Many Hospitals Aren't Meeting Their Own Goals for Limiting Wait Times in Emergency Rooms By Salynn Boyles

WebMD Health News Reviewed By Louise Chang, MD Oct. 2, 2009 -- Even the sickest patients treated in hospital emergency departments across the U.S. routinely wait longer than they should for medical care, new research suggests. Just 14% of hospitals met their own target time frame for treating very sick patients at least 90% of the time. And slightly less than one in three hospitals met target treatment time goals 90% or more of the time for all patients treated in emergency departments. "In hospitals across the country patients are waiting longer than they should for treatment in ERs," study researcher Leora I. Horwitz, MD, MPH, tells WebMD. "There is also tremendous variation from hospital to hospital, which has more to do with how the facilities choose to practice than the characteristics of the patients they treat."

Triage Targets Not Met
The vast majority of hospital emergency departments across the country now have triage nurses or doctors who assess patients as soon as they arrive and determine target treatment times based on how sick the patients are. In an effort to examine whether individual hospitals were meeting these triage goals, Horwitz and colleagues from Connecticut's Yale-New Haven Hospital examined data provided annually to the CDC by medical centers across the country. Their random sample included information on 35,849 patient visits to 364 emergency departments in 2006. The analysis revealed that:
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When patients were found to be in need of hospitalization, less than half (47.7%) of emergency departments admitted 90% or more within six hours of first being seen. Less than a quarter (24.5%) admitted hospitalized patients within four hours. One in three patients triaged for treatment within an hour waited longer to see a treating physician. The average wait time at the slowest 25% of emergency departments was twice as long as average wait times at the 25% of the fastest hospitals.

The study was published online today in the Annals of Emergency Medicine.

Misuse of Emergency Departments
While there is little disagreement that ER wait times are too long, emergency physician Sandra Schneider, MD, says there is a lot of confusion among the public about the reason for this. Schneider is vice president of the American College of Emergency Physicians and she practices emergency medicine at Strong Memorial Hospital in Rochester, N.Y. "When people come to emergency departments [EDs] and have to wait, they assume this is unusual and that people coming to the EDs for primary careare to blame," she tells WebMD. "What they don't realize is that EDs are crowded 24/7 and it has little to do with people using them for primary care." One problem, she says, is that emergency departments have become dumping grounds for patients waiting to be admitted to the hospital and even those who have already been admitted. She tells the story of a hospitalized woman whose condition worsened to the point where she needed to be admitted to the intensive care unit (ICU). The ICU had beds, but no available nurses to take care of her because the hospital limited ICU nurses to two patients each. "The solution was to send her to the emergency department where her nurse was already taking care of two other ICU patients, three other hospitalized patients and three emergency patients," she says. "I wouldn't say that cases like this are routine, but they aren't rare either." Emergency department crowding has become so severe that the National Academy of Sciences called it a "national epidemic" in a 2006 report. Horwitz says her study and others suggest that individual hospitals can do a lot to address the problem. Improving efficiencies within hospitals has taken center stage in the debate over health care reform, and Horwitz says there is a good reason for this. "As we look more closely at how hospitals actually work -- how they register and discharge patients, schedule elective surgeries, and things like that -- I think we will find that these things make a huge difference in how effective and efficient hospitals are," she says. SOURCES: Horwitz, L.I. Annals of Emergency Medicine, Sept. 30, online edition.

Emergency Room Errors
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Emergency Rooms, or ER's, at hospitals all over the country are the most stressful worksites in the healthcare profession. The standard of care in United States hospitals is high quality. Doctors, nurses, surgeons, and all other healthcare professionals take pride in this. However, the fact remains that malpractice occurs in the medical profession and today's hospitals need to improve the care provided in their Emergency Departments. Errors in hospital Emergency Rooms are a common occurrence infrequently talked about and rarely reported to the media. That is why you don't hear about these types of cases on the news. Understaffed hospitals, ill-equipped emergency rooms, and poorly trained staff may lead to fatal errors when dealing with patients requiring emergency treatment. Let's face it - when you arrive at your local hospital ER you know absolutely nothing about who will be taking care of you and there is no time to research the competency and track record of the ER staff. There are many ways that errors or malpractice may occur in Emergency Rooms. The following is a partial list of some of the Emergency Room medical negligence cases we have handled:
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Medication Errors Prescription Errors Failing to diagnose impending heart attacks and strokes Diagnosis Errors Errors in interpreting x-rays, CT scans, and MRI studies

y Discharging patients who are critically ill Over 225,000 people die from medical malpractice related injuries in a single year and nearly half of these deaths are from emergency room errors.

The following is a partial list of the more common medical errors which arise in the Emergency Department: Failing to administer prophylactic antibiotics in patients with open fractures. An open fracture is one in which the bone has broken through the skin, and as such, these fractures present an increased likelihood of infection. The best outcome for these patients is dependent upon prevention of infection and obtaining a quick union of the fracture. Prophylactic antibiotics reduce the risk of infection and should be given as soon as possible. Failing to diagnose compartment syndrome in patients with tibial fractures. The tibia is the larger of the two bones of the lower leg and is the weight-bearing bone of the shin. A compartment

syndrome is a serious complication which occurs when the pressure in a closed fascial compartment rises sufficiently high to cause nerve and tissue injuries. Without timely diagnosis and treatment, compartment syndrome can cause permanent loss of use or function in the involved extremity (legs or arms). The clinical signs of compartment syndrome include pain out of proportion to the injury, pain on passive range of motion, and loss of distal pulses. Immediate consultation with a surgeon is the preferred course of treatment. Failing to treat a perirectal abscess in a diabetic patient as an emergency. Patients who are diabetic present many unique challenges to their health care providers. A perirectal or perianal abscess is a pool of pus that forms next to the anus, often causing considerable tenderness and swelling in that area and pain on sitting down and on defecating. These abscesses or infections have a tendency to rapidly progress to deeper, more serious infections in diabetic patients. The abscess can develop into Fournier's gangrene, a life-threatening infections with a reported mortality rate of 9% - 43%. Again, prompt consultation with a surgeon is the preferred course of action. Failing to provide the proper airway for patients with facial or skull fractures. Establishing and securing an airway is one of the first steps addressed by all Emergency Departments. There are several ways to accomplish this goal but the main techniques are tracheal intubation (either oral or nasal), bag and mask, or a surgical procedure known as a cricothyroidotomy. Emergency physicians should almost never attempt a nasal tracheal intubation in patients with facial or skull fractures due to the possibility of passing the tube into the cranial vault and thereby cause even more serious injuries. Failing to admit unstable patients or patients with unclear diagnoses to the hospital. Remember, the Emergency Room doctor's first responsibility is to stabilize the patient and then make appropriate decisions about the patient's continuing care needs. Most ER doctors do not have admitting privileges at the hospital - they must contact the patient's regular doctor or the hospital admitting doctor for permission to admit the patient directly from the ER into the hospital. Almost everyone has a story about a friend or family member who was discharged from the Emergency Room returned to their home and within hours or a couple of days suffered a disastrous outcome. Make sure your friend or family member is stable, and with a plan of treatment, before discharge from the ER.

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