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Monday, August 4th 2008

Hospitals Are Killing Their ER Patients

I was on a busy surgical specialty service at a large public hospital with a busy level I trauma center recently doing a sub-internship rotation. It’s the same trauma burdened hospital I grew up in. So I have some experience. The service I was on is very trauma oriented and crowded. Our patient census (both those admitted on the service and those we were seeing as consults) regularly topped 80 or 90 patients. 80 patients or more to see and comment on everyday. The service was also very, very trauma heavy. The point is the vast majority of patients the service saw were admitted through the emergency room following injury. Every once in a while we’d get a transfer from another hospital for some complexity but often, actually, because the patient was unfunded.

That’s just one of many reason I don’t buy the argument made by Drs. Zachary Meisel and Jesse Pines in a recent Slate piece entitled “How Hospitals are Killing E.R. Patients.”

This Was A Tragic Case of a Patient Dying in a NYC ER Waiting Room

Patients wait in the ER because the ER beds are full. The ER beds are full because the hospital beds above are full and so patients in the ER cannot get admitted. The hospital beds above are full…well, for several nefarious reasons according to the Slate article. Not all of them are without merit, but at the least I do question those reasons contributions to the problem. And the most malicious and greedy of reasons cited are simply bullshit. Take for example this contention,

Imagine you run a hospital. There are two competing sources for inpatient beds. The first source is patients who come in through direct and transfer admissions. They are more likely to come with private insurance and need procedural care, both of which maximize profits. The second source is E.R. patients, who are more likely to be uninsured or have pittance-paying Medicaid and less likely to need high-margin procedures. Do the math: If you fill your hospital with the direct and transfer admissions and maroon the E.R. patients for long periods, you make more money.

In effect, then, E.R. boarding allows hospitals to insulate themselves from the burgeoning needs of the poor.

I have no idea what data they’re using to conclude that transfers are more likely to be funded patients. A couple of words about that. First, you know the funding status before you take a patient as a transfer. Second, while my anecdotal experience has admittedly been in a public academically affiliated hospital, I have never been on a service where a transfer was handed a bed before someone who had been waiting longer than that transfer down in the ER.

Now granted, I’m arguing with apparently experienced UPenn emergency medicine faculty. But the fact they don’t even bother to cite data for an outrageous claim like the above is fishy. And there are people more experience than I who feel the same (via Kevin, MD).

I think the experiences these two ER docs relate cannot be generalized and their lack of evidence for their really flamboyant claims means that this piece, even targeted to a general audience, was inappropriate for publication.