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ERs face a new urgency

April 27, 2009|Melissa Healy

Those folks who slice a finger chopping vegetables, come home from work to a feverish baby or break a bone in a weekend football game have, at last count, just over 4,000 emergency departments scattered across the country from which they can seek care.

But they had better have plenty of time.

As emergency room visits in the United States have ticked steadily upward, reaching 119.2 million annually, waiting for treatment has become a central feature of emergency-department care.

Patients spend an average of 3.3 hours to be seen, treated and discharged, according to a 2006 report by the federal Centers for Disease Control and Prevention. Last June, a 49-year-old woman died on the waiting room floor of a New York hospital ER -- one of the almost 400,000 patients who, the CDC found, had waited 24 hours or more to be treated in a hospital emergency room. In Arizona, where hospital emergency rooms are most crowded, patients wait just less than five hours on average for care in an ER.

Many people would rather stitch themselves up, splint their own fracture or endure a fussy baby through the night than brave that wait -- not to mention many ER staffs' seeming indifference to their less-then-life-threatening affliction.

Instead, a growing number appear to be voting with their feet. Those walk-in patients are fueling the growth of a kind of healthcare provider now making a comeback -- the urgent care center -- and at some hospitals, a flurry of efforts to improve the ER experience.

The Urgent Care Assn. of America, a trade organization that did not exist until 2004, last year counted a total of 8,000 urgent care centers around the country. For patients with illness or injury that is not life-threatening but can't wait for an appointment with a primary care doctor, these hybrids are a growing alternative to hospital emergency departments.

In the absence of a single standard, the Urgent Care Assn. is currently drafting a list of criteria that would let consumers know what to expect from an urgent care center. Such centers now vary widely: Most keep evening and weekend hours, although few are open 24/7; many are heavily staffed by physician assistants, with at least one physician on site or on call; most have X-ray machines and rudimentary lab facilities, though centers separate from a full-service hospital lack the sophisticated blood chemistry tests, MRIs and CT scans that ER docs use to diagnose and treat serious illness. Urgent care center staff can generally detect and set a simple fracture, administer breathing treatments and write prescriptions to treat sprains, allergic reactions and infections. But if you walk into one with signs of stroke or heart attack, or are about to give birth, they'll call 911 faster than you can say "triage."

About 15% of these centers are affiliated with existing hospitals -- either as satellite facilities or as on-site clinics near the hospital ER that can handle non-emergency walk-in cases. Though one in four urgent care practices serves an urban population, most -- 55% -- are in the suburbs, where affluent and privately insured patients are often reluctant to spend hours in an ER's waiting room.

"The motivation is money, and clearly the finances are there," said Dr. Sandra Schneider, an emergency-department physician at the University of Rochester Medical Center in New York and a vice president of the American College of Emergency Physicians. Many private insurers, keen to keep costs down, also are encouraging patients to use urgent care as an alternative to an ER visit.

Plan in advance

The rapid rise of urgent care centers, and the fact that they are largely undefined and unregulated by state hospital and medical boards, means that they place some important responsibilities on patients, Schneider said. Patients must not only make the crucial decision of what level of care they are likely to need; they would also do well to check, in advance of a potential need, the credentials, capabilities and staffing policies of an urgent-care clinic they might use.

"As it is now, anybody who has an MD or license to practice could put up a sign and say 'I'm an urgent-care doctor,' " Schneider said. "If you're having a heart attack, you really want an emergency physician there, because that's what they're trained to do."

But hospitals too have responded to the growing chorus of patient complaints. In recent years, Schneider said, many have established "fast track" procedures that funnel patients who need non-emergency care to a staff of physician's assistants operating under the supervision of emergency doctors.

Others, including the San Gabriel Valley Medical Center, a 274-bed, acute-care hospital, have taken to advertising their promise of rapid ER care on buses and billboards, and have beefed up staffing and streamlined procedures and practices across the hospital to deliver on that promise.

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