At 10:15 PM on July 28, 2006, 49-year-old Beatrice Vance went to the ED at Vista Medical Center East in Waukegan, Illinois, with chest pain (10 on a 10-point pain scale), shortness of breath, and nausea. A triage nurse sent her to a crowded waiting room; her daughter, an LPN, repeatedly asked ED staff for attention to her mother. Two hours later she was found dead of a heart attack. In September, a coroner's jury declared the death a homicide. Coroner Richard Keller said it resulted from "gross deviations from the standard of care that a reasonable person would have exercised in this situation." The fact that Ms. Vance was African American has led to concerns that this case is yet another example of racial disparities in health care.
How could the triage nurse have failed to act on the classic signs of myocardial infarction? I e-mailed an ED nurse who has worked for many years at an academic medical center in New York City. She wrote that she had been working 14-hour days, despite knowing that it's unsafe to do so:
[horizontal ellipsis] had 14 patients at one point on Monday, total more than 25 for the day, including deathly ill folks, at one point had received four new pts, no assessment except for a three second eyeball for them[horizontal ellipsis]. DANGEROUS [horizontal ellipsis] We don't know what to do, will have to protest [horizontal ellipsis] miracle there are no dead women in [my] ED [horizontal ellipsis] license in jeopardy, humanity in jeopardy, ethics out the window[horizontal ellipsis].
She later told me that the hospital rarely diverted ambulances to other EDs because the ED was one of its most important profit centers. But there's another reason many hospitals don't divert ambulances when they ought to: there's sometimes no other ED that has room. According to a 2006 Centers for Disease Control and Prevention (CDC) report, Staffing, Capacity, and Ambulance Diversion in Emergency Departments: United States, 2003-04, 40% to 50% of hospitals reported being crowded, and 12% were "on ambulance diversion status" at least 5% of the time-despite the expansion of emergency capacity at many. While 56.5% of ambulance diversion was related to too few inpatient beds, 54% (there was overlap) was attributed to a high number of ED patients, 20% to complexity of cases, and 7.6% to hospital staffing shortages. Interestingly, 47.6% of diversions were ordered by nurses, suggesting that nurses will often act to ensure the safety of patients.
The Institute of Medicine (IOM) Committee on the Future of Emergency Care in the United States Health System issued a three-volume report in 2006 (http://www.iom.edu/emergencycare) concluding that the U.S. emergency response system is in chaos and on the verge of collapse. And according to the National Health Policy Forum, there was an 18% increase in ED visits from 1994 to 2004 at the same time that the number of EDs declined by 7% as hospitals closed and consolidated. A survey by the Lewin Group for the American Hospital Association in 2002 found that 90% of level I trauma centers and hospitals with more than 300 beds were operating at or above capacity. The IOM's report concluded that the federal government has largely ignored this crisis, even though it can be fixed in affordable ways. The report recommends that
* hospital chief executive officers assume responsibility for achieving system-wide improvements in the efficiency and effectiveness of emergency services;
* professional associations and other bodies provide training in operations management for appropriate employees;
* the federal government lead an multidisciplinary effort to define and disseminate best practices in emergency care.
The IOM report also notes that more people are relying on EDs for all kinds of care-not necessarily emergency care-because of the many uninsured and underinsured people. This issue of AJN includes an article by Catherine Hoffman, of the Kaiser Commission on Medicaid and the Uninsured, delineating several truths about the uninsured. A companion piece (page 44) depicts one woman's story of cancer and the loss of insurance-a story that helps us remember that the crisis in emergency care is inseparable from the tragedy of the uninsured.