ER waits can be dangerously long

Jackequeline Walls (left) and Jacob Sweat, both with American Medical Response with Dekalb County, arrive with a patient at Atlanta Medical Center on Tuesday, December 10, 2013. It’s one of the worst encounters many people have with the health care system: the incredibly long wait at the emergency room. Atlanta Medical Center, which is a level 1 trauma center, sees 60,000 patients a year in its ER. It is experimenting with a lot of new processes to reduce ER waits. HYOSUB SHIN / HSHIN@AJC.COM
Jackequeline Walls (left) and Jacob Sweat, both with American Medical Response with Dekalb County, arrive with a patient at Atlanta Medical Center on Tuesday, December 10, 2013. It’s one of the worst encounters many people have with the health care system: the incredibly long wait at the emergency room. Atlanta Medical Center, which is a level 1 trauma center, sees 60,000 patients a year in its ER. It is experimenting with a lot of new processes to reduce ER waits. HYOSUB SHIN / HSHIN@AJC.COM



Grady Memorial Hospital’s ER has rows and rows of chairs in its waiting room for good reason: emergency room patients at Grady face some of the longest waits in the nation before seeing a doctor, according to federal statistics.

But Grady is hardly the only metro Atlanta ER at which patients must endure hours of waiting for medical care.

At Piedmont Hospital in Buckhead, patients typically waited 92 minutes in the ER before seeing a doctor — more than three times the national average of 27 minutes, the statistics show.

Thinking about trying Emory instead? At Emory Midtown on Peachtree Street, the typical wait for patients to see a doctor was 110 minutes.

Anyone who has ever endured a long emergency room wait knows it’s unpleasant. Experts say the vast and growing pressures on the nation’s busy emergency rooms have created waits that can also be dangerous, whether it’s a delay in seeing a doctor upon arrival or hours spent “boarding” in the ER before a patient is taken to an inpatient room for a longer stay.

“When politicians complain about Canada or Great Britain or other countries where there are ‘long waiting times’ for surgery — those are elective surgeries for problems that may be uncomfortable but not life-threatening,” said Dr. Arthur Kellermann, one of the nation’s leading experts in emergency medicine.

“The waits that matter are your wait if you are having a stroke or the wait if you’re having a heart attack, or the wait if you’re pulled out of a car wreck and need trauma care,” said Kellermann, who founded Emory University’s Department of Emergency Medicine and is now dean of the Uniformed Services University’s Hébert School of Medicine, which trains doctors for the U.S. military and Public Health Service. “Those are the waits in this country that are unacceptably long — and we’re spending $2.8 trillion a year on health care.”

‘It’s often the worst day of their life’

Make the rounds at Atlanta’s large hospitals and most will have a story to tell about making their ERs better — and faster.

Atlanta Medical Center sees 60,000 patients a year at its ER and advanced-level trauma center near downtown Atlanta. It also has one of the region’s shortest waits from arrival to seeing a medical provider. The hospital created a “rapid triage” and “rapid registration” system that placed a nurse and a registrar together to assess a patient in a three- to five-minute process that helped patients get to the right place for treatment much faster.

Patients who weren’t sick enough to be admitted were in and out of the hospital’s ER in an average of 140 minutes, one of the fastest times in the metro area, according to the federal data. Wait times have since been reduced even more for outpatients, with November’s average under two hours, said John Voight, AMC’s emergency services director.

Voight says he tells his staff to think about every patient in the waiting room as one of their own family members: a parent with chest pain, a child with a broken bone or a spouse with severe abdominal pain.

“I tell my staff that patients who show up in the emergency room, it’s often the worst day of their life,” Voight said. “Our job is to alleviate their anxiety and allay their fears and the best way we can do that is by making the process as smooth as possible.”

Hospitals must report their ER wait statistics to the federal government as part of its Hospital Quality Initiative, which is managed by the U.S. Centers for Medicare & Medicaid Services. The latest data available covers adults coming to the ER between April of 2012 and March of 2013.

Some hospitals say their performance today is much better than when this data was collected.

Emory University Hospital in November opened a much larger ER, double the size of the old one, at its Clifton Road location. Now, Emory said, its patients typically see a doctor in about 30 minutes instead of the average waits of an hour in the old ER.

“We always provided good care, but it just took a while sometimes,” said Dr. Matthew Keadey, chief of emergency medicine at Emory University Hospital.

Doris Morgan doesn’t know for sure how long she had to wait in the ER at Emory Midtown, but she knows it took hours. She felt that every step of the process took too long — especially her wait to see the doctor and the part when she was left on a gurney in a chaotic ER hallway while she waited for a spot in the hospital’s observation unit.

Morgan is 73 and a survivor of multiple myeloma, a type of cancer, and she had gone to the emergency room because she had difficulty breathing.

“When you can’t breathe you want somebody to come and check on you right away and let you know what’s going on,” she said. “It’s scary.”

The typical wait to see a medical professional at Emory Midtown’s ER was 110 minutes — four times the national average – the federal data show.

20 hours in the emergency room

Emergency rooms have become one of the most important and busy players in medicine. Primary care doctors and specialists rely on ERs to do urgent work-ups and handle overflow from their offices. ERs are also the only place many uninsured patients can find a doctor who will see them.

At Grady, which sees 360 emergency patients on an average day — more than 130,000 a year — waits can be long, but not as long as they used to be.

Patients used to spend an average of 14 hours in Grady’s ER before either going home or being wheeled into an inpatient hospital room. After several years of work, the average is about seven hours, according to Grady’s internal statistics.

“An image of Grady in the past was you go down there and there are [patients] everywhere — people lining the hallways right and left and all those other things,” said Dr. Hany Atallah, who oversees the Grady ER . “What we said back in 2011 and 2010 was you wouldn’t expect to go to a hospital and expect to be treated in a hallway.”

So they decided Grady patients should not experience that, either. Changes to the ER’s layout and staffing helped cut the waits and stopped the standard practice of lining hallways with patients on gurneys. During and after an upcoming renovation of its ER, the waiting room will be even smaller than it is today, and that’s appropriate, said Atallah, who wants wait times to be reduced even more.

The Rev. George Kimbrough Johnson turned to Grady twice in the past few years for help with complications of diabetes. The first time, he said, he spent 11 hours in the ER waiting room seeking treatment for an infected foot. He went to Grady again when he needed emergency dialysis. He said he waited more than 20 hours that time before being admitted, part of the time on a stretcher in a hallway lined with other patients. He described the experience as horrendous.

“It was weird — all these people were in stretchers up and down the hallways,” he said. “It was past surreal.”

Grady will soon launch a new system in which ER patients are seen almost immediately by a doctor instead of first going through a series of stops with other staffers. The new approach, called “rapid medical evaluation,” is considered a best practice nationally, and Grady believes it will make the process at its downtown Atlanta hospital more efficient.

Grady handles all sorts of patients that many other hospitals do not: thousands of prisoners; a growing number of people with mental health problems; complex and urgent trauma cases; and thousands of people who have no insurance coverage. They come seeking treatment for the full spectrum of medical complaints, from cuts and bruises and flu to illnesses that have gone untreated and now threaten their lives.

The economics of health care for years was driven on the notion that the poor and uninsured pay for their health care with their time, said Grady CEO John Haupert.

“That’s no longer acceptable,” Haupert said.

'I know we're providing great care'

The uninsured are not the only people who encounter interminable waits in the ER.

“This is universal,” Kellermann said. “It’s not just poor folks. You can have perfect insurance, you can be wealthy and you can be stuck in a waiting room and held in an exam room waiting for an inpatient bed.”

In Atlanta, long waits are common at all types of hospitals —including Piedmont’s Buckhead location, which historically has served an upscale, mostly insured clientele.

Piedmont significantly exceeds national averages on all the latest federal ER wait-time statistics, whether it’s waiting to see a doctor, waiting to get pain medications for patients with broken bones, or waiting to get moved into an inpatient room for those who must be admitted to the hospital.

“I know we’re providing great care in the ERs and that’s the No. 1 priority,” said Kevin Brown, CEO of Piedmont Healthcare.

But Brown also knows Piedmont’s wait times could be improved. Brown came to Piedmont last year from the Swedish hospital system in Seattle. The Swedish ERs handle patients in a fraction of the time that Piedmont takes, according to the federal data.

While patients at the ER at Piedmont’s flagship in Buckhead waited an average of 92 minutes to see a health care provider, patients at Swedish ER typically waited 15 minutes or less, according to the federal data. Piedmont patients admitted to the hospital from the ER typically waited nearly seven and half hours to get to their inpatient room after arriving; most Swedish patients usually waited half as long — or less.

An ER with no waiting room?

In Seattle, Brown helped design an emergency room that didn’t have a waiting room. It didn’t need one. Patients were greeted when they walked into the ER by clinical staff who did a quick assessment and then sent patients to treatment rooms. Most services the patient needed — from registration to X-rays and imaging and lab work — were mobile and brought into the patient’s room, Brown said.

In Atlanta, the ERs are antiquated and not designed to handle today’s volume of patients efficiently. The ERs are also jammed, Brown said, because it’s often hard for patients to get a same-day appointment at their primary care doctor’s office, often leaving the ER as the only alternative.

“The good news is there’s incredible opportunity to improve.” Brown said.

Piedmont recently appointed a team to address the problem, and Brown said he has already seen improvements.

“Just because it is taking more time than it should doesn’t mean that they aren’t getting great care,” Brown said. “Patients are getting triaged so that we make sure that the right care is given at the right time. As a result of that, it does create a length of time for people who may be in [the ER] for something less acute than someone needing immediate medical care.”

Experts say, however, that in emergency medicine, waiting does put patients at risk, even if it’s just a long wait for the sickest patients who end up “boarding” in the ER for hours waiting for an inpatient room.

“When you have a lot of people waiting for beds, the waiting room starts to fill up, and everything starts to bottleneck in a really alarming way,” Kellermann said. “There is an ample body of evidence that long wait times in ‘boarding’ are associated with preventable complications, side effects, medical errors and healthcare-associated infections.”

'We just keep doing the same things'

Making ERs faster and better doesn’t just involve fixing the ER. It involves the entire health care system. That’s what makes it tricky.

If people could get a same-day or weekend appointment with their primary care physician, they wouldn’t have to go to the ER with a bout of the flu or a child’s ear infection. Offering urgent care centers, on top of ERs, would allow emergency rooms to focus on the cases that can’t be handled anywhere else. If smaller ERs that aren’t that busy could use technology to connect patients with specialists, the large ERs wouldn’t be so jammed.

Dr. Ricardo Martinez, an emergency medicine expert who is chief medical officer for the Atlanta-based consulting firm North Highland, recently published a journal article calling on ERs to modernize, especially when it comes to using technology to enable specialists to treat patients in smaller ERs closer to home.

Martinez, a former administrator of the National Highway Traffic Safety Administration who still works emergency department shifts at Grady, said the entire health care system must work together to change what’s happening in ERs.

“We’re still using models from the 1960s and 1970s,” Martinez said. “We’re having these problems which are clearly solvable, but we somehow don’t, we just keep doing the same things. The solution is — let the patients wait.”

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