Tackling the Crisis in Emergency Care

Over at “Home of the Brave,” Annie calls attention to the following Las Vegas Sun story about a man who suffered a heart attack and went to the nearest ER for help:

"But even as Linda Scheinbaum — Morton’s wife of 24 years — was screaming [in the emergency room] for medical attention to save his life, the MountainView Hospital nurse was insisting on getting his Social Security number, emergency contact and insurance information.

"'I’ll give you all the information later!” Linda Scheinbaum yelled at the clerk.

“It would be Scheinbaum’s tragic misfortune to [go] to the emergency room on the night of Nov. 4, 2005, when it was busy and hospital officials said there were no open rooms. The Scheinbaums were told to take a seat and wait — even though a delay of just minutes can make the difference between life and death during a heart attack…

“The precise timeline of the events of that desperate night is in dispute, but hospital records show that it was at least 41 minutes from the time Morton Scheinbaum arrived to the time he collapsed, blue in the face and foaming at the mouth. Only then was he rushed into the emergency room for treatment.

“And that’s where he died, his admission paperwork completed.”

There are many reasons to feel outraged when reading this story. But the tragedies of this tale are part of a larger—and just as depressing—picture in American emergency care. The staffing and overcrowding issues that Linda and Morton Scheinbaum faced three years ago are becoming the rule, rather than the exception, when it comes to emergency departments (EDs) in the United States.   

Begin with the seeming villain of this tale, the pigheaded nurse who forced paperwork on the Scheinbaums in a time of crisis. Blogger Annie has some issues with the Sun’s less-than-probing characterization: “Is the ‘nurse’ cited an unlicensed admission clerk?” asks Annie. “A secretary?...or a licensed registered nurse who is obligated to perform triage and intervention to conform to state regulations and to the hospital’s accreditation agency standards?”

Americans Who Have Insurance —But Still No Access To Care, Part I

A friend who lives in Boston complained, not long ago, about not being able to find a physician. In Boston?  “Come on,” I said. “This is like claiming you couldn’t find a liquor store.”

“They’re all oncologists and cardiologists,” he grumbled. “Last week I cut my hand badly enough that it needed stitches. I have good insurance. But I couldn’t get an appointment with my family doctor—or any of my friends’ doctors. I didn’t want to spend hours in the ER. So I wound up going to my sister’s house. She sewed it up at her kitchen table.”

His experience is not as unusual as it sounds. Some 56 million Americans do not have a regular source of care according to the National Association of Community Health Centers (NACHC) -- even though many of them do have insurance. The problem is a shortage of primary care physicians (PCPs) in many parts of the country, particularly, but not exclusively, in poorer communities.

Even Docs Have to Call In Favors 

Not long ago, Bob Wachter, Professor and Associate Chairman of the Department of Medicine  at the University of California, San Francisco (UCSF) , and author of Wachter’s World warned his readers: “The Long-Awaited Crisis in Primary Care: It’s Heeere.” 

Indeed, if you try get an appointment at UCSF’s general medicine practice, you will find that it is “closed” –even if you are an UCSF physician. They just aren’t taking any new patients. “Turns out we’re not alone,” Wachter adds. “Mass General also is not accepting any new primary care patients.” 

He calls attention to “to two very powerful NPR reports on the topic – the first, a WBUR special by healthcare journalist Rachel Gotbaum called ‘The Doctor Can’t See You Now,’ is the best reporting on this looming disaster I’ve heard .

Wachter summarizes highlights:  “Getting a ‘regular doctor’ (a PCP) at Mass General now takes the combination of cajoling, pleading, and knowing somebody generally referred to as ‘working the system.’ In other words, the process of finding a primary care doc is now like getting a great table in a trendy restaurant.

“The report also makes clear that providing more ‘access’ through expanded insurance coverage won’t do the trick,” Wachter explains.  “Massachusetts, you’ll recall, markedly expanded its coverage a couple of years ago (in legislation proposed by that ex-liberal, Mitt Romney). Scott Jasbon, a 47 year-old contractor/bartender, thought he was all set when he enrolled in one of Massachusetts’ subsidized health plans. He was wrong.

Addressing the Nursing Shortage

Back in October, Maggie touched on America’s shortage of nurses, as well as the different factors behind the crisis—namely, hectic working conditions, insufficient academic resources for nurse training, and a hospital building boom that has outstripped the nursing workforce. Thanks to the convergence of these forces, the government predicts that the nursing shortfall will grow to more than 1 million nurses over the next 12 years.

What can be done to nip this problem in the bud? According to a new white paper, our priorities should lie with expanding the capacity of nursing schools and doing more to make sure that existing nurses work under better conditions.

First, the nursing schools: “there is widespread agreement that the primary bottleneck at this point in time is the faculty shortage,” say Jennifer Joynt and Bobbi Kimball, authors of “Blowing Open the Bottleneck,” published jointly by the AARP, the U.S. Department of Labor, and the Robert Woods Johnston Foundation. According to the authors, “a 2007 survey of baccalaureate nursing schools found that 71.4 percent of schools indicated faculty shortages as a reason for not accepting all qualified applicants.” Turning away potential nurses is a bigger problem than you might think: according to a companion write-up in JAMA, more than 42,000 qualified applicants were turned away from nursing programs in the U.S.