In the News

As published in the Danbury News-Times, June 15, 2006.

ERs Pushed to the Brink

By Robert Miller

Every day, about 185 people come to Danbury Hospital's emergency department — some 67,000 a year.

"Ten years ago, we were seeing about 50,000 patients a year,'' Dr. Patrick Broderick, chairman of emergency medicine at Danbury Hospital said Wednesday.

"We were at capacity at 9 a.m. this morning, and we'll stay that way probably until 3 a.m. tomorrow,'' Dr. Robert Fuller, clinical chief of emergency medicine at the University of Connecticut Health Center in Farmington, said Wednesday.

Across the state, across the country, the news is the same. Hospital emergency rooms are crowded. If there were a mass emergency — a bioterrorism attack, a wave of avian flu — they'd be overwhelmed.

"We're like a series of pans of water, all connected and all nearly full,'' Fuller said. "Throw a bucket of water into one, and we'd all overflow.''

Those are the same concerns expressed Wednesday in three reports issued by the Institute of Medicine on the state of emergency care in the United State — the first comprehensive studies on the subject in 40 years.

"We are being pushed beyond our capacity to respond,'' said Dr. Brian Keaton, president-elect of the American College of Emergency Physicians.

"If we're already running at 95 percent capacity, it wouldn't take a lot to knock us back,'' said Broderick of Danbury.

The three reports, issued by the Institute of Medicine, pointed out that in 1993, about 90 million people in the United States made an emergency room visit. By 2003, the number was up to nearly 114 million.

At the same time, the number of U.S. hospitals declined by 703 and the number of emergency rooms by 425. There are 100,000 fewer hospital beds in the country, and a shortage of nurses estimated at 150,000.

"In 1993, there were 30 million people on Medicare,'' said Keaton, who practices emergency medicine for Summa Health Systems in Akron, Ohio. "Today, we've got 44 million."

The result can be a huge backlog of patients stuck in the emergency room until a hospital bed becomes available.

Broderick said patients in the Danbury ER can have waits of five or six hours before getting moved upstairs to a hospital bed.

"We're not as bad as some inner-city hospitals, where the wait can be days,'' he said. "But that's not to say five or six hours is acceptable.''

The problem is that hospitals now often run at or near capacity; Broderick said for the past few days, Danbury Hospital's 371 beds have been nearly full.

"It's really a vicious circle,'' he said. "You try to walk the line between the number of beds you have and the people you need.''

Dr. Thomas Koobatian, chief of emergency medicine at New Milford Hospital, said Wednesday the problem isn't as severe there.

He said the New Milford emergency room's caseload — about 20,000 patients a year — has stayed steady. The lag time in getting a patient moved from the ER into the hospital has more to do with completing paperwork, he said, than juggling space.

But Koobatian said New Milford Hospital's emergency room — like others — is seeing more uninsured patients coming through its doors. By federal mandate, hospital emergency rooms must treat patients who seek help from them.

Sometimes, Koobatian said, the patients who come to New Milford's ER illustrate the current gaps in the nation's health care system.

"There's not a day goes by that we don't see patients with dental problems,'' Koobatian said. "But we don't have a dentist in our ER."

Koobatian said the New Milford emergency room is also seeing an increasing number of people coming to it with non-emergency medical problems and good insurance coverage.

"We're a center of convenience,'' he said.

But for many patients who have insurance — particularly Medicare and Medicaid — the reimbursements aren't keeping up with the cost of medical care.

And Fuller of UConn said as the patient population grows older, their problems are far more complicated, slowing down emergency care.

"A patient with poison ivy we can take care of in minutes,'' he said. "A patient who is on a ventilator and should be in intensive care, that can take hours.''

Fears of a broad regional emergency — either through terrorist attacks or a pandemic such as a mutated avian flu virus — bring these issues to the limelight.

But post-9/11, emergency rooms — which are an essential part of any response to a mass attack — have gotten short shrift from Department of Homeland Security.

In 2002 and 2003, the department distributed $3.38 billion for emergency preparedness programs; only $135 million went to emergency rooms. Many of the ER grants were only $5,000 to $10,000, Broderick said, while Danbury Hospital got about $100,000 for decontamination technology.

But Koobatian of New Milford Hospital said if there were a disaster, emergency rooms would find ways to cope.

"Right now, I'm treating people with poison ivy, sore throats, sprained ankles,'' he said. "If we were in a true emergency, I'd clear those people out.''

But he said the next step — moving a wave of patients from the ER to a hospital setting — would probably prove a greater challenge.

The Institute of Medicine reports call for the U.S. Congress to set up a $50 million fund to compensate hospitals for unpaid emergency care, along with more emergency preparedness funding.

It also calls for Congress to pass the Emergency Medical Services Act, a bill proposed in 2005. Among is provisions would be reducing the liability risk of caring for emergency room patients. That would allow all specialists to be involved in ER care, without the fear of being sued.

The reports also fault hospital emergency departments for their pediatric care, saying only 6 percent of hospitals in the United States are well-equipped for child patients.

Danbury Hospital, which has an emergency room pediatric suite, is part of that elite 6 percent, Broderick said.

The reports also pointed out that the entire U.S. emergency system is fragmented. There are no national standards for paramedic and EMT care, and communications between emergency rooms doctors and ambulance staff is often shaky.

Broderick said communications between hospitals and EMTs in the field in Connecticut are good.

"We still need better communications between hospitals,'' he said.

Keaton, the president-elect of the American College of Emergency Physicians, compared the creation of an national communications system between ambulances, emergency rooms and hospitals to President Dwight Eisenhower's creation of a national highway system.

"Eisenhower built those highways so that in case of a nuclear attack people could evacuate the cities and troops could move more easily," Keaton said.

"Neither of those things ever happened. But the highways completely changed America.''