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Feb. 4, 2000

ER conditions: Critical

By Julie Appleby, USA TODAY

Fire Capt. Joe Gulotta found himself in the middle of a Tucson intersection recently, on the radio, demanding that one of the city's two swamped trauma centers take five seriously injured car wreck patients.

"I said, 'I don't care where we take these patients, but someone's got to take them,'" Gulotta says. His demands led one hospital to take all five. "It's becoming disastrous. We're traveling across town, shopping for hospitals."

From California to Massachusetts, emergency officials are reporting similar problems: Crowded hospitals leading to long waits for emergency care. Patients kept in the ER for days because no beds are available in the hospital. Ambulances forced to drive farther and farther for help.

Is it just the flu?

No, according to doctors, nurses and other experts. They fear that emergency room and hospital overcrowding are proof that a decade of cost cutting has created a crisis in emergency care.

rarrow.gif (846 bytes)For nearly 10 days in December, 60 of Los Angeles' 81 ERs were so full that hospital administrators asked to send ambulances elsewhere.

rarrow.gif (846 bytes)In nearby Riverside, hospitals were so busy this month that ambulances had to wait up to 30 minutes outside the ER with their patients.

rarrow.gif (846 bytes)The amount of time Maryland hospitals spent on near-capacity "yellow alerts" has doubled in each of the past three years.

"Emergency rooms are the safety net for health care in this country, and the system's rapidly crumbling," says Peter Boss of Hemet Valley Medical Center in Riverside County, Calif.

"As a patient, it's frightening," says Rickey Folck, 54, who has congestive heart failure. She recently spent 18 hours in an ER cubicle in a Southern California hospital with two other patients, separated only by curtains, before an intensive care unit bed became available. At one point, she says, the man on the next gurney almost fell over onto her.

The problem could worsen, experts fear, as hospital finances remain uncertain, a nursing shortage grows and more Americans find themselves without health insurance.

"Unless the problem is solved, the general public may no longer be able to rely on emergency departments for quality and timely emergency care, placing the people of this country at risk," a report in January's Annals of Emergency Medicine warns.

Responding to tight finances, pressure for profits and demands by employers to reduce health care costs, many hospitals have trimmed expenses and cut staff. Some regions also are trying to cope with a nursing shortage.

Staffing is sometimes so thin that hospitals can't admit additional patients to intensive care units and other wards. So seriously ill patients must be kept in ERs, sometimes for days, adding to the backups.

"We have 13 ICU beds. At one point, we had 21 ICU cases," says Mary Ann Bush, chief nursing officer at Parkview Community Hospital Medical Center in Riverside, Calif.

"We were using our recovery room and some patients had to wait in the ER, sometimes for 24 hours. We were all maxed out."

In an ICU, nurses generally care for one or two patients. In an ER, the nurses often have to care for more.

In ER wards for days

"As wonderful as ERs are, they're not designed to be intensive care units," says Bruce Auerbach, vice president and chief of emergency services at Sturdy Memorial Hospital in Attleboro, about 35 miles south of Boston.

"I think we need to worry about it," he says. "It's only a matter of time before patients are sitting in ER wards for upwards of two or three days waiting for admission - and getting less-than-ideal care."

"A busy ER is very noisy and there's limited privacy," says Boss, chief of the ER at Hemet, where he says the situation gets worse every year.

"We routinely put two people in a cubicle made for one. We treat patients in chairs and in the hallways. We've had scenarios where an ambulance sat there with the patient on a gurney and a monitor because we had no beds and no monitors. That pulls an ambulance off the street."

Paramedics in California, Arizona, Massachusetts and other states say they are growing increasingly concerned about delays at busy ERs that keep them off the streets - or increase their travel time when they are diverted to hospitals farther away.

"When we get to a hospital, we either have to wait with the patient on a stretcher or are told on the radio, 'No, you can't come to this hospital,'" says paramedic Ken Levey, who works in metropolitan Boston. "Sometimes we have to travel with a pretty sick person a good distance."

Gulotta, in Tucson, says family members of injured or sick patients are further distressed when they arrive at one hospital only to find the patient isn't there because the ambulance was sent to a hospital that wasn't as busy.

Gulotta and others blame the crowding, in part, on a shortage of nurses caused both by hospitals cutting staff and by a growing shortage of trained critical care nurses.

Hospitals have turned to just-in-time staffing, bringing in enough nurses and other workers each day to cover anticipated patient loads. If the day is busier than expected, many hospitals cannot respond quickly.

"There's not a lot of flexibility in the hospital system anymore," says Virginia Hastings, emergency medical services director in Los Angeles County. "The slightest blip (like a severe flu season) becomes a crisis."

Financial factors

Hospital finances also play a role. With reductions in revenue from insurers, as well as a declining amount of time patients spend in the hospital, many facilities are financially struggling. In 1998, 27% of hospitals were losing money, up from 20% the year before, the American Hospital Association says.

Such finances lead some hospitals to close. In the past decade, about 500 hospitals nationwide have shut their doors, federal data shows. From 1993 to 1996, the number of hospital beds per 1,000 residents in the USA fell by 9%. Regions with the fewest beds include cities in Washington state, California, Arizona and Colorado.

Other hospitals have shut their emergency departments, which often draw patients who can't afford to pay. In just a decade, from 1988 to 1998, the nation lost 1,128 ERs, the hospital association says. A decade ago, 94% of hospitals reported having an ER. In 1998, that percentage dropped to 92.6%.

"In the 1940s and 1950s, people thought we had too few hospitals; then in the '70s and '80s, too many," says Alan Sager, a health care economist at Boston University School of Public Health. "Now we're going back to too few in many parts of the country."

With fewer hospitals and fewer ERs, the remaining facilities are becoming busier. Adding to the crunch are doctors' offices that are too busy to see patients - and people who fall ill after regular hours. For those patients, there's nowhere else to go.

"My daughter-in-law took my grandchild to the ER when she was very sick and could not see her doctor, who didn't have an appointment available for two weeks," says Hastings, the emergency director for Los Angeles County. "She went to an urgent-care center, but it was closed. There is nothing else in the health care system that's guaranteed to be available 24 hours a day."

Those factors, joined with a growing number of uninsured, all play a role in the growing pressure on the emergency medical system.

"This is a nationwide problem," says Robert Bass, emergency medical services chief in Maryland.

Yet states are limited in their ability to track and regulate the factors leading to the problem.

State officials, for example, don't know how often hospital intensive care units are full, which can back up patients in the ER.

They also don't know how often ERs are so busy that they divert ambulances to neighboring facilities. That data is tracked by hospitals and 911 centers but usually is not collected statewide or studied.

Similarly, there's no reliable data on how long patients wait to see a doctor once they arrive at a hospital. A study done in the early 1990s estimated that the average wait in an ER was two hours. But patients often wait far longer.

"I have spent hours in the ER waiting room with pancreatitis, which is very painful," says Kenny Tomsen, a computer technician in southern California. "As bad as they wanted to get me in there, they were unable to. There were no beds."

Doctors and nurses say the problem is getting worse.

"We're talking about people with relatively serious conditions having to wait for hours," says Boss, the emergency director in Hemet, where his hospital was so busy one day in December that it ran out of ventilators and cardiac monitors.

"A technician had to hand-bag a patient for three hours until we could get a ventilator," Boss says. Overcrowding is not just an occasional problem, he says. "It's a constant problem that becomes very acute during the winter."

Several states are trying to tackle the problem:

rarrow.gif (846 bytes)California lawmakers adopted a law giving local emergency medical services agencies power to review the community effect of proposed hospital closures. The agencies, however, lack authority to force a hospital to stay open. Nor do they have the funding to prop up financially failing facilities.

rarrow.gif (846 bytes)A number of cities and regions refuse to allow hospitals to divert ambulances to other facilities if a sizable proportion of other hospitals is similarly overburdened. If all the hospitals are full, officials say, it doesn't make sense to send ambulances "shopping" around town.

rarrow.gif (846 bytes)Several southern California cities, including Los Angeles and San Diego, can monitor ER and ICU availability instantly, by computer, helping emergency officials assess current conditions.

rarrow.gif (846 bytes)Voluntary efforts to reduce crowding, increase staff and better monitor available hospital beds are in effect in Maryland, Massachusetts and other states.

Solutions are limited

But all such efforts are limited, hospital officials say.

"One of the critical factors is getting at solving the underlying problem of the uninsured," says Carmela Coyle, senior vice president at the American Hospital Association.

With the number of uninsured at 44 million and growing, that problem isn't likely to be resolved soon.

The other issue is money.

"The combination of Medicare reductions and the financial squeeze from managed care has put enormous pressure on the health care system," says Judy Glasser of the Massachusetts Hospital Association, whose members reported total profit margins of 0.3% in 1999, down from a still-slim 1.9% the previous year.

"There clearly are solutions," says Auerbach, the emergency chief in Attleboro, Mass. He suggests "out-of-the-box" thinking that might include relaxing regulations to allow for mobile hospital vans that could be brought into areas to temporarily relieve hospital crowding.

"The difficulty will be picking solutions that are affordable," he says, "that fit within what we're willing to pay for health care."

What has caused ER crowding?

More and sicker patients coming to ERs

ER visits increased from 90.4 million in 1994 to 94.7 million in 1998. At the same time, patients are often sicker, requiring more complex care.

Fewer hospitals, ERs and beds

In the past decade, about 500 hospitals nationwide have closed, federal data show. From 1993 to 1996, the number of hospital beds per 1,000 residents in the USA fell by 9%, the Dartmouth Atlas of Health Care says. And from 1988 to 1998, the nation lost 1,128 ERs, the American Hospital Association says.

Nursing cutbacks and shortages

With fewer nurses, hospitals can make fewer beds available. Without beds in the intensive care unit and other wards, some patients must remain in the ER, adding to backups.

More treatment in the ER

New drugs and technology allow patients who once might have been admitted to the hospital to be treated in the ER. For example, asthma patients are given treatment, then observed for 6 to 8 hours, but this ties up an ER bed.

Lack of access to other health care

Not a new problem, but a growing one. Uninsured patients, for example, often have nowhere else to turn. Some insured patients also find their doctors are busier than ever under managed care, making it difficult to get timely appointments. So they turn to ERs.