It is obvious that the current state of many of our emergency rooms (ERs) is a failure of our healthcare system. It is the problem of overcrowded emergency rooms. Diverting patients is a systemic problem that must be resolved on an immediate basis. Indeed, it is a very disturbing situation, and hospitals and healthcare organizations either alone or in conjunction with state and federal governments must act to resolve it, and soon. Many people are harmed or literally killed, some say murdered, due to the overcrowding of emergency rooms.
The Problem The Centers for Disease Control and Prevention in a 2005 study found that visits to emergency rooms had increased by 20 percent over the previous ten years, and at the same time the number of ERs to treat patients had declined by 9 percent. This trend continues today. The reasons for this increase include more patients with less serious medical problems seeking treatment in ERs because they have difficulty getting care elsewhere. This is due to a dearth of primary care facilities and primary care doctors.
The age of specialization has left scanty monetary support for primary care, ERs, and other vital care establishments that are not meant for profit anyway. What’s more, the federal government passed Emergency Medical Treatment and Active Labor Act (EMTALA) in 1986 – a law mandating that all hospitals would receive Medicare reimbursement to provide screening for an emergency condition, stabilizing treatment when necessary, and appropriate transfers of patients, regardless of their ability to pay.
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 with the infusion of more funding initiated stricter enforcement of EMTALA. This brought an influx of patients to the ERs. Many of these patients were poor, uninsured or underinsured. The aging population of America also brought more visits to the ER, inevitably adding to the problem of overcrowding. Unfortunately, this increased demand on the ERs in turn increases errors in medical treatment. The feeling of being rushed and under time pressure results in more errors and puts the staff and hospital at risk for malpractice or legal action.
Decision errors have resulted from miscommunication during periods of overcrowding. Overcrowding also increases the frequency of mislabeling and drug administration errors, e. g. mislabeled specimens or drug dosing. In fact, overcrowding has resulted in a high proportion (70% to 82%) of preventable errors in ERs. Such errors frequently lead to permanent disability or death and open up the prospects of legal action against hospitals. A survey of ER doctors has shown that many of these doctors have seen patients in serious distress at times when there are no beds available.
Such patients have to be held in the ER, too – an emergency room in a state of emergency. Many ER doctors participating in the survey also reported having witnessed deaths of patients as a result of overcrowding. Overcrowded ERs may also create more violence. Tempers flare and some patients tend to be more agitated and violent in crowded conditions. Violence has occurred in ERs over who is to be seen first. Bodily harm has occurred in the past to both staff and emergency physicians. Other adverse outcomes are possible as well.
Patients with serious diseases such as heart attacks or strokes may miss what is known as the ‘golden hour’ of treatment as they wait in the hallway. Due to the underlying reasons for overcrowding of ERs, ambulance diversion has increased. The consequences of these diversions include increased transport times, risk of traffic accidents, and the potential for poor clinical outcome. In one case a patient was diverted to a hospital 1,600 miles away. Statistics show that an ambulance is turned away from an ER every minute of every day due to overcrowding.
Needless to say, all of these associated problems can leave hospitals and their staff more vulnerable to lawsuits and liability issues. The following incidents shed more light on the issues at stake. Homicide in the ER A 49-year-old woman went to the ER complaining of chest pain, nausea, and shortness of breath. She was triaged and it was decided that she could wait. She was told to wait for her name to be called. Two hours later when she was called the woman did not respond. The nurse found her dead and attempts at revival did not succeed.
A coroner’s inquest ruled the woman’s death a homicide, which opened the door for criminal prosecution. Unavailability of ER Services In a final example a woman who lay bleeding on the emergency room floor died after she called 911 dispatchers. The woman was not getting any care in the ER. The dispatcher refused to call paramedics or an ambulance to take her to another facility. She died of a perforated bowel. Her death was ruled accidental by the county coroner’s office. In this case the chief medical officer at the hospital was placed on “ordered absence” after the incident.
Deficiences in the ER These are not just a few isolated cases but have become more frequent across our country. This is also true in the hospital I work at and at least some of the system of 17 hospitals it runs. In preparing this report, I conversed with trauma nurses, physicians and staff who work in and use the ER at the hospital where I work and some of the other hospitals in their system. I was told that patients are often slow to move out of some of their ERs to units if they are admitted. Patients may have to wait most of the day for a bed (6-8 hours or more) before admission.
Much of the time waiting rooms are full and patients have to line the halls. Moreover, the ER can be understaffed when it is busy. At least one doctor, in fact, had belittled alcoholic patients in an ER during a busy time. I further learned that ERs do not divert patients or discharge them once stabilized if they do not have insurance but need care nevertheless. This may be due to the fact they had been investigated a few years ago by the state attorney general for lack of charity care, their billing practices and putting too much emphasis on profits.
They do in my opinion, however, need to try more solutions to correct deficiencies that exist in their ERs today – deficiencies that can them lead to lawsuits and liabilities. Conclusion Governing boards and executives of the hospital and system I work for as well as others around the country should keep an eye on their ERs and make every effort to prevent their overcrowding. They should note that ERs have come under closer scrutiny by the local, state and federal governments.
Federal inspectors, in one case, stated that ER patients were in immediate jeopardy of harm or death, and so a certain hospital was given 23 days to correct deficiencies or risk losing federal funding. Lawsuits have been filed targeting some hospitals alleging poor quality care due to overcrowded ERs and fewer choices in primary care. The possibility of hospitals closing down or losing federal funding does exist in many such lawsuits. The possibility for a hospital or staff to be charged with murder due to overcrowding might be remote, but the political climate could be changing.
Healthcare executives may also find themselves on forced-leave due to incidents that are created by overcrowding in their ERs; in fact, it has already happened. Many non-profits with record profits should, therefore, consider putting more money into making their ERs better. In the long run they actually may end up saving money. This would be due to fewer liabilities, lawsuits, and lawyers defending them against different government agencies about care issues related to the present conditions of their ERs.
Furthermore, there is an obvious need to develop better primary care for communities where improvements in this area are slow to come; and provide greater access to urgent care wherever it is lacking. This would take some patients out of the ERs, which may be their only source of care at present. In addition, hospitals may get together with state and local governments to try to come up with solutions. As an example, in California, Proposition 67 would raise millions of dollars for emergency room services and community clinics. This proposition would place a tax on in-state telephone use.
The individual phone user would pay very little, however. Regardless of the decision to use a certain solution over the other to fix the conditions of ERs around the country, hospitals that participate in the effort would face less chance of being accused of not effectively fulfilling their legal responsibility for their conduct. Of course, it would also help to leave them less vulnerable to lawsuits and liability issues stemming from overcrowding in emergency rooms. Needless to say, healthcare organizations need to give serious thought to the problem at hand, and right away.