Jul 7 2011
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Ambulance Diversion, ER Crowding, and How It Affects You

Renee Y. Hsia, M.D., M.Sc., is an emergency physician at San Francisco General Hospital and an assistant professor in the Department of Emergency Medicine at the University of California San Francisco. She is a Robert Wood Johnson Foundation Physician Faculty Scholar.

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A few weeks ago, my colleague Yu-Chu Shen, Ph.D., and I published the results of a study in the Journal of the American Medical Association (JAMA) (abstract) showing that if you are unlucky enough to have a heart attack on a day that your hospital is busy, you have a higher risk of dying. More specifically, we found that for every 100 patients unfortunate enough to have a heart attack when their emergency rooms are diverting ambulances for long periods of time – a key indicator of a busy ER – there are about three potentially avoidable deaths in the 30 days after patients are admitted to the hospital.

Why might this be? We know ER crowding has become rampant; we’ve all experienced the annoyances (as patients, family members or providers) of hours-long waits to be seen. Many of us have also experienced the panic of worrying that a loved one isn’t getting the best care they could because the ER is crowded.

As an ER doctor at a busy county hospital that’s also a trauma center, I feel the stress of providing care to patients under tense circumstances. It’s a daily – sometimes an hourly – challenge. None of our staff – technicians, pharmacists, nurses and doctors – feel good when we are crowded to the point that we cannot provide the best care possible.

To make matters worse, overloaded ERs are more common than they used to be – at least in part because some hospitals are closing down their emergency departments. Another recent study we published in JAMA (covered in the New York Times on May 18, 2011) shows that emergency departments at several types of hospitals are at increased risk of being shut down: those at financially distressed hospitals (witness the recent closure of St. Vincent’s in New York City), and those that are for-profit and located in more competitive markets . In addition, ERs in hospitals that serve a high proportion of poor patients and poorly insured patients have a higher risk of closing their doors.

These factors point to an uncomfortable reality about our market-based approach to health care in the United States: When we rely on the market to determine who gets care and who doesn’t, the market will not correct for certain things. Access to the critical services provided in ERs is a good example.

“Market-based health care” and “consumer-driven health care” are attractive jargon, but we need to recognize that some types of care – like emergency care – don’t pay. Complete reliance on the market will mean that the gaps we see for the vulnerable – which in times of emergencies can mean any of us – will only grow wider.

Recent health care legislation takes a few steps toward reforming our health care system, but much, much more is needed. Although change is inevitably frightening, we cannot ignore that we have huge market failures in our health care system. Expecting the market to solve all of our health care ills simply will not work.

It’s easy to think that the closure of an emergency department in a distant community is someone else’s problem. But access-to-care issues have a way of crossing zip codes. When an emergency department in one community closes down, its former patients still need care, and they’ll seek it at neighboring hospitals, increasing their load. So in addition to the moral and philosophical reasons we have to care about communities losing access to care, we should also be concerned that a closed emergency room across town will increase the burden on the ones closer to home.

Learn more about the Robert Wood Johnson Foundation Physician Faculty Scholars program.

Read an article on the RWJF Human Capital Web site about one of Hsia's studies, "Trauma Center Locations and Procedures a Barrier to Care for Elderly and Vulnerable Patients."

Tags: Disparities, Emergency Care, Emergency care, Health & Health Care Policy, Human Capital, Patients, Physician Faculty Scholars, Publications, Research & Analysis, Voices from the Field