Carolyn Caldwell, president and CEO of St. Mary Medical Center, said that while the hospital administration has plans to eventually build a new emergency department, in the mean time progress is being made to expand the existing facility to accommodate more observation bays. (Photograph by the Business Journal’s Brandon Richardson)

Depending on when someone visits an emergency room, the wait time can range between minutes to several hours, according to health care executives. For those waiting hours, a number of questions and concerns arise, chiefly among them – why is this taking so long?

Dr. Muhammad Husainy, a spokesperson for the American College of Emergency Physicians (ACEP) who has worked as an emergency room (ER) doctor for 10 years, told the Business Journal that approximately 75% of all hospital admissions are attributed to their emergency departments. Patients who seek care in an ER and must then be admitted to a hospital for surgical or medical reasons have to wait for an available bed – and often, there aren’t any, Husainy said. As a result, that patient is left waiting for hours in the ER, which can cause a back-up during times of overcrowding, he explained.

“We keep patients in the emergency room for prolonged periods of time basically because we don’t have a room to put them in,” Husainy explained to the Business Journal. This issue of admission throughput is one of the top reasons for extended emergency room wait times, he noted.

Husainy, who works at Hellen Keller Hospital in Alabama, noted that ER wait times become overcrowded during specific times of the year, particularly during winter months when the flu is more common. “All of the sudden [when] you have crowding, you have patients who are probably put in places like hallways or are forced to wait in triage longer just because there are no true surge capabilities of most emergency departments,” he said.

According to Husainy, In 2018 there were about 142 million visits to emergency rooms in the United States. Ten years prior, there were 100 million. He attributed the increase to population growth, the aging Baby Boomer generation, and a shift in attitudes about care among younger generations.

While Husainy said older generations preferred to make appointments to seek care, younger people often prefer not to wait. “People my age and younger are like, ‘I’m not making an appointment because I’ll never keep it. I’ll forget about it or I’ll be traveling, or I’ll be busy,’” he explained. He noted that while lab tests or scans ordered by primary care physicians take time to schedule, patients who visit an ER are able to receive results within hours.

Prolonged wait times in emergency rooms result in the increased likelihood that a patient will experience “an adverse event,” according to Husainy. “It is a huge risk.”

In Long Beach, MemorialCare Health System’s closure of Community Hospital in July 2018 has impacted emergency departments, according to executives at Dignity Health – St. Mary Medical Center and MemorialCare Long Beach Medical Center (LBMC). “The primary impact was that we saw more ambulance runs because our numbers increased relatively closely to the ambulance runs that they [Community] historically received,” John Bishop, CEO of LBMC and Miller Children’s & Women’s Hospital Long Beach, said.

Carolyn Caldwell, president and CEO of St. Mary, said that her hospital has experienced a “significant increase” in ER patient volumes since Community Hospital closed. “With the closure of Community Hospital, [St. Mary] has seen around a 33% increase in the number of 911 calls,” she said. “Since the closing of Community Hospital, our emergency services have seen an additional 200 ALS visits per month, or advanced life support visits, and about [an additional] 135 BLS, or what we call the more minor, basic life support visits, compared to six months ago ending December of 2018.”

In 2018, LBMC’s emergency department treated approximately 109,000 patients. St. Mary’s treats about 56,000 patients per year.

Both hospital executives said that they were prepared for the increase in patient volumes. Long Beach Medical Center hired some of the ER nurses who had worked at Community after its closure, Bishop noted. Additionally, he said, “We set up some processes to be able to increase our throughput by creating some additional beds.” Patient volumes in LBMC’s emergency room actually decreased from 2017 to 2018, because 2017 was a particularly bad year for the flu, Bishop noted.

St. Mary Medical Center had already put in action some new strategies to reduce ER wait times before Community closed, according to Caldwell. “We were already working on a patient throughput process where we looked at the entire process of a patient being admitted, pulling in all the multi-disciplinary teams, even including housekeeping, which plays a huge role in patient throughput,” she said. “So, we have been able to manage the volume appropriately.”

In 2018, LBMC’s emergency department treated approximately 109,000 patients. St. Mary’s treats about 56,000 patients per year.

Hospitals triage ER patients to assess the acuteness of their condition. According to Husainy, Bishop and Caldwell, patients are typically assessed within minutes of entry to the ER. Those with potentially life-threatening conditions are put at the front of the line to see a physician, while those who can wait – such as someone with an ankle sprain – receive less priority.

“Our goal is to be able to triage the patient and have a medical evaluation within 10 minutes. Our average for the past six months is actually seven minutes,” Ike Mmeje, chief operating officer of LBMC and Miller Children’s, said. However, at LBMC, patients who are not acutely ill could wait as long as 10 hours for care during particularly busy times, which typically include weekends, Bishop noted. The hospital increases staffing during busy hours, he added.

Caldwell said the majority of St. Mary’s emergency room patients “are assessed within 30 minutes of their arrival.” She explained that the wait time for non-acute patients increases when multiple trauma patients come through the ER.

Both LBMC and St. Mary employ “fast-track” procedures to process patients through their ERs. “We have a fast track in the emergency department where we try to get the patients with a physician within 30 to 45 minutes to begin any lab work or any pre-testing to assess whether or not they need to be treated on a more urgent basis,” Bishop said.

At St. Mary, patients who are deemed non-acute are put on their own fast-track. “Those patients are able to get in and out pretty quickly,” Caldwell said. She noted that it typically takes four to five hours to process patients who need to be admitted to the hospital.

To try to combat emergency department overcrowding, MemorialCare Health System has opened numerous outpatient, urgent care and imaging facilities in Long Beach, according to Bishop, who added that the centers are a less costly, more efficient method of care for patients. Mmeje said that the health system is working to educate the community about the convenience of these centers.

Both LBMC and St. Mary have ER expansion plans. At LBMC, “We have a plan at this point to add nine additional observation bays,” Bishop said. St. Mary has plans to construct a new ER due to state seismic requirements, Caldwell said. But, in the meantime, the hospital administration plans to add up to 10 treatment bays in its ER.

Challenges For Hospitals And ER Physicians

One challenge for hospital emergency departments is caring for patients who come in for behavioral health care, according to Caldwell. “Most of our facilities, we are acute care facilities. We don’t have behavior health beds,” she explained. “It does provide a challenge for our emergency room because we have to provide one-on-one support for those patients. We utilize our case workers . . . to try to have those patients transported to a more appropriate facility as quickly and as safely as possible.”

In Long Beach, specifically, another challenge is a higher than average volume of homeless patients. “One thing I have noticed being in Long Beach now for almost two years is we do seem to have a pretty significant homeless population. And I am very happy that our mayor and our community is really taking this seriously,” Caldwell said. Last year, the city convened a task force to develop a plan to tackle homelessness. Caldwell and Bishop participated, as did representatives from local colleges, the business community, nonprofits and city agencies.

Bishop said that insurance reimbursements are a challenge for emergency departments. “One challenge that exists for every emergency department is you treat all patients regardless of ability to pay,” he said. “We’ve also seen an increase in our uninsured population now that the individual mandate was repealed as part of the recent tax cuts.”

Husainy said that dealing with insurance companies has become a hindrance for emergency room physicians and administrators. At particular issue is that some insurance companies violate federal law and initially refuse to pay for care if, for instance, a patient visits an ER thinking he or she is having a heart attack, but is ultimately diagnosed with acid reflux, he explained. “The American College of Emergency Physicians has levied several lawsuits against Anthem and other insurance companies recently in the last 12 to 18 months,” Husainy said.

“Without trying to sound too heroic, you’re asking me to take somebody I have never met before who comes in with an acute complaint, and within about three to five minutes figure out what’s wrong with them, and in about 10 minutes have a treatment plan,” Husainy said. “And oh, by the way, try to make them happy at the same time and satisfied that they got what they want, which is a very complicated thing. It’s hard enough to do that when you’re getting paid, and it’s even harder to do it when you’re constantly trying to work and have to defend yourself from insurance companies and reimbursement.”

Husainy added, “Our aim as a college of medicine . . . [and] as someone who came into this to be an asset to all patients, is to be honest and to do the right thing.”