Innovation Update

Return to Article

Don't Believe the Emergency-Room Laments

Gavin Magor

But, a look under the hood shows that it's not all bad news.

You may have read about the massive decline in the numbers of Emergency Departments. The report indicates a 4.6% decline from 4,019 in 1996 to 3,833 in 2006.

The report fails to highlight that there was a 3.8% decline from 4,176 between 1995 and 1996, and this decline continued through 1998 -- by which time the damage was done. The actual situation in 2006 represents a welcome increase of 1% in the number of emergency rooms since last year's report.

Again, there are misleading media reports about the 119.2 million visits to ERs in 2006 which represents a 32.1% increase since 1996, large but significantly lower than the widely reported 36% increase. The year on year increase was 3.4%.

The report indicates that the number of visits per 100 of the population has gone from 34.2 in 1996 to 40.5 in 2006, an increase of 18.4%. The upside of this report is that over the past two years, there has been a marked reduction in the rate -- to half that of the average increase over the past 10 years. This increase represents just two patients per day for each ER.

What we do not know is the numbers of physicians and nursing staff attending at these facilities, so it's difficult to make exact comparisons -- but it would be reasonable to guess that staff must be more efficient now than they were in 1996, and handling only one additional patient per hour.

Patients -- How Sick, and Who Are They?

On arrival at the ER in 2006, 15.9% of patients were classified immediate or emergent (emergency) the top two classifications for patients needing care. This is similar to the previous year's 15.3%, but up from 12.9% in 2004. It's hard to compare accurately with older records because the categories used to measure the patients' condition have changed.

Perhaps for obvious reasons, the over-65s were a significant number of those attending the ER, at a rate of 48.5 per hundred of the age group. They represented 36.1% of all ambulance rides and 24.6% of all cases assessed as requiring emergency care. The trend is up each year of those over 65 attending the ER, from 45.4 per hundred in 1996 -- and this could well be an indication of things to come as the population of older people increases with the Baby Boomer generation.

An incredible 84.5 babies under one year old out of every 100 went to the ER in 2006, but a smaller percentage than the average were considered emergency cases, at 10.7%. This is actually down from 91.3 per hundred in 2005 and 95.8 per hundred in 1996, so the trend does appear to be down.

Where Is the Healthiest Region to Live?

Based on the statistics available for injuries, poisoning and adverse effects from medical treatment, the healthiest region to live is the West, where only 11 visits per hundred of the population took place. The most likely to use the ER are those in the South, at 16.2 visits per hundred, but there was not a great difference between the South and Northeast. All regions have shown a great improvement over the past 10 years, when over 30 visits per hundred was normal.

Is It Illegal Immigrants?

Actually, if you think that increased illegal immigration is responsible for the increases in ER use, you would most likely be wrong. The percentage of people going to the ER with no insurance has been steady over the past 10 years, until 2006 when it went up 0.6%. This increase may be symptomatic of problems with overall health insurance coverage, more than anything else.

What it does show is that this small percentage is hiding a massive 37% increase in the uninsured attending ER, some 5.5 million additional visits, and someone somewhere is paying for that. There is insufficient detail to indicate whether an individual actually paid the hospital fees or not, but this represents an enormous burden of expense not covered by insurance.

Waiting and Service Times

If you believed what you read in the papers or heard on the television, you might be forgiven for thinking that you would need to take a copy of 'War and Peace' with you to read. Although the average waiting time to see a physician in the ER is 56 minutes, this is affected by outliers -- some people wait a very long time to be seen.

Perhaps a better measurement would be the 31 minutes that the majority of people are waiting and the 62% who are seen within one hour, although the percentage of those seen within an hour is declining.

In the 1997 report, the average waiting time was 38 minutes, but the maximum time measured was capped, so this is misleading to compare. Despite the service times, every year, 2% of people who come to the ER just don't wait to be seen.

What Happened When You Were Seen?

Back in 1996, 96% of people going to the ER would see a physician, while now that's only 90%. This might be due to increased triage care reducing the need or perhaps indicative of the relative seriousness of the reasons people are attending ER.

Also, 15.35% of those attending ER were admitted in 2006. This is a higher number than in 1996 when it was 12.4% and represents a large seven million increase. This percentage of admittances does vary from year to year and there is no clear trend.

When to Attend -- if You Can Choose

Clearly, there are a lot of people who are attending ER for relatively minor reasons. Those people, assuming that they feel that they need to go but have some choice over the time, should try to be there between 4 a.m. and 7 a.m. After that time, the ER gets very busy, and peak attendance lasts from 10 a.m. through 10 p.m., so you could be waiting for those longer times.

The suggestion has been made that some people are using the ER as a substitute for primary care physicians because they cannot get an appointment, assume that they will be sent there anyway, or perhaps if they have no insurance they feel that they cannot get to see a doctor any other way. None of these suggestions have been tested by the survey, but if emergency cases are not rising, there may well be an element of truth in there.