The Nearest ED is How Far?

Carrie Vaughan, for HealthLeaders Media, April 29, 2008

I was going through my daily ritual of scanning the news when the headline “Duh! Science confirms the obvious” caught my eye. What I found was a number of studies trying to scientifically prove conventional wisdom, such as vacations are better without your cell phone, teenagers drink to have fun, and you catch the flu in winter.

I paused when I got to, "Long ambulance rides make you more likely to die." Not because it is an earth-shattering revelation—if you're having a heart attack and it takes you 50 minutes to get to the nearest emergency department versus 15 minutes, you're likely to incur more damage, of course. The story caught my eye because the number of emergency departments has decreased by 14% since 1993, according to the American College of Emergency Physicians.

The study, "The Relationship between Distance to Hospital and Patient Mortality in Emergencies: An Observational Study," researched four British ambulance services and determined that every six miles between the patient and hospital increased the risk of death by 1%.

I am sure that a similar statistic holds true here in the United States. Not the best news for rural America when you consider the number of EDs has decreased by 425 between 1993 and 2003 while the number of ED visits has increased from 90.3 million to 113.9 million during the same time period, according to the Institute of Medicine.

The uninsured certainly play a large role in the spike in ED usage. But hospitals have also seen an increase in the number of people with insurance who turn to the ED when their primary-care doctor is unavailable. It's no wonder the nation's emergency system as a whole earned a C- from ACEP, which posts grades for every state's emergency system based on access, quality and public safety, public health and safety, and medical liability. While no state earned a failing grade, 12 states--Alabama, Arizona, Arkansas, Idaho, Indiana, New Mexico, Oklahoma, South Dakota, Utah, Virginia, Washington, and Wyoming—weren't too far off, receiving a D+ or D.

I read about communities every week struggling to get a hospital approved in their town to improve access to quality healthcare for their residents. Personally, I would be happy to have an emergency department just 10 minutes away from my house, as well (which may soon be the case). Yet, I also read about community hospitals closing because they don't have the volumes, payer mix, or staff to be successful. Take New Jersey, for instance. Of the state's 78 hospitals, four hospitals closed in the past 18 months, four others announced plans to close, and five filed for bankruptcy protection. Twenty years ago, the state had 112 hospitals. This seems to suggest that New Jersey had too many hospital beds. Now, hopefully, New Jersey's other community hospitals will be stronger—at least that's what the state's health commissioner says.

No town wants to see its hospital close, and others would like nothing more than to build a hospital for its residents. But for those struggling to keep their hospital open or get approval for a hospital in their neighborhood, what options are there? The critical-access-hospital designation helps provide healthcare to some of the most remote and vulnerable areas. Yet not all facilities qualify. So how can our healthcare system improve access to emergency medical services?

I am reading more and more about freestanding EDs. Advocates hype the convenience for patients, increased access to emergency services, and their ability to offset overcrowding in nearby hospitals. But critics question their limited services and their impact on healthcare spending. I wonder how these facilities will impact nearby community hospitals. Will these facilities force more community hospitals to shut their doors? Can community hospitals and freestanding EDs work together successfully?

It has been said that EDs are the gateway into the hospital, so what happens when fewer people stroll through your doors, opting to go to a freestanding ED closer to home? I don't have the answers. But I am curious what you think about freestanding EDs. Will we continue to see more of them? What impact will they have on community and rural hospitals? After all, who wants to travel an hour to an ED when they are having a heart attack?

Carrie Vaughan is editor of HealthLeaders Media Community and Rural Hospital Weekly. She can be reached at
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