Rhode Island Hospital has seen a sharp rise in its emergency-room patient count since the April 5 opening of its $40-million, 51,000-square-foot emergency department, with roughly 1,000 more people going in each month than in the same period last year.
In June, for example, the ER treated 7,494 patients, almost 16 percent more than the 6,483 treated in June 2004, a chart provided by the hospital shows. If the recent patient volume continued for a full year, it would exceed 89,000 people. In fiscal 2004, 76,170 were treated.
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For insurers and many public health experts, seeing such a dramatic jump in ER patient volume can be troubling, because ER treatment is expensive and it’s not conducive to building the relationships with patients that are crucial to promote long-term health.
But even before Rhode Island Hospital opened its new ER, President and CEO Dr. Joseph F. Amaral had predicted a volume increase. He’d also stressed, however, that it wouldn’t be due to efforts to attract patients, but to pent-up demand that the ER would finally be able to meet.
Asked about the recent jump, Amaral reiterated that point.
“We built this emergency room because there was a desperate need,” he said. “Anyone who came here would tell you that.”
Nationwide, ER use has been rising – by 26 percent from 1993 to 2003, according to the Centers for Disease Control and Prevention, even though 12.3 percent of the nation’s ERs shut down.
With the state’s only Level I trauma center, sophisticated equipment and university-affiliated doctors, Rhode Island Hospital already gets an extra-large share of the most severe ER cases. But its size and central location have also made it the first choice of many less-sick patients.
When the hospital sought state approval for a new ER, officials predicted that the patient volume would rise by 3.5 percent each year. Starting with fiscal 2000 as a baseline, that would mean 87,325 patients in fiscal 2005 (which ends in September), and 103,714 by 2010. The new ER is designed to serve 110,000 patients a year.
Yet as it turned out, the hospital’s ER census didn’t rise steadily. In 2000, the year he became president, Amaral said, two work stoppages led to many patients being steered away from the hospital, and in 2001 a shortage of nurses also resulted in many ambulances being diverted.
In fiscal 2002, Amaral imposed a no-diversion policy, and he boosted staffing to meet the expected rise in demand. In a single year, the patient count jumped 7.9 percent, to 80,072.
In October 2002, however, construction began on the new ER, and the volume dropped again, to 76,792 for fiscal 2003, as traffic congestion and parking problems kept people away. The count dropped by another 812 patients in fiscal 2004.
But the demand didn’t dissipate; patients still needed care, but many just didn’t rely on Rhode Island Hospital to deliver it. So when the new ER opened, officials expected an increase.
“I would be disingenuous to say that if we weren’t seeing more patients than we did in 2002, I wouldn’t be disappointed,” Amaral said. “But that’s because people were coming here and couldn’t get in, so they were leaving without being treated.”
Amaral said he expects the patient volume to hold steady or rise a bit more, “because we do have better service.” Wait times for less-seriously ill or injured patients have dropped considerably, he said, and people are getting in and out much more quickly.
Part of that is due to the new ER’s size: It has 74 treatment spaces, up from 34 in the old ER.
But the ER now also has two separate entrances – one for the public, one for ambulances – and six units for different types of patients, from critical care, to fast-track, to a detox and psychiatric area. Combine that with the prettier environment, the new parking garage and the larger treatment areas, which allow for family members to stay with patients, and it’s no surprise that the ER patient satisfaction scores have shot up.
A Press Ganey report provided by the hospital shows the old ER’s mean scores had hovered in the upper 70s for the last two years, with a 78.1 score for the first three months of this year (out of 100). For April through June, the score was 83.6 – a big enough jump that the hospital went from about the 40th percentile for its class, to about the 90th (it has been as low as the 20s).
“This is why we did the emergency room, not (patient volume), and this is what I monitor,” Amaral said. “People should get the highest level of service.”
Colleen Foley, an assistant clinical manager in the ER, said patients talk about the difference, and the nurses hear about it in the community. Before, they used to get “lots of feedback” along the lines of “It was horrible. We waited forever. It was terrible,” she said. Now, “pretty regularly, I get people saying, ‘I met my mother’s brother’s cousin, and they said, I was there, and it was the best experience they ever had. It’s a wonderful facility.’”
Asked whether he’s concerned that making the ER too convenient will lead to even more inappropriate use, Amaral said he’s not going to discourage people from using it, and insurers and policy-makers should shift their attention to the root of the problem.
“I would prefer that they figure out why people are going to emergency rooms instead of doctors’ offices,” he said. “Because I don’t think there’s the capacity out there to take care of all the people who go to ERs.”
