of the Belgian medical system even before this. I’ve been lucky in having had very good GPs in England and they are equally good here. But it’s easier to get an appointment, even though your phone call goes straight through to the doctor who gives you an appointment herself (or himself). No dragonish receptionists.
The system is based on insurance: the doctor or hospital charges you and you claim the money back off your “mutual”. It’s rather odd that such a system, which frightens the living daylights out of those keenest on preserving free health care in the UK, is used in Belgium and France, which are rather less keen on the glories of free enterprise.
I stress that I write as a consumer, rather witless about my own financial affairs, rather than as a journalist who has studied the system, but the disadvantages are not plain to me, nor do they seem to point to a particular political outcome. What I don’t know is how the mutual system works for someone who hasn’t got enough money to pay the rather large bills in the first place.
An Oxford University Press release for a book published April 2006, Emergency Department Treatment of the Psychiatric Patient: Policy Issues and Legal Requirements:
Many hospital emergency departments are overcrowded and short-staffed, with a limited number of hospital beds. It is increasingly hard for emergency departments and their staff to provide the necessary level of care for medical patients. Caring for people with psychiatric disabilities raises different issues and calls on different skills.
This eye-opening book explores the structural pressures on emergency departments and identifies the burdens and conflicts that undermine their efforts to provide compassionate care to people in psychiatric crisis. In addition to presenting a new analysis of the source of these problems, Dr Stefan also suggests an array of alternatives to emergency department treatment for people in psychiatric crisis. Moreover, the author proposes standards for treatment of these individuals when they do inevitably end up in a hospital emergency department.
Now, I don’t know how these anecdotes and studies ultimately stack up against the US system. It may be that, despite these problems, they still do ER care better in the aggregate. It’s quite likely that they do it less well for those for whom cost is no object and better for the very poor. Still, let’s not cite every problem in our system as an Aha! moment to prove we’d be better off if only we were more like England or Canada.
UPDATE: From the front page WaPo story on the reports: “Fixing the problems is likely to cost billions of dollars and will require the leadership of a new federal agency, which Congress should create in the next two years, they wrote.” Name the last federal agency created to solve a problem which it then fixed? The Defense Department, maybe?