As cardiologists struggle to shorten “door to balloon” time, the reality of emergency department overcrowding and delays in receiving care is working against us. Research from the Cambridge Alliance and Harvard Medical School (Health Affairs, January 2008) indicates that heart attack patients' waiting time to see a physician increased by 12 minutes in the period from 1997 to 2004.
My recent experience on a Saturday afternoon with a friend at an emergency department in a county hospital in upstate New York that provides regional emergency services attests to that observation. When we arrived in the waiting room of the ED, a sign indicated that we should wait until the triage nurse finished admitting a patient in an adjoining room, as she carefully catalogued his list of medications and past medical history before attending to my companion. Fortunately, my friend was not experiencing chest pain.
Nationwide, emergency department visits have increased by 18% and the number of EDs in this country has decreased by 12%. This recent research indicates that median wait time in the ED has increased by 36% for an increase of 30 minutes.
For patients needing urgent care, waiting time increased from 14 to 20 minutes. For patients with an acute myocardial infarction, it increased by 150% for a typical delay of 20 minutes before seeing a doctor. Over a quarter of the patients with an acute myocardial infarction had wait times that increased by 50 minutes or more. With the exception of urban hospitals, which had longer waits than did rural hospitals, the delays to see a doctor were fairly uniform across the nation, regardless of insurability and demographic characteristics.
Much of the delay can be explained by an increase in the volume of patients who use the emergency department for both acute and chronic care.
The survey also indicates that there has been a change in the mix of patients coming to the ED, with a decrease in the number of patients coming for urgent care and an increase in those arriving seeking nonurgent care. For the more than 45 million Americans without insurance, the emergency department has become the family physician. As the uninsured population continues to expand, the ED burden will increase.
The decrease in the number of U.S. emergency departments has resulted in part from the closure of hospitals in both urban and rural America. Few of us consider the consequence of these closures on the availability of ED facilities. Often, we see this process as a reallocation of hospital resources to areas in need. However, this reallocation often results in the closure of an urban hospital and the transfer of beds from the inner city to the affluent suburbs. As the number of hospital beds decreases and the age of patients increases, more sick, nonurgent patients will be spending more time waiting in the ED for hospital beds.
Considering the tenuous nature of our urban hospitals, the potential effect on the availability of emergency care should be of great community concern. Hospitals that have not closed have tried to cut back on emergency care because of financial losses incurred by providing that care. The projected decrease in budgeted Medicaid payments represents a further disincentive for the provision of emergency care. At the same time, there has been a decrease in physicians willing to take ED call because of a decrease in reimbursement and increase in medical liability.
For those patients with obvious acute signs and symptoms, emergent care is often prompt, but for those with chest pain and less overt evidence of disease, time to medical response is slower. As the cardiology community attempts to shorten the time between the onset of symptoms and the treatment for acute coronary syndromes, we need to be more attentive to the state of emergency care that we practice in. Each hospital merger or closure leads to further decreases in the number of ED facilities available to our cardiac patients. It is clear that the state of emergency care in America is going from bad to worse and requires urgent solutions.