How to Stop the Bleeding

Many members of Congress argue that much more needs to be done. Democratic Rep. Henry Waxman, chair of the House Committee on Oversight and Government Reform, says he's been trying to draw attention to the woeful state of emergency care since the 9/11 terrorist attacks. Now that Democrats have taken over Congress, he's ramping up scrutiny of the administration in this area. Around mid-June—the one-year anniversary of the release of the IOM study—he plans to hold an oversight committee hearing to examine, as he terms it, "the federal government's failure to address the crisis in emergency care." Other congressional committees plan to take up the issue as well. The House Committee on Homeland Security has two hearings planned for later this year—one to focus on surge capacity, the other to address the Emergency Medical Services system. And the House Committee on Ways and Means—whose health subcommittee held a hearing last year on the IOM reports, then chaired by Republican Rep. Nancy Johnson—is examining the issue of on-call specialists, who often aren't available to hospitals; when they are, they can cost a fortune.

There is also a lot that hospital administrators themselves can do. Consider the issue of overcrowding. Eugene Litvak at the Boston University Health Policy Institute has studied the flow of patients in and out of hospitals—not just those in the ER but throughout the facility. His conclusion: if elective surgeries like angioplasty or hip replacement could be scheduled in a more organized way, the ER might not get so backed up. Christy Dempsey, vice president for surgical and emergency services at St. John's Hospital in Springfield, Mo., put Litvak's plan to work in 2002. Surgeons began "smoothing" their elective surgeries throughout the week, rather than bunching them together on Mondays, Tuesdays and Wednesdays. They also carved out blocks of time to ensure that ER patients requiring surgery would have the beds and operating rooms they needed. The reforms created 59 percent more available space for inpatients—without actually adding any beds, says Dempsey. And they helped unclog the ER, resulting in better patient and staff satisfaction and less overtime. "It was a win-win for everybody," she says.

Some hospitals have introduced innovations to deal with the boarding problem. Dr. Peter Viccellio, vice chair of the Department of Emergency Medicine at Stony Brook School of Medicine in Stony Brook, N.Y., came up with a simple fix: move patients waiting to be admitted from hallways in the ER to hallways in specialized units elsewhere in the hospital. They're still not in rooms, but they receive better care and rest more comfortably outside of the ER. At Stony Brook, the program has reduced the average length of stay in the hospital from 6.2 days to 5.4 days—a dramatic savings in resources and money. The move has also reduced the strain on ER nurses, because patients awaiting admission usually require more attention. Since Viccellio's innovation was implemented, Stony Brook has never had to divert a patient (it receives about 75,000 ER visits per year, compared to around 170,000 at a large urban hospital like Grady Memorial in Atlanta).

In the absence of grand solutions from government, hospitals will have to focus on internal steps like these. "You just keep chipping away at the stone and hope that at some point, someone will say, 'We've got to fix this'," says Dr. Frederick Blum, past president of the American College of Emergency Physicians. "We're not there yet, but we'll keep chipping away." Hopefully it won't take a catastrophic failure for others to realize the state of emergency the emergency health-care system is in.

With Claudia Kalb

© 2007