How hospitals are killing E.R. patients.
Posted Thursday, July 24, 2008, at 6:54 AM
What about the staff upstairs, who take care of the admitted patients once they leave the E.R.? Their incentives are misaligned, too. Put yourself in an inpatient nurse's shoes. You are overworked, and your current patients need attention. You get a call from the E.R., saying that a patient like Green is ready to come upstairs. The bed is clean and ready. But you have 20 more things to do before your shift ends in two hours, and you won't get paid an extra cent if you accept Green to the empty bed. Can't she wait just a bit more in the E.R.? When the next nurse comes on fresh, you tell yourself, she can admit the new patient. You won't get in trouble for stalling because no one really measures how long patients stay in the E.R.. So you tell the E.R. nurse that the bed isn't ready yet. This practice of "bed-hiding" is more common than you think.
What can be done about all this? We think the answer is that hospitals should have to disclose and take responsibility for how long E.R. patients—that is, you—wait for beds. But, not surprisingly, hospitals have lobbied hard to not be held accountable for E.R. crowding and boarding. If they won't measure and eliminate E.R. boarding on their own, then the federal Centers for Medicare & Medicaid Services, which pays many hospital patients' bills, or the Joint Commission, which accredits hospitals, should take this on.
And let's also hold congressional hearings on E.R. boarding. In England, the National Health System now has a rule that 98 percent of patients have to spend less than four hours in the E.R.. Apparently, the son of a member of parliament spent too long in an E.R., we've heard. Esmin Green wasn't well-connected. But her death should serve as a similar prompt to fix the problem of endless waiting.
Meanwhile, if you have to go the E.R., you can vote with your feet. When you are really sick, of course, go to the closest E.R. or call an ambulance. But if you can wait long enough to choose, go to the E.R. where they don't make patients wait or board for long periods. Yes, we know—since hospitals don't publicize E.R. waits or boarding, you'll have to go by word of mouth. If, despite your efforts, you or your grandmother is forced to lie in the E.R. all night, complain directly to the hospital administrators who actually have the power to fix the problem. But don't count on any major changes. As long as hospitals profit more from boarding and aren't forced to admit to doing it, your trip to the E.R. will be as long as a flight to Africa—but without the in-flight movie and far more risky.
Zachary F. Meisel is a practicing emergency physician, a Robert Wood Johnson Foundation clinical scholar at the University of Pennsylvania, and a senior fellow at the Leonard Davis Institute of Health Economics.
Jesse M. Pines is a practicing emergency physician and an associate professor of emergency medicine and health policy at George Washington University in the Center for Health Care Quality.
Still from Kings County hospital surveillance tape of Esmin Green courtesy NYCLU.