Joliet's Presence Saint Joseph working to combat emergency department overcrowding

JOLIET – One day in early September, a man walked into the emergency department at Presence Saint Joseph Medical Center in Joliet.

A department clinician assessed the man’s complaints of a cut finger, then went through his medical history and did a routine exam.

When the clinician pressed the man’s midsection, the man felt pain.

It was a lacerated liver. He could have died if not for the cut finger.

“You learn to respect what comes through the front door,” said Dr. Jerry Oliaro, interim medical director at Saint Joseph’s emergency department.

But when 50,000 to 60,000 patients a year come through that emergency room door at Saint Joseph, some may be waiting for hours, depending on the severity of what brought them in. This is common at hospitals across the nation.

Hospitals such as Saint Joseph have been dealing with emergency department overcrowding for years. National articles and studies have called it a problem since the 1980s or earlier, while it's been referred to in recent years as a crisis.

Billions of federal dollars are being devoted to bolstering primary care access, while organizations such as the American College of Emergency Physicians continue to raise awareness about the issue.

Locally, the three emergency facilities in Will County totaled 24,081 nonemergency visits in the 12 months before September 2015, according to a health needs assessment from the Will County Health Department.

Nonemergencies include fevers, sore throats, coughs, earaches, toothaches, minor cuts, sprains and more. For these ailments, health care professionals recommend patients go to a “medical home,” coordinated through a primary care physician.

But for various reasons, people won’t or can’t get to a medical home.

Saving lives, even when a patient may have come in for a minor ailment, happens all the time in the emergency department. That’s why Oliaro would never turn away a patient, no matter how minor their symptoms.

It’s part of the hospital’s mission.

Saint Joseph has a mortality rate of 0.76, the same as Northwestern Memorial Hospital and better than Rush University Medical Center's rate of 0.81. The lower the number, the better. The national average is 1.0, according to MayoClinic.org.

Who’s seen first?

As one of the busiest emergency departments in the state and the only one in Joliet, Saint Joseph has averaged more than 175 emergency patients a day since the beginning of 2016, with about 50 of them arriving daily by ambulance.

Upon arrival, patients are evaluated by the department’s most experienced clinician and given an acuity level between one and five.

Level 1 is for people on the cusp of death, such as trauma victims, while those with minor ailments, such as strep throat or a twisted ankle, receive a level of 4 or 5.

The patients are then treated by staff based on their acuity level. Someone who broke a finger will probably wait a lot longer than someone having a heart attack.

So far in 2016, 76 percent of Saint Joseph patients who access care through the emergency department are at or above the midpoint for acuity. The breakdown is as follows: 2 percent are level one, 26 percent are level two, 48 percent are level three, 20 percent are level four and 1 percent are level five.

The cause of overcrowding

When a mother walks into the emergency department at 3 a.m. with a child who might have strep throat, it’s usually for good reason, Saint Joseph Director of Nursing Annmarie McDonagh said. The mother might not have insurance and access to a primary care physician.

If she does have insurance, it’s not a guarantee she can see her family physician the next morning.

She might be waiting several hours in the emergency department if staff is tending to people with severe ailments. But at some point, she and her child will get seen and taken care of.

“We’re the safety net,” Oliaro said. “We’re open 24 hours a day, seven days a week and 365 days a year for everyone who needs help.”

A shortage of primary care physicians across the country is one reason for emergency department overcrowding, Oliaro said, while McDonagh noted that even with “good insurance” it can take two weeks or more to see a primary care physician.

The shortage is expected to grow, according to a study titled "The Complexities of Physician Supply and Demand: Projections from 2013 to 2025," completed at the request of the Association of American Medical Colleges.

Total physician demand is projected to increase by up to 17 percent come 2025, which will exceed supply by a range of 46,000 to 90,000 physicians. An aging and growing population will lead to the majority of the physician demand, the study stated.

While medicine has improved to the point that life expectancy in the United States is, according to the Centers for Disease Control and Prevention, at an all-time high of 78 years, this means people are living longer with chronic illness and need to be treated.

The Association of American Medical Colleges study states that, because physician training can take up to a decade, a physician shortage in 2025 is a problem that needs to be addressed immediately.

Oliaro, noting other studies on the topic, said there are several factors leading to the shortage is the lack of medical students pursuing a primary care career. With rising tuition costs, health majors ask themselves an important question.

“Do I want to leave medical school with a lot of debt, or start making money sooner?” Oliaro said.

Billions in incentives have been invested in recent years toward expanding the primary care workforce, according to the U.S. Department of Health and Human Services.

But, for now, when those aging patients who are in part the cause of the physician demand come to the emergency department, staff is treating them for an episode related to an underlying or ongoing condition rather than the condition itself, which should be handled by a primary care doctor.

McDonagh said more than 60 percent of Saint Joseph emergency department patients are 65 or older and often have chronic illnesses.

Illinois Hospital Association spokesman Danny Chun said emergency department overcrowding has been an issue “for years” but admission totals fluctuate from year to year.

One reason for overcrowding, he said, is that people who don’t have a medical home tend to use the emergency room as a first and last resort, whether it be for episodes related to chronic illnesses or a bad cold or flu.

“The emergency room is not necessarily the most appropriate or best place to get that care,” Chun said.

Filling the ACA gap

The Association of American Medical Colleges study found that full implementation of the Affordable Care Act will account for about 2 percent of the 17 percent growth in physician demand projected by 2025.

Dr. Gary Lipinski, chief medical officer of Presence Health’s south suburban region, said the ACA has given people health care coverage who wouldn’t otherwise have it.

And while it’s great for catastrophic health needs and guaranteeing one primary care visit per year, he said it lacks in preventative care.

Chun said there’s about 1 million people in Illinois who now have health care because of the ACA who didn’t have it prior to 2014. But because most of these people never had insurance, and as a result no ongoing primary care, they may not be aware of all their options.

“The default, again, is to go to the emergency room,” Chun said.

Lipinski said some thought emergency room visits would decrease as a result of the ACA, but they haven’t. In some cases, they’ve increased. He said people may be more comfortable going to the emergency room now that they have insurance.

He said hospitals have to find a way to get patients out of the emergency department and connected to physicians in the community.

“A lot of it has to do with care coordination,” Chun said. “Across the board, people are in agreement that we need to do a better job of coordinating care.”

Addressing overcrowding in Joliet

Local efforts are also being made to address the issue. Since that September afternoon, Saint Joseph has opened a new triage center adjacent to its emergency department waiting room.

It may come as a bit of a surprise to the public, McDonagh said, because the triage center was made possible by reconfiguring existing space. There weren’t big bulldozers and cranes on site.

The triage center, made possible by the Presence Health Foundation’s fundraising effort, seeks to improve patient satisfaction and reduce wait times. To date, just over $1 million of the foundation’s $2 million goal has been raised.

The donations have ranged from $100,000 to a few dollars. They included contributions from a large percentage of Presence’s employees.

The vast majority of patients who visit the emergency department are now routed through the triage center. The exceptions are those of extremely high acuity, such as severe trauma or unresponsiveness. Those patients are brought directly into trauma rooms.

Other patients who are of low acuity, such as those with minor fractures, may bypass the triage room and be fast-tracked into an express care area. Mid- to low-acuity patients are treated and released from the triage center and mid- to high-acuity patients are seen in the emergency department.

“We’re extremely excited about it,” McDonagh said. “The new triage area will help fast-track things and get more people with lower acuity out the door in 90 minutes or less.”