Emergency-room visits carry more ‘wait’ than ever

People in the United States who slice a finger chopping vegetables, come home from work to a feverish baby or break a bone in a weekend football game have, at last count, just over 4,000 emergency departments scattered across the country from which they might seek care.

But they had better have plenty of time.

As emergency-room visits in the United States have ticked steadily upward, reaching 119.2 million annually, waiting for treatment has become a central feature of emergency care.

Patients spend an average of 3.3 hours to be seen, treated and discharged, according to a 2006 report by the Centers for Disease Control and Prevention.

Last June, a 49-year-old woman died on the waiting-room floor of a New York hospital ER – one of the almost 400,000 patients who, the CDC found, had waited 24 hours or longer to be treated in a hospital emergency room.

Many people would rather stitch themselves up, splint their own fracture or endure a fussy baby through the night than brave the wait – not to mention many ER staffs’ seeming indifference to less-than-life-threatening afflictions.

It is in this atmosphere that the urgent care center is making a comeback, and some hospitals are taking a hard look at the ER experience.

The Urgent Care Association of America, a trade organization that came into existence in 2004, last year counted a total of 8,000 urgent care centers around the United States. For patients with illness or injury that is not life-threatening but can’t wait for an appointment with a primary care doctor, these hybrids are an alternative.

In the absence of a single standard, the Urgent Care Association is drafting a list of criteria that would let consumers know what to expect from an urgent care center.

Such centers now vary widely. Most keep evening and weekend hours, although few are open 24/7; many are heavily staffed by physician assistants, with at least one physician on site or on call; most have X-ray machines and rudimentary lab facilities, although centers that are not connected to a full-service hospital usually lack the sophisticated blood-chemistry tests, MRIs and CT scans that ER doctors use to diagnose and treat serious illness.

Urgent care center staff generally can detect and set a simple fracture, administer breathing treatments and write prescriptions to treat sprains, allergic reactions and infections. But if you walk into one with signs of stroke or heart attack, or are about to give birth, they’ll call 911 faster than you can say “triage.”

About 15 percent of urgent care centers are affiliated with existing hospitals, either as satellite facilities or as on-site clinics near the hospital ER that can handle nonemergency walk-in cases.

Although 1 in 4 urgent-care practices serve an urban population, most – 55 percent – are in the suburbs, where affluent and privately insured patients often are reluctant to spend hours in an ER’s waiting room.

“The motivation is money, and clearly the finances are there,” said Dr. Sandra Schneider, an emergency-department physician at the University of Rochester Medical Center in New York and a vice president of the American College of Emergency Physicians.

Many private insurers, keen to keep costs down, are encouraging patients to use urgent care as an alternative to an ER visit.

The rapid rise of urgent care centers, combined with the fact that they are largely undefined and unregulated by state hospital and medical boards, puts important responsibilities on patients, Schneider said.

They not only must make the crucial decision of what level of care they are likely to need, they also would do well to check, in advance of a potential need, the credentials, capabilities and staffing policies of an urgent-care clinic they might use.

“As it is now, anybody who has an M.D. or license to practice could put up a sign and say, ‘I’m an urgent-care doctor,’ ” Schneider said. “If you’re having a heart attack, you really want an emergency physician there, because that’s what they’re trained to do.”

At the same time, some hospitals are responding to the chorus of patient complaints. In recent years, Schneider said, many have established “fast-track” procedures that funnel patients who need nonemergency care to a staff of physician assistants operating under the supervision of emergency doctors.

At San Gabriel Valley Medical Center, in the Los Angeles area, monthly ER meetings convene the heads of nursing, labs, radiology, information technology and housekeeping with hospital executives to check flow charts, look for bottlenecks and find ways to move patients through the ER more quickly.

“We don’t blame them for going elsewhere,” said Dr. W. Richard Bukata, medical director of the emergency department, which last month saw patients, on average, within 34 minutes. “But our resources are so much better, and we want to see them all.”

Those ER resources – although necessary for diagnosing and treating heart attacks, strokes, abdominal blockages and life-threatening injuries – are not always necessary for the afflictions that patients take to urgent care centers, and they come at a very high cost.

“For 8 out of 10 problems seen in a hospital emergency department, we’re able to treat them every bit as well, and our fees are probably one-quarter of what they would be in a hospital emergency department,” said Dr. Richard Foullon, medical director of the Los Angeles area’s Verdugo Hills Urgent Care Medical Group, which sees walk-in patients seven days a week, spread over 85 hours.

These trends may do little to stem a crisis in emergency medicine.

In recent years, public officials and the medical establishment have bemoaned a shortage of ER physicians and on-call specialists; the cost of caring for uninsured patients who turn to emergency departments for treatment; and a shortage of hospital beds for acutely ill or injured ER patients who need to be admitted.

Siphoning off patients who have less-dire medical problems (and private insurance) will leave hospital ERs, which under federal law must treat all comers, insured or not, with the patients who are the biggest drain on resources – the poorest, the sickest and those most likely to spend hours or days “boarding” in the emergency department waiting for a bed to open elsewhere in the hospital.

“If we only took care of the patients who needed to come into the hospital, we would close down,” said Bukata, of San Gabriel Valley Medical Center.

“The people who keep us open are these bread-and-butter cases who go home – the 80 percent of patients who come into the emergency department who are not admitted. It’s those patients who allow ERs to sustain themselves.”