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SERIOUS CONDITION: As More Patients Turn to ERs for Medical Care, a Sutdy Finds That Hospitals Are Straining to Keep Up.

Posted on: Thursday, 15 June 2006, 06:01 CDT

By Maria M. Perotin, Fort Worth Star-Telegram, Texas

Jun. 15--Even on ordinary days, the nation's emergency-care services are besieged -- with too many patients and too little money to keep up with the demands on a system in crisis. And if a terrorist's bomb exploded or an epidemic broke out, U.S. hospitals would be ill-prepared to deal with the surge of patients that would flood their emergency departments.

Those are the findings in a series of reports released Wednesday by the Institute of Medicine, which urged better regional coordination and more federal money among a spate of recommendations to improve emergency care.

"We've seen important advances in 911 services. We've seen very important advances in trauma care. We've seen important advances in lifesaving procedures. And we also have seen development of specialties that are focused on care of emergencies," said Gail Warden, chairman of the committee that spent almost three years examining the emergency system.

Yet, "in most communities, there is a crisis under the surface," he said.

In North Texas, hospital officials have been making constant changes to deal with the increased load, said John Gavras, president of the Dallas-Fort Worth Hospital Council.

"Our emergency rooms are very full, very crowded," he said. "Hospitals, in their expansion programs, it seems like they're always expanding the emergency rooms."

Among the reports' findings:

Hospital emergency departments are often overcrowded, with patients waiting hours in hallways for inpatient beds. The problem has worsened as more people seek treatment in the ER, even as the number of hospital beds and emergency departments has declined nationwide.

The emergency team at Harris Methodist Fort Worth hospital has gotten familiar with crowded hallways, especially since the closure of another Fort Worth medical center in 2004 brought an influx of patients there, said Lillie Biggins, the hospital's vice president of operations.

"We had about 15 a day during the flu season that were lining the hallways down in our" emergency department, Biggins said.

To relieve that strain, the hospital has created a discharge area where patients who are ready to go home can wait -- freeing their inpatient beds a little sooner.

The hospital also steers some patients from the halls of the ER to other floors where they're slated to eventually get treatment, Biggins said.

Although those patients still must wait in a hallway for their beds, they're in less-cramped quarters and closer to the nurses who can care for their specific problems, she said. They also get earplugs, eye covers and even pop-up televisions to help pass the time.

Glenn Raup, senior director for emergency and trauma services at John Peter Smith Hospital, has taken a different approach.

He knocked down walls, converted offices and made other renovations at the public hospital's emergency department to make room for patients who are waiting for beds.

And when the ER is especially crowded, healthcare providers draw blood and treat patients in the waiting room, he said.

"When you include our recliners and hallway beds and everything, I'm up to 86 beds," he said. "We've been very creative and been able to focus."

The crowding has prompted an increase in "diversions," when an ambulance carrying an emergency patient is turned away from a full ER and sent to a more distant hospital.

On average, the practice happens once every minute nationwide, with almost 70 percent of urban hospitals diverting patients at some point, according to the report.

In Tarrant County, diversions had become all too prevalent, said Kristine Powell, director of the emergency department at Baylor Regional Medical Center at Grapevine. But local hospitals agreed last summer to make changes that have put a stop to them in most circumstances.

"It was happening very, very often," Powell said. "It's not that we've completely eliminated diversions, but we have reduced them significantly."

Many emergency departments lack the appropriate equipment and trained staff to treat children, even though they represent more than a quarter of ER visitors.

Many ERs struggle to recruit enough specialists who are willing to remain on-call to treat their patients. In part, that's because physicians are concerned about working erratic hours, taking on the liability risk of caring for emergency patients and going unpaid for treating uninsured patients.

Dr. Kimberly Aaron, medical director of emergency services at Cook Children's Medical Center, said that Fort Worth hospital has tried an array of strategies to ease the burden on specialists.

For example, physician assistants are on hand to help surgeons speed up their calls.

And a local plastic surgeon several years ago helped train a group of paramedics to stitch up kids' wounds.

Now, with the paramedics stitching patients all day, doctors can spend less time on those routine cases.

"Before, in the summertime, we would literally have children lined up waiting for laceration repairs," Aaron said.

The system depends on an assortment of agencies to transport and treat emergency patients, with inadequate coordination and few standards for effective care, leading to wide disparities in how many patients survive their ailments.

Gavras said regional coordination is especially challenging in the Metroplex, where there are numerous hospitals and agencies that care for patients.

"We've got two large cities. We have six to seven major suburban areas, and we have several health departments," Gavras said. "Bottom line, we have many jurisdictions. So coordination and even the problem of communication kind of magnifies itself."

With so many hospitals operating at full capacity, most facilities are not ready to handle a major disaster.

In part, that's because of inadequate funding, because only a small fraction of the federal money for disaster preparedness has gone toward medical services, the report found.

Gavras said North Texas emergency-service providers have joined forces to figure out how best to spend the available money and to ensure that resources can go to the hospitals that need it the most.

"Are we where want to be?" he said. "We're getting there, but there's a lot more to be done."

The report recommended creating a federal agency to oversee emergency care, setting aside more money to prepare for disasters and increasing funds for safety-net hospitals that treat lots of uninsured patients.

Jeff Talbert, chairman of health management and policy at the University of North Texas Health Science Center in Fort Worth, said more money would help, but it may not go far enough, especially in Texas, where a quarter of patients lack insurance.

"Until you address that problem of where are the uninsured going to go for their treatment, you're never going to be able to make a dent in this problem," Talbert said. "Where do they go when something happens and they get hurt? They go to the ER."

IN THE KNOW

Full report

Go to www.national academies.org for more information about the Institute of Medicine's study or to see the full text of the three reports that were issued Wednesday.

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Maria M. Perotin, 817-390-7339 mperotin@star-telegram.com

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Copyright (c) 2006, Fort Worth Star-Telegram, Texas

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Source: Fort Worth Star-Telegram (Fort Worth, Texas)

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