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State’s ER policy passes checkup

Hospitals accept ambulance rule; Wait times don’t spike for patients

HEALTHY SIGNS Alice Bonner, director of the Massachusetts’ health care safety bureau, says other states are calling for emergency room policy advice. HEALTHY SIGNS
Alice Bonner, director of the Massachusetts’ health care safety bureau, says other states are calling for emergency room policy advice.
By Liz Kowalczyk
Globe Staff / December 14, 2009

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A new state policy requiring crowded hospital emergency rooms to accept all patients delivered by ambulance has not worsened conditions, as some doctors had feared.

According to an analysis by state public health officials, the average time patients spent in 75 of the state’s emergency rooms remained about the same since the rules went into effect in January. Patients who were admitted to the hospital spent between 5 and 5 1/2 hours in the emergency room, while patients who were sent home spent about 2 1/2 hours.

“This policy was a risk,’’ said Alice Bonner, director of health care safety and quality for the state Department of Public Health. “We wanted to be sure there was no spike in waiting time or any unintended consequences. It’s been a success.’’

For decades, Massachusetts hospitals had been allowed to turn away most ambulances when their emergency rooms were overcrowded. The practice, called diversion, can delay treatment and tie up ambulances, and it upset patients who were denied care at their usual hospitals.

During these periods, emergency rooms took walk-in patients and trauma and burn patients. But they often did not take patients brought by ambulance with complaints such as chest pain or minor broken bones, even if their doctors worked at the hospital and their medical records were stored there. Public health officials decided last year to put a stop to the practice.

Massachusetts was the first state to ban ER denial statewide, but officials in other states are calling for advice, said Bonner.

“Ultimately, this [system] should provide better patient care,’’ said Dr. Stephen Epstein, an emergency room physician at Beth Israel Deaconess Medical Center in Boston, where length of stay in the emergency room has varied only slightly since the new policy was implemented.

The busy Massachusetts General and Brigham and Women’s hospitals in Boston accounted for most of the ambulance diversions statewide in previous years, and leaders of their emergency rooms said that, despite initial concerns, the policy has worked fine. It has reduced wait times because it helped force doctors and administrators to tackle underlying reasons for overcrowding.

Although sending away ambulances gave hospitals temporary breathing room, public health officials said, it didn’t address the backup of patients into ER hallways because the hospitals had no open beds.

Still, at most hospitals, the analysis shows that emergency room wait times can still be lengthy. In October, the last month for which the health department has data, patients at some hospitals spent an average of 8 or 9 hours in the emergency room before being transferred to a bed on another floor. The state does not track how much of that time was spent receiving treatment in the emergency room and how much was spent waiting for a bed.

Mass. General, which sees about 85,000 patients a year in its emergency room, accounted for about 35 percent of the 1,826 hours during which hospitals closed their emergency rooms to ambulances in 2007. That means the hospital’s emergency room turned away ambulances for the equivalent of almost four weeks that year.

In the time since emergency rooms could no longer close temporarily, ambulance traffic jumped 13 percent, said Dr. Alasdair Conn, chief of emergency services. He said the state’s near-universal-coverage health insurance mandate has also contributed to that increase, because thousands more Massachusetts residents now have health coverage and are more likely to use hospitals.

But as volume has climbed, he said, the hospital has made improvements that have reduced emergency room waits, which have been a longstanding problem at New England’s largest hospital. For example, a new triage system means patients see a nurse within a half-hour of arrival; if tests are needed the nurse can get those started more quickly than before.

The average length of stay for patients who are treated and released is down to 3 1/2 hours, from about 5 1/2 hours two years ago, Conn said. Patients who are treated and admitted to the hospital are in the emergency room 6 to 7 hours, he said, compared with 10 hours three years ago. Mass. General is working on other improvements, including hiring nurse practitioners to get patients on floors discharged early in the morning to free up hospital beds for emergency room patients.

At the Brigham, the hospital opened a “surge pod’’ in October, where patients can go from the emergency room while they wait for a regular hospital bed to become available. The 12-bed pod is a former intensive care unit, where patients are in their own rooms rather than on a gurney in a hallway, said Dr. Richard Zane, vice chairman of the emergency department.

Average stays in the Brigham emergency room fell 8 percent, to 4.8 hours, in the fiscal year that ended Sept. 30, from the previous year.

Bonner said hospitals are working on other ways to reduce emergency room stays, but they involve changing practices in almost all areas of the buildings. For example, a pathology department can cause delays if it doesn’t have enough overnight staff to analyze test results for emergency room patients.

The state will post emergency room length-of-stay data on its website later this month. Bonner said the website will not identify hospitals by name. The data should not be used to compare hospitals, she said, because they are not adjusted for the severity of patients’ illnesses and other factors.

She said the public will be able to get the names of hospitals by filing formal freedom of information requests with the health department.

Liz Kowalczyk can be reached at kowalczyk@globe.com.

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