the waits that matter

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n engl j med 364;24 nejm.org june 16, 2011

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ably, the aggregate ER admissionrate today, 16.5%,3 is nearly thesame as Hartford Hospitals wasmore than 50 years ago.1

The range of treated conditionsis broader than ever, but modernERs remain focused on highly

acute care. According to the Na-tional Center for Health Statis-tics, less than 8% of emergencydepartment visits in 2007 wereclassified as nonurgent. Twicethat number required immedi-ate or emergent care, implyingthat the patient had a life-threat-ening or dangerous condition.3

It is unlikely that the authorsof the Hartford study envisionedhow heavily Americans would

come to rely on ERs. Althoughemergency care consumes only3 cents of every health care dol-lar and employs 4% of U.S. phy-sicians, emergency departmentshandle 11% of all outpatient vis-its, 28% of all acute care visits,and half of all hospital admis-sions.4 Hospital-based emergen-cy care is the only treatment to which Americans have a legalright, regardless of their abilityto pay. This probably explains why emergency physicians pro- vide more acute care to Medic-aid patients, beneficiaries of theChildrens Health Insurance Pro-gram, and the uninsured than therest of U.S. doctors combined.2,4

The ER is more than a hospi-tal department. Its a room witha view of our health care sys-tem.5 The quickest way to assess

the strength of a communitys

public health, primary care, andhospital systems is to spend a fewhours in the emergency depart-ment. If public health is under-resourced, you will see more pa-tients with vaccine-preventableillnesses, smoking-related health

problems, preventable injuries,and foodborne diseases than youotherwise would. If primary careis fragmented or weak, the ERswaiting room will be full of pa-tients with problems that shouldhave been prevented or treatedby primary care providers. If thehospitals administration is notadept at managing the flow ofpatients, the ERs exam rooms,resuscitation bays, and hallways

will be packed with ill and injuredpatients, many of whom were sta-bilized and admitted hours earli-er but now have nowhere to go.2

Modern ERs offer two com-peting views of the future. One,driven by deteriorating access tocare, is a future where primarycare is unavailable, specialty careis unaffordable, and no one an-swers the phone after 4 p.m. Itsa future where a trip to the ERis a perilous journey filled withlengthy waits, harried staff, non-existent privacy, and the prospectthat any patient may fall victimto medical error.2

The alternate view is muchbrighter. Its a future where healthcare is centered on the needs ofpatients, not the convenience ofproviders. Health informationflows readily and securely from

a patients home to his or her

doctors office, the ER, or thehospital whenever and wher-ever its needed. Thanks to team- work and a powerful commit-ment to safety, care transitionsare seamless and risk-free. As aresult, patients consistently get

the right care at the right timein the right place.

Management consultant PeterDrucker once observed, The best way to predict the future is tocreate it. As physicians, we havepower to determine what will be written about us 50 years fromnow. What future do we wantfor our patients? The choice isup to us.

Disclosure forms provided by the authorsare available with the full text of this arti-cle at NEJM.org.

From RAND Corporation, Santa Monica,CA (A.L.K.); and the Department of Emer-gency Medicine, Emory University Schoolof Medicine, Atlanta (R.M.).

1. Shortliffe EC, Hamilton TS, Noroian EH.The emergency room and the changing pat-tern of medical care. N Engl J Med 1958;258:20-5.2. Institute of Medicine Committee on theFuture of Emergency Care in the United

States Health System. Hospital-based emer-gency care: at the breaking point. Washing-ton, DC: National Academies Press, 2006.3. Niska R, Bhuiya F, Xu J. National hospitalambulatory medical care survey: 2007 emer-gency department summary. National healthstatistics reports. No. 26. Hyattsville, MD:National Center for Health Statistics, 2010.4. Pitts SR, Carrier ER, Rich EC, KellermannAL. Where Americans get acute care: in-creasingly, its not at their doctors office.Health Aff (Millwood) 2010;29:1620-9.5. Asplin BR, Knopp RK. A room with a view:on-call specialist panels and other healthpolicy challenges in the emergency depart-ment. Ann Emerg Med 2001;37:500-3.

Copyright 2011 Massachusetts Medical Society.

The ER, 50 Years On

The Waits That Matter

John Maa, M.D.

She was 69 years old and, with the exception of mildheart disease, was in excellenthealth. One day, around mid-

morning, she noticed that herheartbeat was irregular and shefelt slightly short of breath. Us-ing her home blood-pressure cuff,

she found that her pulse was 130.Since her blood pressure wasstable, she decided to forgo acall to 911 and instead asked her

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husband to drive her to the localhospital one of the most high-ly regarded academic medical cen-ters on the West Coast.

After waiting about an hour tobe seen, she was diagnosed withrapid atrial fibrillation around

8 oclock on a Thursday evening.Given her age, the emergencydepartment (ED) staff and theconsulting cardiologist decided toadmit her to the hospital. Themedical team started giving herintravenous heparin for anticoag-ulation and planned to performelectrical cardioversion the follow-ing day if a transesophageal echo-cardiogram (TEE) confirmed theabsence of an atrial thrombus.

Because no inpatient bed wasavailable, the patient was kept inthe ED overnight. The narrownessof the stretcher and the noiseand bright lights of the ED hall-way made it hard for her to getmuch sleep. The following day,shortly before noon, she waswheeled upstairs to a bed.

Early in the afternoon, the car-diologist stopped by to let herknow that because her admissionhad been delayed, it would notbe possible to complete her pro-cedures before the end of the workday. Therefore, she wouldremain in the hospital receivingintravenous heparin and oral war-farin throughout the weekend andwould undergo TEE and cardio-version the following Monday.

The next day, without warn-ing, the patient sustained a mas-

sive embolic stroke. The clot oc-cluded her right common carotidartery and extended into the in-tracranial branches. Within mo-ments, signs of middle cerebralartery syndrome developed. A neu-rosurgeon rushed the patient tothe operating room and attempt-ed to extract the embolus. Unfor-tunately, the procedure tore her

internal carotid artery. Because ofthe anticoagulants in her system,rapid intracranial bleeding ensuedand led quickly to brain-stemherniation. For the next 2 days,the patient lay intubated in theICU without evidence of neuro-

logic recovery. Her family askedthat she continue to receive me-chanical ventilation until prepa-rations for her funeral could befinalized. At that point, life sup-port was withdrawn 112 hoursafter she walked into the hospital.

Perhaps the various delays inthis womans care played no rolein her death. After all, she was69 years old and had chronicheart disease. But earlier initia-

tion and closer monitoring of heranticoagulant treatment mighthave prevented the development ofthe thrombus that subsequentlybroke loose. Since its difficult forprofessionals working in a crowd-ed ED to precisely monitor intra-venous infusions for long periods,undesirable compromises are of-ten made in the quality of caredelivered. Had cardioversion beenperformed shortly after the pa-tient entered the ED, she might bealive and healthy today. Well nev-er know for sure. Only one thingis certain: an intelligent womanwho loved her husband and sonis dead. She was my mother.

Ironically, I am an academicsurgeon and founder of a surgi-cal training program dedicatedto improving the availability andquality of emergency surgical

care. But because I practice in adifferent city, I was unable topersuade the staff of my mothershospital to expedite her care.Many Americans cling to the no-tion that the shortcomings thatafflict our health care systemaffect only the poor. They aremistaken.

The cardiologist who post-

poned my mothers care never re-turned. One of the only doctorswho acknowledged our loss wasthe ICU intern, who offered mehis condolences in the hallwaythe following day. But when helearned that my father and I

wanted to finalize my mothersfuneral plans before withdraw-ing life support, he told us, in afrustrated tone, that her conditionmade further treatment futileand her ICU bed was needed forother patients. He added that itwas very selfish of us not to im-mediately withdraw life support.His words stung, but they weretrue. I have since wondered howmany additional patients spent

unnecessary hours in the ED be-cause my mother was occupyingan ICU bed.

Such tragic deaths happenevery day in U.S. hospitals. Thefactors that contribute to EDcrowding and its consequenceshave been amply documented inreports by the Institute of Medi-cine, the Government Account-ability Office (GAO), the RobertWood Johnson Foundation, theCenter for Studying Health Sys-tem Change, and others.1,2 Board-ing admitted patients in EDexam rooms and corridors forextended periods has become socommonplace that it is acceptedas the norm, particularly in largeurban hospitals. But a crowdedED is more than a nuisance; it isa threat both to individual pa-tients and to overall public health.

Still, the financial imperatives ofhospital operations trump patientsafety. The GAO has noted thatmany hospital administrators tol-erate ED crowding and even di- vert inbound ambulances ratherthan postpone or cancel electiveadmissions.3

Crowded EDs are only onepart of the problem. Inefficient






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hospital operations are another.Death, disease, and injury occuraround the clock, but many hos-pitals still operate the majorityof their services only 5 days aweek. A growing number of spe-cialists are either refusing to take

after-hours call or demandingpayments for doing so.4 After-hours and weekend gaps in cov-erage have real consequences;mortality rates associated withacute myocardial infarction andother time-critical conditions aresignificantly higher on weekendsthan on weekdays.5

Politicians decry long waitinglines for elective procedures inBritain, Canada, and other coun-

tries. A lengthy wait for electivesurgery can be irritating, but itis rarely deadly. The waits thatmatter are those for emergencytreatment such as defibrillationfor out-of-hospital cardiac arrest,surgical management of trau-matic injuries, initiation of anti-biotic treatment for meningitisand other deadly infections, andpercutaneous coronary interven-tion for acute myocardial infarc-tion with ST-segment elevation.The passage of the AffordableCare Act may actually make sto-ries like my mothers more com-mon, as 32 million more Ameri-

cans seek access to an emergencycare system that is already over-whelmed.

Those of us who have dedi-cated our careers to health caremust confront the fact that ourinability (or, more likely, unwill-

ingness) to reduce the waits anddelays that bedevil emergencycare is harming and even killingour patients. The Shakespeareanwarning Defer no time, delayshave dangerous ends is an aptprecept for the treatment of emer-gency and urgent conditions whichhas been underemphasized of late.We fill our hospitals with pa-tients recovering from electivesurgery and then run out of hos-

pital beds for the patients in theED. In other countries, hospitalsfirst take care of all the patientswho are in the ED or are waitingas inpatients and then allow theoperating room to proceed withelective surgery if beds are stillavailable. A solution to ED board-ing may thus be to invert thecurrent paradigm of incentivesand reimbursement and reprior-itize our scarce health care re-sources and hospital beds for pa-tients with emergency or urgentconditions, whose immediate med-ical needs exceed those of pa-tients undergoing elective proce-

dures. But this is not a problemthat ED physicians, surgeons, andnurses can solve alone. It is aresponsibility we must sharewith others throughout the hos-pital and, ultimately, the entirehealth care system.

The solution will come too lateto save my mother. But it wouldhelp me honor her memory.

Disclosure forms provided by the authorare available with the full text of this arti-cle at NEJM.org.

From the Division of General Surgery, Uni-versity of California, San Francisco, Schoolof Medicine, San Francisco.

1. Institute of Medicine Committee on theFuture of Emergency Care in the UnitedStates Health System. Hospital-based emer-gency care: at the breaking point. Washing-ton, DC: National Academies Press, 2006.2. Hospital emergency departments: crowd-ing continues to occur, and some patientswait longer than recommended time frames.Washington, DC: Government Accountabil-ity Off ice, 2009. (GAO-09-347.)3. Hospital emergency departments:crowded conditions vary among hospitalsand communities. Washington, DC: GeneralAccounting Office, 2003. (GAO-03-460.)4. American College of Surgeons Division ofAdvocacy and Health Policy. A growing crisisin patient access to emergency surgical care.October 2006. (http://www.facs.org/ahp/

emergcarecrisis.pdf.)5. Bernstein SL, Aronsky D, Duseja R, et al.The effect of emergency department crowd-ing on clinically oriented outcomes. AcadEmerg Med 2009;16:1-10.Copyright 2011 Massachusetts Medical Society.





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