Hospitals Expand Emergency Rooms as Patient Volumes Rise

Patient visits to hospital emergency rooms (ERs) are on the rise nationwide. The causes are the increase of uninsured patients which ERs cannot turn away, and managed care patients who cannot wait a handful of days to see their group network physicians, or who don't want to travel long distances outside

Coupled with a nursing shortage and a lack of hospital beds on main floors, which both create a logjam of ER patients, either lying on hallway stretchers or sitting in waiting rooms, it seems emergency departments (EDs) need a cure for their own illnesses.

New Jersey hospitals are applying remedies to combat the situation by expanding emergency room facilities, implementing technologies that better track the flow of patients and open beds, and expanding nurse recruitment efforts.

Patient visits at University Hospital, Newark, the core teaching facility of the University of Medicine & Dentistry of New Jersey - New Jersey Medical School, have increased from 35,000 during its first full year of operation (1979 - 1980), to 75,000 patients per year today The increase in volume, according to Dr. Suzanne Atkin, associate director of the emergency department at University Hospital, is due to the closing down of area hospitals such as United Hospital, a growing number of uninsured patients and "the fall out of managed care."

Atkin blames part of the increase in patient volume on managed care. "When managed care came into being, the 'experts' predicted that visits to emergency departments would decrease. Many people would see private physicians which would relieve the ER," she says. "But doctors didn't have office hours that coincided when people got sick."

The hospital, which is a Level I Trauma Center that features the NorthSTAR helicopter emergency and critical care transport system, is in the midst of a $14.7million renovation of its current emergency room, expanding the facility from 27 beds to 45 beds. To be completed by this November, the project includes a six-bed psychiatric emergency unit (already operational), the joining of what was once two separate adult ER areas with an additional eight beds, a four-bed fast track area for patients who have minor injuries, an asthma room, a larger emergency pediatrics unit, larger triage evaluation area plus waiting room and new ambulance entrance.

At a time when more patients are visiting University Hospital's ER, the facility is also grappling with a nursing shortage which, in turn, limits the number of inpatient beds a hospital can make available. This then creates a logjam of patients in the ER waiting to be admitted.

"We continuously go out on recruiting missions at nursing schools, advertise in publications and try to get referrals from other nurses," says Chris McCallion, director of patient care services for the ED at University Hospital.

McCallion is attempting to fill eight vacancies for nurse positions in the ER. What makes this difficult is that since the hospital is a LEVEL I Trauma Center, it cannot hire nurses right out of school. Two years of experience at an acute medical/surgical arena is needed.

The hospital is attempting to work around this by introducing a pilot program this spring in which it will take three graduate nurses and give them an extensive orientation.

McCallion is currently balancing the workload by a combination of regular staff nurses, per them nurses and agency nurses. The latter two groups usually work in the fast track area and holding area in which a patient is observed after treatment.

Chilton Memorial Hospital, Pompton Plains, is dealing with its nursing shortage with heavy recruitment efforts. Of great interest is its "Helping Hands" program which the 256-bed acute care hospital has implemented. Here, nurses and other personnel from different medical areas of the hospital are cross-trained to assist in the ER during times of high patient volumes.

Chilton has also been seeing ER patient volumes increasing, which now total between 35,000 and 40,000 visits per year. "We are serving 14 different townships in Northern New Jersey which are bulging at the seems," says Brian White, spokesperson for the hospital. Patient volumes are expected to increase by 8 percent to 10 percent annually Some of this increase is the result of a senior housing development being built in the region.

To combat growth, the hospital, last year, completed $3.5 million worth of ER renovations which entailed a patient bed increase from 18 to 28, mostly private rooms.

Updates were made to make the patient visit as comfortable and efficient as possible. This includes automated bedside monitoring equipment, which enables doctors and nurses to keep closer track of patients' vital signs such as blood pressure, pulse and oxygen saturation every one to two minutes.

The ED also installed state-of-the-art digital radiology imaging equipment which allows instantaneous viewing of digital X-rays by doctors and radiologists. This results in three to four times faster patient throughput and remote viewing capabilities since X-rays can be e-mailed. "Not only does this expedite the entire Xray process, it also reduces the amount of time patients spend in the emergency room and waiting area," says Dr. Gennaro Marino, director of the ER department at Chilton.

For children, the ER now has on staff in-house pediatricians available 24/7. In addition, not to intimidate children with "scary" medical technology, enclosures were built into walls to hide equipment. "Besides the medical resources, we put a lot into addressing the emotional issues of patients," says White.

To help manage the flow of patients, a fast track area has been made available, as well as six holding rooms for patients waiting to be admitted.

At Overlook Hospital, Summit, part of the Atlantic Health System, patient movement from the ED to an inpatient bed is monitored by a computer system that looks at demand and capacity throughout the hospital. There is also a computer system that is networked to laboratories that make results available as fast as possible. "For a number of years, we have aggressively been looking at the process side of things, including waiting for lab results, radiology studies, physician interpretations of those studies, and have put changes in place to make the process more efficient," says Patricia Gabriel, nurse manager of the ED at Overlook.

The changes are necessary. Overlook has seen patient visits to the ER increase 5 percent per year for the past eight years, with approximately 36,500 patient visits in 2000. To accommodate the growth, the hospital is planning to expand its ED from 19 beds to 46 beds. The renovation will include a separate pediatrics area, important because Overlook has seen pediatric visits to the ER increase 14 percent between 2060 and 2001, with admissions increasing 50 percent. There will also be a cardiac observation area, fast track section, a more-defined triage area, separate waiting areas to serve different patient cases and, because of September 11 and the related anthrax scare, a decontamination area to treat chemical exposures.

The new ER will also have space for radiology equipment, including CAT-scan and a new PAC system which allows for the digital display of X-rays (old and new) on any computer terminal. Overlook, in February, also became the first hospital in New Jersey to acquire a PET/CT hybrid scanner that identifies cancerous tumors faster and more efficiently.

"The new vision of the ER is to treat the whole human life cycle," says Dr. James Espinosa, medical director of the ER department. He adds that Overlook's ER department no longer acts as a silo, separate from other hospital departments. "That view is passe," he explains. "The ED is a vital part of the hospital structure. We are the 'front door' to the hospital, so we also have the added pressure of delivering more patient satisfaction."

Hunterdon Medical Center, Flemington, will soon be embarking on a major expansion of its ER department which has seen patient visits surge from 17,134 in 1996 to 25,132 in 2001.

The buildout is necessary. The hospital is the only acute care facility in a county that is experiencing fast population growth. "We are ending up with people in situations in which we don't want them in, such as being on stretchers in the hall," explains Marjorie Whelan, director of critical care and emergency services. "We don't want to treat any of our community members that way," She adds that since the beginning of 2002 the hospital has been experiencing its heaviest seasonal volumes.

The original ER was built more than two decades ago to handle 15,000 patients per year. The new expansion, from 5,820 square feet to 15,350 square feet, is expected to handle 32,000 annual visits. One of the main features of the renovation, which should commence this fall, will involve a transition from 14 bays, or beds separated by curtains, "where you can hear everything going on in the next bed," says Whelan, to 24 private rooms. These include 14 standard treatment rooms, two isolation treatment rooms, two cardiac rooms, and four comprehensive triage rooms.

A separate pediatrics area will include colorful rooms, with appropriate toys and cheerful pictures, plus TVs with VCRs. Presently, there is no special pediatrics area, so children are "prone to hear words they shouldn't," says Whelan.

A special psychiatric surveillance room will be built, as well as a negative pressure isolation room to treat patients with an air-borne infectious disease.

Two designated trauma rooms will be specially equipped to handle patients with cardiac emergencies. Cardiac monitors will enable physicians to monitor patients at all times from computer screens which will be centrally located in the ED. There will also be an X-ray department within the ER so that patients do not have to be transported to the Medical Imaging Department. This will result in faster test results.

Faster test results are what all hospital ERs are striving for, but today's increased diagnostic tests, such as echocardiograms, ultrasounds, MRIs and CAT-scans, now being done in or near the ER, are slowing people down. "The speed-up phenomenon has a slow down component," explains Whelan. "Since we have more technology today, we want to make sure that all the bases, are covered to make sure we send patients home safely."

Atkin, at University hospital comments, "We are doing more extensive work in the ER because we have fewer beds open on the floors because managed care is saying 'get those patients out of the hospital."'

With nurses aides, consumer affairs professionals and a concierge attending to the needs of patients and visitors, Hackensack University Medical Center is doing its best to comfort people who are waiting in the ER. According to Laura Cima, vice president, ER continuum and outpatient departments, visits to the emergency room are increasing every year.

To cope with the increase, the hospital will soon be more than doubling its acute care area from 10 bays to 24. An automated patient tracking system has been installed which networks the ER to the hospital's admissions department so that the latter office can keep tabs of how many patients are in the ER.

Staff members inside the ER use closed circuit television to monitor the ER waiting room to see crowds and patient conditions. The next step in efficiency will be the automation of triage data collection so that physicians and nurses inside the ER can see the information of arriving guests at any given time.

"The biggest problem facing the ER is the public's understanding of it," says Cima. "The average person doesn't know how an ER is run. Someone may come in with a cut finger, while two serious trauma cases roll in right afterward. The trauma cases have to be seen first. The average person may not understand that. There's a 'Gee, I was here first' mentality, but that's not how ERs work."

The increase in ER patient visits at Jersey Shore Medical Center, Neptune, from 46,000 in 1998 to 60,000 in 2001, can be attributed to many factors. According to Dr. Robert L. Sweeney chairman, department of emergency medicine at the hospital and chief of emergency medicine for the Meridian Health Care System, an aging population that is living longer with chronic illnesses, a more active population leading to more minor trauma and the lack of accessibility of primary physicians are among the top reasons.

Jersey Shore Medical Center is just putting the finishing touches on its ER expansion of eight beds. "That doesn't sound like much, but it will increase our capacity to greater than 30 percent," says Sweeney. The hospital underwent a substantial ER renovation seven years ago. With the new beds, the emergency facility has a total of 41 beds, encompassing trauma, pediatric, psychiatric, fast track, observation and general emergencies.

The hospital's last track area has seen patient volumes increase from 9,000 to 24,000 per year. Commenting on hospital programs that try to get ER patients seen within 15 minutes or 30 minutes or the visit is free, Sweeney comments, "That smacks of gimmickry and trying to suck patients in. I would prefer patients use this facility, for example, because they know they can receive the best medical care available rather than because they know they can get it fast or for free."

At St. Francis Medical Center, Trenton, part of Catholic Health East health care system, the emergency department attempts to see and place visitors into the ER as fast as it can. "It's very fast paced here," says Judy DiBartolo, nurse manager of the emergency department. "Our goal is to get a patient into the ER as soon as possible. Patients are immediately sent to triage and then brought in for bedside registration."

The task sounds immense since last year, patient visits to the ER reached an all time high of 25,000, a 6 percent increase from 2000. Fortunately, the hospital completed an expansion of its ER by increasing beds from 12 to 20 in various specialty areas,

Asked if the increase was enough, DiBartolo responds, "We have already had some crazy days. Yesterday, we saw 80 patients and all of our critical care areas were full, It's just the nature of the beast." She says the hospital is looking towards another increase of bays for the future.

The existing ER at Holy Name Hospital, Teaneck, is expected to be completely torn down and renovated to accommodate an increase in patient visits from 29,000 in 1993 to 40,000 last year. Although no start date has been planned, Kevin McCarthy, vice president of public affairs, explains hospital administrators are meeting with a team of architects, doctors and radiology technicians.

The plan is taking into consideration the growth in patient volumes for the next 20 years. More importantly, "we want to maintain our efficiency without losing patient control. Traffic flow patterns of patients is ail being taken into consideration," says McCarthy.

The emergency department at Holy Name is also implementing a management information system that will integrate laboratory, radiology and other department information to help speed the diagnosis of patients. In addition, the outpatient radiology department will be located next to the emergency room for quick service and close working relationships.

Hospital emergency rooms have diagnosed the future with expansion and construction projects to treat New Jersey's critically ill.

NJHA's Carter Discusses ER Malady

Hospital emergency departments are not operated as revenue centers, even though they are the windows for these institutions to which most patients are referred and, if need be, admitted, says Gary Carter, president of the New Jersey Hospital Association, Princeton. "People are using ERs as their primary care physicians and that is clogging up these centers," he says.

The rules, however, call for hospitals and emergency departments not to turn patients away, even those who cannot pay. And the number of people who cannot pay is quite large, Approximately 1.3 million residents lack health insurance in the state and last year, hospitals provided $900 million in charity care and bad debt service.

The increase in patient volumes is a national dilemma. In five years (1995 to 1999) visits to the emergency rooms jumped by nearly 5 million, from 94.7 million to 99.5 million. In New Jersey, the annual number of ER visits jumped from 2.5 million to 2.7 million during the same time period,

Besides the increase in patients, emergency rooms are faced with a shortage of available in-patient beds in other areas of the hospital, which causes a logjam of patients in the ER. According to the NJHA'S Department of Health Economics, the number of beds in use by a hospital differs from the number of its state licensed beds. Statistics may reveal that there are more licensed beds, but a nursing shortage (a shortfall of 14,000 RNs in the next five years) and other factors cut down the number of beds that can actually be used to efficiently handle patients.

While looking at state licensed beds, hospitals report an occupancy rate of 57 percent, but when counting maintained beds, the occupancy rate is 71 percent. Some hospitals are even reporting an occupancy rate of 90 percent or more.

In his "Perspective" column, published in the NJHA newsletter, Carter states, the solution to the ER and hospital problem must be multifaceted, but, "it all starts with adequate funding - something that has been kept from hospitals for too long. Medicare cuts, charity care under-funding and the tight-fistedness of managed care all contribute to the crisis. Nurses can't be given raises so they quit the profession. The shortage of nurses leads to inadequate patient beds, and lack of beds create ER logjams."