Waiting for emergency care

It’s a Wednesday, and it’s late.

A man, appearing to be in his mid-50s sits in a bay-area emergency room.

He has a gash above his eye that is in obvious need of stitches. Five hours ago, the blood flowed freely from the wound. Now, the flow has slowed, the blood hardened, caking into a rust colored scab.

The man stands, sits, paces and sighs. He waits, but still his name is not called.

Across the room, a man is helped into the room. His leg is broken, his foot pointing at a grotesque angle. He sits, in obvious pain, for two hours, before he is taken for care.

Two nurses walk through the waiting room some time later. They are bombarded with questions, all of the patients wondering when they will be called. As the nurses fight through the crowd, one comments to the other, saying that’s why she never walks through a waiting room.

As the clock begins to turn toward the wee hours of Thursday morning, a man becomes upset, telling a hospital representative that his sister has been waiting for eight hours. She is sick and has lost her color. The man yells at the representative but is told that nothing can be done. He soon storms from the room, taking the girl home before she receives care.

One by one, other patients leave without receiving care, while those remaining in the waiting room jump up in anticipation every time the doors swing open.

According to nurse Barbara Uzenoff, who is trauma coordinator for Hillsborough County, scenes such as these are not only common in Florida emergency rooms, but nationwide. Uzenoff said, in fact, that a report was issued to the governor in 2000 discussing the issue.

“It is a big problem,” Uzenoff said. “A multi-faceted problem.”

Uzenoff said determining the waiting time for an average trauma patient is difficult. She said it varies greatly depending on the day and time, and the occasional unusual circumstance.

Uzenoff said, however, there is a way to measure the operation of emergency rooms. That measurement is made through a situation known in the health care community as “diversion.”

Diversion occurs when an emergency room declares that it cannot handle any more trauma patients that arrive by ambulance. Once an emergency room declares such a situation, ambulances are diverted to another hospital.

Diversion can, at times, mean that patients must travel several miles further to receive care. In addition, the report to the governor points out another growing problem.

“In recent years, it has become common for more than one hospital in the same community to divert ambulances,” the report says.

The report continues by pointing out that, in the past, most emergency room diversions occurred during the winter tourist season. Now, however, the report states the scenario seems to occur year round.

And if a hospital is on diversion, there is little space available for walk-in patients.

Uzenoff said the complex problem is continuing to be studied, but a resolution is difficult. She said the reason behind emergency room overcrowding does not lie in a lack of personnel, but instead can be found in the rules that govern modern healthcare.

“Managed care is the big evil,” Uzenoff said. “It clogs up the system.”

Under the managed care system, emergency rooms must accept any patient, rich or poor, insured or uninsured. At the same time, walk-in clinics, which can handle most minor emergency care, expect money. Family practitioners expect insured patients.

Because of this system, Uzenoff said, patients who do not need immediate care still come to the emergency room.Dave Coughlin, director of emergency services at University Community Hospital on Fletcher Avenue and Bruce B. Downs Blvd., said UCH spends between five and 10 percent of its time on diversion. He said, with 39 beds, emergency room clogging is a problem.

Coughlin said some patients take an hour to be removed from their stretchers. Others are held in hallways awaiting admission.

Coughlin said diversion does not alleviate the situation.

“If we’re on diversion, other (hospitals) are too,” Coughlin said. “It’s really not a major factor.”

Coughlin said incoming patients are divided into three categories. Those needing urgent care are seen within two hours. Semi-urgent patients are seen in six hours. Coughlin said non-urgent patients may wait as long as 24 hours.

“If you keep getting a lot of urgent patients, and you’re in (a semi or non-urgent category), you keep getting pushed back,” he said.

Another problem, Coughlin said, is non-urgent patients catching a ride on the ambulance, what he calls “ambulance abuse.”

Coughlin said in addition to non-urgent ambulance riders, there are some habitual users who ride the ambulance several times a year.

In addition, Coughlin said, there is a major problem in the form of a nursing shortage.

The problem is so severe, Coughlin said, that some hospitals have lost money and been forced to close entire wings.

Such a loss of beds, Coughlin said, can further jam emergency rooms.

Coughlin said he does not know of a true solution. He said one idea is to create free-standing clinics, run by the hospital, for the less critical patients.

“The beds in the emergency room (will be saved) for the true acute patients,” he said.

John Dunn, spokesman for Tampa General Hospital, said the hospital is constantly being evaluated for its performance.

“We’re regulated by joint commissions. The emergency staff does their own critiquing and evaluating,” Dunn said. “We’ve got an alphabet soup of agencies.”

Dunn said there are a lot of variables in the problem, including the issue of insurance coverage. But, Dunn said, there are other ways to view the issue.

“Is five hours in an emergency room better than a week to two weeks waiting to see a (family) doctor?” Dunn asked.

Dunn said emergency rooms gain nothing by having patients waiting. He said it’s a difficult problem and tough on patients.

“Anytime someone comes into an emergency room, there is a state of anxiety, just by the very fact that they’re going to be upset, and they’re going to be scared,” Dunn said. “Every patient, and I count myself as one, when you go in you want it fixed right away.”