Emergency Not Enough Room

June 23, 2006
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GRAND RAPIDS — The emergency in the United States' emergency medicine system doesn't have anything to do with the illness and injuries of the patients coming in for treatment. It has more to do with how many patients are coming in and how many of them are paying their bills.                  

A report on the state of the country's emergency medical system was recently released by the Institute of Medicine, part of the nonprofit research organization, the National Academies. The report, "The Future of Emergency Medicine," does not paint a pretty picture of the system.

The nation's emergency rooms are overcrowded. While the number of emergency rooms fell by 425 (or 198,000 beds) between 1993 and 2003, the overall demand for emergency care grew by 26 percent. To complicate matters, health care systems are not very good at communicating and cooperating with one another. This leads to two common failures of a community's emergency medical system: diversion and boarding.

Diversion is the practice of temporarily closing an emergency department because it cannot take any more patients. Boarding refers to keeping non-emergency patients in the ED because of a lack of available inpatient beds.

Both of these practices are widespread and growing in frequency, the report shows. Poor collaboration between health systems also makes for a public health network not well equipped to handle a large-scale emergency such as a natural disaster or terrorist attack.

In addition to all of those factors, there is a nationwide shortage of emergency and trauma specialists, especially those trained in pediatric emergency medicine.

The state of emergency rooms across the country looks pretty bleak. Fortunately for residents of West Michigan, things here aren't so bad.

"We're not as bad in Grand Rapids as some of the major cities where people drive in ambulances around and around town to find a hospital that will take them. That's terrible," said Dr. Bryan Buller, chief of staff of the emergency department at Saint Mary's Health Care. "So we are lucky that our hospitals and emergency rooms cooperate enough with each other in this kind of a situation."

Helen Berghoef, director of emergency and ambulatory services for Metro Health and a member of the executive committee for Kent County Emergency Management Services, said that Grand Rapids has seen the same increase in stress on its emergency medicine system that has been common throughout the country. What has allowed this community to stay ahead of its peers is greater planning and cooperation.

"I know we're not seeing the level of overcrowding and diversion that many other communities are experiencing," she said.

Over the past several years, West Michigan's hospitals have been streamlining their procedures in order to ease the strain on their emergency departments. Berghoef said that by improving the efficiency with which patients are moved out of ED into inpatient beds, the local health systems have greatly reduced the need for diversion.

"It was a commitment by the hospitals' upper management to recognize the emergency departments as sort of a safety net, and that we couldn't just have us handle all of the incoming traffic and have the inpatient units say 'Oh, we're not ready for that patient. We don't have a bed for them.'"

Metro, Saint Mary's and Spectrum Health have all undertaken similar efforts to improve the efficiency of their emergency care.

Spectrum Health's emergency department was ranked 19th busiest in the country by a 2005 Modern Healthcare study. Spokesman Bruce Rossman said that, despite a dramatic increase in ED traffic, Spectrum has instituted procedures that have cut down on wait times, length of stay and diversion.

"We rarely ever close one of our EDs to (all) traffic, but may occasionally close to lesser kinds of cases coming by ambulance," he said.

Under most circumstances, Spectrum can balance its emergency patient flow between the Blodgett and Butterworth campuses. Rossman said that it is not unheard of for patients to be forced to wait in the ED for an inpatient bed to open up, but that those wait times are much shorter than the two-day average mentioned in the Institute of Medicine study.

"In less than a year, we've dropped our average wait time at Butterworth to 28 minutes and about 60 (percent) to 64 percent of our patients go from door to doc in less than 30 minutes," said Rossman. "Not bad for an ED that will likely see 130,000 patients this year."

Despite the comparative health of West Michigan's emergency medical system, there are plenty of challenges. Both Saint Mary's and Metro Health are building new emergency departments, due in part to the increased demand for their services. Metro's departure from the city of Grand Rapids — when it moves its emergency services to its new southern Wyoming campus next year — will also affect the region's ability to handle emergency patients.

"I think we're still going to see enough professionalism among the departments that they're still going to have the cooperation," said Saint Mary's Buller. "But, the patient load that Metro used to take was a load that, quite frankly, is not going to be able to make it all the way out there (to southern Wyoming). It's a long distance. And those patients — the underserved, the poorer patients — are not going to be going to Metro. So they're going to be going to the other hospitals in the area. So is that going to create a burden for us? Yeah."

Buller said that Grand Rapids' three health systems have historically shared the responsibility of caring for "the un-financed or under-financed." With Metro leaving the city, he believes that Saint Mary's and Spectrum will face increased financial challenges.

Metro's Berghoef doesn't think that will be so. She doesn't believe that the move will result in a decrease in Metro's patient load — poor or otherwise.

"Absolutely not. I don't think any ER anywhere in the United States is going to experience lower volumes in the next several years," she said. "We expect to continue to grow."

Both Metro and Saint Mary's are implementing new "lean" processes that they will incorporate into the treatment given in their new facilities.

"We're working on new processes so we don't just take our old, broken-down processes and just put them in a new facility. That isn't going to work," said Buller.

Those efforts underscore one of the reasons for the area's success. Even though Grand Rapids is in better shape than the rest of the country, there is still a great deal going on to improve and streamline emergency care in this area.

"We have everybody working together, from EMS to hospitals to the health department," said Berghoef. "So I think, overall, we are doing very well."

The Institute of Medicine study had several recommendations, though many of them were somewhat abstract. The concrete proposals mainly had to do with Congress increasing funding to encourage greater regional collaboration.

"Regional planning and finding a way for the departments to work together? That's fine, but put some of the money into the departments themselves," said Buller. He said there is a limit to the ability of emergency departments to "lean out" their processes.

"Good for us that we're stretching, but bad for the system when it's 'Oops, we can't stretch any more. That's it.'"    

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