CDC: “Visits to U.S. Emergency Departments at AllTime High…”

It must be official, the CDC confirms it: U.S. Newswire : Releases : "Visits to U.S. Emergency Departments at AllTime High…".

WASHINGTON, May 26 /U.S. Newswire/ — Visits to the nation’s emergency departments (EDs) reached a record high of nearly 114 million in 2003, but the number of EDs decreased by 14 percent from 1993 to 2003, according to a new report released today by the Centers for Disease Control and Prevention (CDC).

The report attributes the rise in ED visits to increased use by adults,65 years old and over. Among people aged 65-74, the ED visit rate was more than five times higher for those residing in a nursing home or other institution compared with those not living in an institutionalized setting. especially those

The report also finds that Medicaid patients were four times (81 visits per 100 people) more likely to seek treatment in from an ED than those with private insurance (22 visits per 100 people.)…

Other findings in the report include:

From 1993 through 2003, the number of ED visits increased 26 percent from 90.3 million visits in 1993 to 114 million in 2003. The U.S. population rose 12.3 percent during this period, and the 65-and-over population rose 9.6 percent.

The average waiting time to see a physician was 46.5 minutes, the same as it was in 2000. The wait time was unchanged despite increased visits. EDs have implemented a number of efficiencies, including "fast track" units, which may have kept the wait time constant. On average, patients spent 3.2 hours in the ED, which includes time with the physician as well as other clinical services.  …

In 2003, patients arrived at the ED by ambulance in 14 percent of the visits, representing over 16 million ambulance transports. More than a third of patients who arrived at the ED by ambulance were 65 years of age and over.

– About 58 percent of all EDs were located in metropolitan areas, and they represented 82 percent of the annual usage. Board-certified emergency medicine physicians were available at 64 percent of EDs and almost half of all EDs had a nursing triage system. …

For a copy of the full report visit http://www.cdc.gov/nchs

Well, this is what we’ve all heard, and anecdotally this fits what I see.  As the nation ages, and the aged get warehoused, the ED visit rate goes way up.  I’m sure there are some truly excellent nursing homes where patients are well cared for, but I don’t see their patients.  I see the ones like the gentleman a few shifts ago: awakened at midnight, told ‘you have pneumonia and CHF and need to go to the hospital’, and tha patient had no complaints.  He also didn’t have pneumonia, and his CHF was at its baseline.  Back to the same nursing home.

The other interesting thing was the finding that "Board-certified emergency medicine physicians were available at 64 percent of EDs…", a stastic that bodes well for patients and the Specialty both.  The actual quote from the study is:

"Board-certified emergency medicine (EM) specialists were available 24 hours a day and 7 days a week in the majority ofEDs (63.5 percent), and pediatric EM specialists were only found in 18.1 percent of EDs."

I’m assuming they mean EM Boarded here, and I hope that’s the case.  Good for us, but the Peds EM market looks wide open.


Comments

  1. I’m afraid my daughter added to the stats this week… nursemaid’s elbow. ugh.

  2. This is a real problem, likely to get worse.
    There is no penalty for going to the ER (increased copay or some such), and many disincentives for going elsewhere.

    As a neurologist, what I try to get the ER docs to consider is that, for headache as a big example, there is a basic principle: If you give the patients everything they want — not only pain-free, but maybe even a little “high” from the experience — you have to realize you have just created a satisfied customer who will be back again.

    You don’t have to be perfect, tip-top, or pain-free to leave the ER — only good enough to go home and call your regular doc in the morning.

    For inexperienced docs admitting headache patients to the hospital, you have to realize that patients do not have to be totally pain-free to be discharged. Many of these people are never pain-free (at least be report).

  3. Anonymous says:

    In response to the headache patients mentioned above, I know that one of the ER’s I worked at a few years ago was very concerned about the Pain Initiative going around at the time. The word we got from the QC folks was that JCAHO felt that the goal of pain management was to cut the initial pain rating of a patient by half. With headache patients there were obvious problems with that, there were more than a few patients who would rate their pain 10/10 even when barely conscious. Our ER director told us flat out “we’re not here to be the narcotic police”, so it was essentially hospital (and possibly JCAHO, not sure on that) policy that we give the shots. I’m not trying to justify over-medicating or inappropriate prescribing, but mainly to mention sometimes we get pulled in opposite directions.

  4. I know what you mean. Sometimes you just don’t have the time to be too holistic or intellectual about things.
    One of the things which I find disturbing, though, is that we end up de facto abdicating decision making to insurance carriers — patients go home because insurance won’t pay for further in-hospital care. At an elemental level it gets these people out and I suppose that’s good, but maybe for the wrong reason(s).

  5. just to let you know i linked your site…thanks.

  6. Well, Hell. this is nothing new. I don’t think anyone calls their primary care provider for any type of new onset illness anymore – especially if they live in a care facility. Even if they do, the doc’s office staff tells them to ‘go to the hospital’. Usually they then interpret this as ‘call an ambulance’, even for the most minor stuff. Our ED calls this “Doctor Dumping”.

  7. I have seen a lot of those nurses. They come onto their shift, and have to justify their existence, so they call an ambulance. This way, they can say: “see how needed I am? I made sure Mr. So-and-so got to the hospital when he needed it.” Nevermind the fact that he did not, in fact, need it.
    It is also interesting to note that the rate of use of the ED has been higher than the rate of >65 year olds has been. This lends me to think that it is not the older generation which is using the ER more, but the younger.

  8. Goat Whacker says:

    There are a lot of issues swirling around in these comments. As background, I am a solo FP who went back to office medicine after working ER, so I sympathize with both sides. Undoubtedly too many nursing home patients end up in the ER. There are several reasons for this. During the day I am happy to see them in the office as long as they are not crashing. If they are, they belong in the ER. The problem though is usually that the residents have no way to get to the office except by ambulance, and Medicare will not reimburse such visits. I could go to the nursing home but I’m not going to make 5 or 10 other patients sit around to go see one patient. I could and have swung by the NH after office hours but there is no lab or X-ray there, which is somewhat limiting.

    The NH patient’s family often enters into it – many times I get phone calls that the patient’s family has demanded they go to the ER and they’ve already called the ambulance. There is also a certain percentage of nurses who mis-evaluated the patient and felt there was an emergency when there was none.

    On a somewhat related note, those nurses’ help lines many hospitals run are awful at preventing ER visits. The ones I’ve seen use algorithms that end up in referrals to the ER over 50% of the time. In my town we call it the “go to the ER” line, just call it and you will be told to go to the ER. The big problem is they’re set up to completely avoid any legal risk while actually providing useful advice is considered too risky.

  9. I’m not so sure Emergency Physicians should be criticizing Nursing Home employees. They basically do the same thing we do; pass the liability buck. Nursing homes have really high malpractice liability, like us. Here’s an example: Grandma Swanson with Alzheimer’s shows up at the ED because she’s more “confused”. We see the “acutely” confused Ms. Swanson at 3 am. What do we do? Nurse straight caths her, urine shows bacteria (what 89 year old female doesn’t have bacteria in her urine?) We admit to hospital for “UTI” or “Urosepsis” passing the liability buck on to the hospitalist. Like us, the nursing home is only liable if they miss something, so they overtreat (Like us). Especially when the nursing home is short-staffed (Friday afternoons), so they transfer everybody, which overwhelms us, so we take shortcuts and over-treat and admit everybody.

  10. GruntDoc says:

    Huh? Shouldn’t criticize the ‘nursing home employees’? What planet do you live on? If medicine and nursing happened in these people warehouses, I wouldn’t be griping.

    And, what’s with the “pass the liability buck” crap? The liability stops with me, the only doc to actulally see the patient in a month, or six. Yes, I admit a fair share of patients sent from our warehouse-homes, but I send a dcecent percentage back.

    Just because the NH has staffing problems doesn’t mean we should admit a percentage of their patients for them. (Insert rant about ‘qualifying stay’ here).

  11. Staffing problems cause a lot of other problems in the industry – long wait, low level of care, unsatisfied medical staff… We should think of some solution for that. Probably shift bidding systems, or something else… we should seek for it.