hospital emergency rooms

MYTH: Emergency room overcrowding is caused by non-urgent cases

According to critics, patients with minor problems take up limited emergency room (ER) resources and create backlogs, leaving the sickest patients at risk of facing unreasonable and unsafe waits for potentially life-saving care. If this were true, then clearing the backlog would depend on diverting non-urgent patients away from the ER ….

[This would have costs.] It’s generally considered unsafe medical practice to divert non-urgent patients from the ER, since a small percentage [of non-urgent patients – 4.3% in one study, 7.6% in another -] will legitimately need to be admitted for care. ….

Lower complexity patients don’t worsen the situation because their care tends to be simple, brief and require few resources. Through a process of triage, priorities for patient care are based on the type and severity of patient symptoms. In Canada, the Canadian Emergency Department Triage and Acuity Scale (CTAS) is the nationally recognized tool for assigning priorities for patient care. Although triage is not an exact science and its benefit for clearing backlogs is yet unproven, it does help to ensure that the sickest patients are cared for first. Increasingly, non-urgent patients are seen by professionals working in fast-track units embedded in the emergency department. These units free up emergency room resources to meet the most urgent care needs.

Canadian Health Services Research Foundation, Mythbusters, October 2009.

For further details and 18 references, download the complete two-page essay. Additional Mythbusters can be downloaded here.

Of related interest, with reference to ER costs and charges in the USA:

Consider the oft-quoted “statistic” that emergency-room care is the most expensive form of treatment. Has anyone who believes this ever actually been to an emergency room? My sister is an emergency-medicine physician; unlike most other specialists, ER docs usually work on scheduled shifts and are paid fixed salaries that place them in the lower ranks of physician compensation. The doctors and other workers are hardly underemployed: typically, ERs are unbelievably crowded. They have access to the facilities and equipment of the entire hospital, but require very few dedicated resources of their own. They benefit from the group buying power of the entire institution. No expensive art decorates the walls, and the waiting rooms resemble train-station waiting areas. So what exactly makes an ER more expensive than other forms of treatment?

Perhaps it’s the accounting. Since charity care, which is often performed in the ER, is one justification for hospitals’ protected place in law and regulation, it’s in hospitals’ interest to shift costs from overhead and other parts of the hospital to the ER, so that the costs of charity care—the public service that hospitals are providing—will appear to be high. Hospitals certainly lose money on their ERs; after all, many of their customers pay nothing. But to argue that ERs are costly compared with other treatment options, hospitals need to claim expenses well beyond the marginal (or incremental) cost of serving ER patients.

David Goldhill, “How American Health Care Killed My Father”, The Atlantic, September 2009.

Princeton economist Uwe Reinhardt supports Goldhill’s suspicions in an essay written years ago:

Hospital emergency departments have long been decried as one of the most “expensive” places to deliver routine health care, even by policy analysts who ought to know better. Once an emergency room is built, staffed, and ready for calamities, it can deliver routine care at relatively low incremental costs when it is not preoccupied with an emergency. To be sure, the algorithms that hospital accountants use to allocate overhead, and the pricing policies that hospital executives erect on those algorithms, have made such routine care seem expensive. But that appearance has nothing to do with the true incremental social costs of rendering routine care there during downtimes.

Uwe E. Reinhardt, “Spending More Through ‘Cost Control’: Our Obsessive Quest To Gut The Hospital”, Health Affairs 15:2 (Summer 1996), pp. 145-154.

For empirical evidence, see “The Costs of Visits to Emergency Departments”, by Dr Robert M. Williams, in The New England Journal of Medicine, 7 March 1996, pp. 642-646.

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