CHICAGO — Beatrice Vance died of a heart attack. The coroner says waiting in the emergency room helped kill her.
The 49-year-old woman’s chest was tight with pain when she walked into the ER at Vista East Medical Center in Waukegan last July. A blood clot had lodged in her heart.
It was 10:15 p.m. when Vance checked in, a coroner’s report shows. But she was told to wait for a doctor. So she sat and waited. And waited. And then at 12:25 a.m., she collapsed, her heart starved of blood flow.
Doctors rushed to treat her, but she had no pulse. It was too late.
Her wait, the coroner said, lasted two hours and 10 minutes.
Even when the consequences aren’t so tragic, time seems to pass at an excruciatingly slow pace when you’re waiting for medical care.
Whether it’s emergency room treatment, a routine doctor’s appointment, or those anxious days between getting poked and prodded for medical tests and receiving the results, waiting happens to just about everyone seeking medical care. It’s often one of the most frustrating parts about seeing the doctor.
Doctors, hospitals taking action
After years of overcrowding, overbooking, and angry patient complaints, many hospitals and doctors’ offices are finally doing something about those waits:
Providing test results quickly onsite or online. Offering same-day exams to patients who call early. Speeding up emergency-room triage to get patients faster treatment. And offering restaurant-style pagers so not-so-sick patients don’t feel stuck in a crowded emergency waiting room.
Shortening waiting times is part of a nationwide move toward empowering patients, reducing medical errors and improving health care, said Frank Federico, a director of the Institute for Healthcare Improvement. The nonprofit group helps doctors and hospitals devise solutions.
When patients are ill, “the longer that they have to wait to get into the system, the greater the chance” their sickness will worsen, too, said Sue Gullo, a nurse and also an IHI director.
“That’s a huge problem,” Gullo said, because it puts patients’ health at risk and costs hospitals more in resources and dollars.
Gullo knows the experience from both sides.
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She used to work in a hospital maternity center and often faced the wrath of women who arrived for a scheduled Caesarean section only to learn they’d have to wait so emergency cases could go first.
“It was very frustrating, any one of us knew we could be a patient tomorrow,” Gullo said.
And then she was, arriving in the emergency room one day with a broken leg after slipping on ice.
“It was overburdened. I ended up in a hallway without a stretcher” for more than an hour, she said. “I was sick to my stomach, I had to yell to get anything that I needed.”
An Institute of Medicine report on the crisis in U.S. emergency care detailed trends that have contributed to long emergency room waits, including increased demand, staff shortages and hospital closings.
Excess demand might have contributed to Beatrice Vance’s death because a nearby hospital had recently closed, a coroner’s employee said.
In a highly unusual ruling in September, a coroner’s jury called the death a homicide, in part because of the long wait for treatment. These juries determine cause of death but don’t try cases.
Prosecutors are investigating, but no criminal charges have been filed. A civil suit is almost a certainty. A Vista spokeswoman declined to comment “beyond extending our continued sympathies to the Vance family.”
Fewer emergency departments
Between 1993-2003, the number of U.S. emergency departments fell by about 425, or about 12 percent, while the number of patients seeking ER care jumped 26 percent to 114 million. They include uninsured or underinsured patients and those who seek emergency care for non-emergencies because they have no regular doctor.
Many hospitals are creating “fast-track” programs for these patients who will not require hospitalization and who tend to wait the longest for emergency care.
Montefiore Medical Center in New York City spent at least $35 million in the past five years on ER improvements, including a fast-track program that has cut average arrival-to-discharge times for less serious cases from about six hours to two.
Changes included hiring about 50 additional emergency room doctors, building a separate area for fast-track cases; and investing in electronic systems to speed up patient registration.
Montefiore’s walkout rate, reflecting patients who get fed up with waiting and go home, dropped from about 5 percent to 1.5 percent this year, said Peter Semczuk, the hospital’s vice president of clinical services.
That’s significant because walkout patients often get sicker and show up later in worse shape.
Spectrum Health’s Butterworth Hospital in Grand Rapids, Mich., added a fast-track system as part of an emergency department overhaul three years ago.
Reduced door-to-doctor time
Then, three-hour patient waits were typical, and eight hour waits were not unheard of, said Jeanne Roode, Butterworth’s emergency services director.
Now the average door-to-doctor time is about 23 minutes for all ER patients.
Improvements include adding 25 nurses, and during busy times having triage begin with a preliminary physician exam. That allows X-rays and other tests to be ordered immediately, with results ready when the patient is assigned to an emergency room bed, Roode said.
Patient satisfaction was the idea behind restaurant-style pagers distributed in the emergency waiting room at Silver Cross Hospital in Joliet, Ill. They allow patients awaiting care to grab a bite in the hospital cafeteria or just get some fresh air.
Anita Uthe gave the new pagers a thumbs-up. The 43-year-old mother from New Lenox, Ill., waited four hours for emergency care with her 11-year-old son last winter after he slipped on ice and suffered a concussion.
She braced for another long wait at Silver Cross last month when her son stepped on a rusty nail. This time she got a pager.
“It helps, because if you want to step outside,” you can, she said.
“I think everybody feels the same way going to the emergency room — you just don’t know when you’ll get called,” Uthe said.
But just then, her pager suddenly flashed — it was her turn, after only half an hour.
For Santa Clarita, Calif., college professor David Stevenson, 46, the Wait from Hell involved a procedure he was a little anxious about, a vasectomy. He and his wife took time off work, hired a baby sitter for their three children, checked in at the doctor’s office, and then sat. After 15 minutes in a crowded waiting room, they were told he was next. The waiting room emptied, filled, and emptied again “and then it was just me,” Stevenson said.
After an hour and a half, the doctor said he had to leave for an emergency. Fuming, Stevenson said he’d just wait some more, but the doctor replied curtly that he wouldn’t be returning that day.
“He just said, 'Sorry buddy, you’re going to have to reschedule,”’ Stevenson said.
For 30-year-old Ihor Andruch of Elmwood Park, N.J., the unbearable waits were just for routine exams. Until he recently switched doctors, Andruch had to take a partial sick day for doctors’ visits that would last 10 minutes but required waiting two to three hours.
One time, after checking in, he took a “brunch break” at a nearby bagel shop, returning with plenty of time before he was called.
“I was as patient as I could be, but it was very frustrating,” Andruch said.
Overbooked doctors' offices
Such waits often are due to overbooking. That happens partly because under many health insurance reimbursement systems, doctors are paid by volume.
Doctors “are responsive to the same economic pressures that everybody else is,” said Dr. Michael Barr of the American College of Physicians.
The group, which represents about 120,000 internists and other doctors, issued a policy statement earlier this year advocating changes that Barr said could help address the waiting problem.
Recommendations include insurance reimbursement for less traditional patient visits, such as telephone and e-mail consultations to give patients speedier access to doctors.
The group also supports “open-access” scheduling, which some doctors already use, reserving up to 70 percent of their daily schedules for patients who call early for same-day appointments.
Patient-friendly scheduling is also a feature in so-called “boutique” medical practices, which offer virtually no waiting but often aren’t covered by insurance.
Playing phone-tag for test results
Most patients have experienced playing phone-tag to get test results. That’s at least partly because of the traditional paper-based method of relaying information. Test results are transcribed onto paper, then given to the doctor, who then phones or snail-mails them to patients.
At Boston’s Beth Israel Deaconess Medical Center, patients can get test results electronically the same time as the doctor through a private online account called PatientSite.
“There is no waiting for paper printouts to arrive by mail,” said Dr. John Halamka.
All test results show up on the site, except those involving diagnosing cancer or HIV, “assuming that this news should be delivered in person,” he said.
The waiting that goes along with diagnosing and even ruling out cancer can be particularly nerve-racking.
Dr. Marisa Weiss, a Philadelphia-area breast cancer specialist, hears from patients upset about long waits for routine mammograms, then more waiting for the results.
“This is part of the job description” of being a woman today, said Weiss, founder of an online resource center for breast cancer patients.
Weiss, 47, said she dreads her own annual mammogram — especially that windowless waiting room full of women in ill-fitting hospital gowns who are nervously waiting, too.
'Thank God it's only once a year'
“Meanwhile, I have a full practice, three kids, I’m text-messaging back and forth — thank God it’s only once a year,” she said.
In conventional busy mammogram centers, technicians perform dozens of routine screenings daily, piling up X-ray images that a radiologist reads later in bulk. Patients get the results days or weeks later.
Many physicians consider that process the most efficient, although research has shown that having a radiologist read mammograms immediately and give results during the appointment makes women feel much less anxious.
Malpractice concerns and low insurance reimbursements for mammograms have led to radiologist shortages in some places, and not all centers are equipped to offer same-day results for routine exams.
But Faulkner Hospital’s breast center in Boston is, with three radiologists reading mammograms full-time and a computer-assisted system that helps identify X-ray abnormalities.
Dr. Norman Sadowsky, a radiologist who helped create the program more than 30 years ago, said he’s given talks around the country promoting the same-day service but few centers have followed suit.
“This is the most anxiety-producing routine exam,” Sadowsky said. “You come in and you worry, and you worry until you get an answer.
“If we can get the patient an answer before she leaves, that’s the way to do it. You get a lot of kisses” instead of complaints, he said.
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