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Jewish World Review March 19, 2001 / 24 Adar, 5761

Lee Bowman

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Consumer Reports

Our emergency rooms are ailing -- AMERICA'S emergency rooms are stressed out, stretched thin and often dangerously overcrowded.

A new report prepared for the American Hospital Association says the root of the problem doesn't lie so much in the emergency departments, but with a lack of hospital inpatient beds and caseloads of sicker patients, many of them recently discharged from the same hospitals.

"When there aren't enough staffed beds, the system backs up and we get on the verge of gridlock,'' said Dr. Arthur Kellerman, chief of emergency medicine at Grady Memorial Hospital in Atlanta. "Around the nation, there are thousands of sick and injured patients in hallways with nowhere to go.''

At Grady, Kellerman and his colleagues have a system for keeping track of patients on gurneys in hallways and linen closets of the department. "We started out taping numbers along the hallways and attaching plastic hooks to the tiles to hold IVs. Now we're up to labeling spaces 1A and 1B,'' Kellerman said.

A national survey of 575 emergency-department directors found that 91 percent were experiencing overcrowding at least several times a week, and many on a daily basis. Overcrowding was defined as having all beds occupied, patients in the hallways and acutely ill patients waiting an hour or more to see a doctor.

Patients needing more complicated care and a lack of hospital beds topped the reasons for overcrowding cited in the survey that was conducted by Dr. Robert Derlet and published last month in the journal Academic Emergency Medicine.

Around the nation, the problem has crept into public view most often because emergency rooms are frequently forced to ask ambulance dispatchers to stop sending them patients.

In February in Cincinnati, for example, 11 hospitals went "on diversion'' - sending ambulances away - for 112 shifts, according to the Greater Cincinnati Health Council, topping the previous record in January.

In Omaha, ER diversions increased from 13 in the first two months of 2000 to 72 in the first two months of this year.

Diversions are up all around Massachusetts this winter, with at least one diverting patients every day in Boston, and as many as six on some days.

In Richmond, Va., in early January, all 12 general hospitals in the area were almost simultaneously advising ambulances to go elsewhere. The region's disaster plan for handling mass casualties had to be put into action.

"We're having days when not only our public hospital, but all the emergency departments in greater Atlanta are on diversion,'' said Kellerman, who is also on the board of the American College of Emergency Physicians. "But this is like applying a Band-Aid to a gunshot wound. Ambulance crews still come with critical patients if we're closest, and people still walk in on their own. We can't turn off the tap.''

Hospital emergency departments are the only health-care facilities required by law to at least evaluate and stabilize any patient who walks through the door. Americans do so more than 100 million times a year.

"For many people, the ER is the only point of care they have,'' said American Hospital Association President Dick Davidson. "Yet throughout the '90s, the number of emergency departments went down, while the volume of patients grew.''

The association reports that more than 1,000 emergency departments have closed over the past decade, many in already under served rural areas, but also in cities and suburbs. Emergency departments tend to lose more money than other hospital operations because more patients lack insurance.

Doctors trying to duck managed-care restrictions, outmoded government rules and many other factors are bringing emergency rooms to the edge of what Davidson says could be "a very serious public health crisis.''

But the biggest contributor to the problem, according to the report, is that seriously ill patients have no place to go in the hospital besides the ER.

Hospitals eliminated more than 100,000 acute-care beds and 7,800 surgical/critical-care beds in the past decade as both government and private insurers moved to cut the length of hospital stays.

Now, even hospitals that still have beds in reserve can't find enough nurses amid a growing national shortage of nurses. And, Kellerman concedes, some hospitals hold back beds for patients having elective surgery, "since they're the only ones not paying discounted prices for their care. A lot of administrators need those patients to stay in business at all.''

For the short term, Kellerman said emergency rooms have no choice but to "keep doing the best we can while looking for every resource possible to help us deal with personnel shortages and keep the people we have.''

The hospital association and many other health groups at the state and national level are forming committees to come up with ideas for dealing with staff shortages. However, officials also argue that fundamental reforms in health insurance coverage and payment policies for emergency care will be needed to reduce the burden for emergency departments.

"People are always going to need emergency care, but society also needs to do a better job promoting health and safe behaviors, because the cheapest patients are the ones we never have to see,'' Kellerman said.

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