By Dr. Mercola
Throughout the U.S., there were over 130 million emergency room (ER) visits in 2013, 12.2 million of which resulted in hospital admission, or just over 9 percent.1 These numbers were a reflection of care prior to the Affordable Care Act that went into effect in 2013.2
By 2015 those numbers were rising, contradicting the prediction that ER visits would decrease with greater access to health care coverage.3 What had not been anticipated were the sheer number of people who would struggle to find a physician.
Consequently, more people were being seen in the ER, as wait times to get into a doctor's office may be up to two months. ER visits at Baptist Health in Lexington, Kentucky, rose by 10 percent in 2014 and almost 20 percent in the first months of 2015.4
As the number of ER visits rose, the number of patients requiring immediate attention declined, taking a toll on ER staff and equipment across the country. Has this changed patient outcomes after a visit to the ER?
Dr. Ziad Obermeyer from Harvard Medical School was the lead author on a retrospective study, uncovering a rise in deaths in otherwise healthy people after discharge from the ER.5
People Dying After Not Being Admitted Through the Emergency Room
Using claims data from the U.S. Medicare system, researchers focused on generally healthy people living in the community. People who were over age 90, who may be living in a nursing home, receiving palliative care or had an emergency room visit in the previous year, were excluded from the study.
The researchers counted the number of people who died within the first seven days after an ER visit, excluding those transferred from another hospital before being discharged from the ER. From the results they estimate a little over 10,000 relatively healthy people die each year within seven days of being discharged from the ER.6
The leading causes of death of the cohort sample included myocardial infarction, chronic obstructive pulmonary disease and narcotic overdose, largely in people whose ER visit was for a musculoskeletal problem.
These causes of death were related to the more common diagnoses in the ER, including dyspnea (shortness of breath), altered mental status and fatigue.7 Curiously, the highest number of deaths were from ERs that admitted the least number of patients.
Despite the fact that the patients who arrived at these hospitals were relatively healthier than those at other hospitals where the admission rate was higher, the patients suffered higher rates of death after discharge. Obermeyer commented on the discrepancy, saying:8
"In general, the high-cost, big academic hospitals tend to admit a lot of people. A lot of other hospitals, which are leaner, private and non-academic, admit fewer patients. I don't think this is a story about irresponsible, cowboy docs who are just sending people home to die.
I think it's just a reflection of how difficult the job is; people who work in ERs work incredibly hard, see a lot of patients and just have to make really an insane number of very, very important decisions with very, very little information."
Rural Settings Have Fewer Emergency-Trained Physicians
Another factor unearthed in the study were patients treated in rural hospitals had a higher death rate in the week following their ER visit. Not only are these hospitals less likely to admit patients from the ER, but these rural areas also had fewer doctors working.9 Obermeyer explained these results, saying:10
"Part of it is that there aren't enough doctors and human manpower to go around. Patients are getting far more complex, the technology we have available to us is getting more advanced, but we haven't kept pace in the human side of medicine."
Many of these rural hospitals don't have a dedicated emergency physician to treat patients, increasing the length of time before patients were seen and presenting a significant barrier to admission. According to Obermeyer:
"Once there's an evidence base for how to manage patients with this specific problem, we actually do it well. But it also highlights a lack of evidence for a lot of other kinds of patients.
Even though this is a really critical decision, both for cost and for patient safety, that we in the emergency department are faced with a lot, it's really understudied."
Elderly Face Functional Decline After an Emergency Room Visit
Another study evaluating care of the elderly after an ER visit found they were at greater risk of suffering a disability in the six months following the visit.11
To compare two groups of individuals, the researchers gathered data from over 750 elderly people who visited the ER and another 800 people with similar health conditions, who had not been treated.
At the start of the study both groups scored fairly low on a disability scale, indicating they were very physically functional. However, after treatment in an ER, patients scored an average of 14 percent higher on the disability scale six months post discharge.12
Over this 14-year study, home assessments were done every 18 months and phone interviews every month.13 The participants averaged 84 years old at the start of the study and lived in the community, not in a nursing home or assisted care facility.
The researchers also discovered those who had an ER visit were three times more likely to be admitted into a nursing home in the following six months, and twice as likely to die as those who did not have an ER visit.
Researchers also found that people admitted to the hospital during their ER visit had experienced greater negative health effects. Study co-author Dr. William Fleischman, emergency medicine researcher from the University of Maryland, commented:14
"The higher risk of disability following emergency department visits is likely related to the illness or injury that led these patients to seek care in the emergency department.
This does not mean that these patients should have avoided the emergency department or that they should have been hospitalized.
Rather, it suggests that older adults who are medically appropriate for discharge from the emergency department may benefit from the kind of discharge planning that often occurs in the inpatient setting."
The study was limited as it was not a controlled experiment, and included only patients insured under one health plan in a small urban area.
However, researchers felt the results should be a red flag to doctors and patient families that more attention needs to be paid to discharge planning from the ER. More at-home services also need to be provided to prevent ER visits.
Clinical Practice Guidelines May Reduce Number of Deaths
In the study evaluating the number of deaths in the first seven days after discharge from an ER, patients whose clinical symptoms were treated with a strict set of protocols had lower death rates than any of the other patients treated.15
Evidence-based, clinical practice guidelines are designed as a framework to help physicians make clinical decisions about patient care. Often they are formed after a systematic review of evidence and a comparison and assessment of the benefits and risks associated with treatment options, including alternative care protocols.16
However, while clinical practice guidelines are designed to help improve patient outcomes, not all physicians follow these guidelines.
Despite wide publication of some guidelines, they have had little effect on changing physician recommendations.17 The researchers discovered barriers to physician compliance were different, in different practice settings.
An analysis of Dutch general practitioners found similar results, and that physicians may respond better when the underlying evidence for the guidelines were more transparent.18
A study of doctors in Estonia discovered those with long-term clinical practice and in outpatient settings perceived more barriers to implementing clinical practice guidelines, including lack of transparent information about why the recommendation is made.19
In a recent study looking at pre-operative testing on cataract patients, researchers found ophthalmologists continued to order pre-operative testing deemed unnecessary.20
In this instance, physicians continued to order the same preoperative testing commonly done in 1995 prior to published guidelines. Lead researcher, Dr. Catherine Chen, anesthesiologist at the University of California–San Francisco, concluded, "In about 20 years, nothing has really changed in terms of physician performance."21
Inpatients Are Often at Great Risk of Sepsis
Infections that progress to sepsis in the hospital may increase risk of death. Researchers found the death rate of patients with sepsis was 10 percent compared to 1 percent among patients without sepsis.22 In fact, the same study found 50 percent of all in-hospital deaths were related to sepsis.
Recent research published in the Canadian Medical Association Journal proposes sepsis should be recognized as a distinct cause of death in hospitals around the world.23 Researchers argue that changing the focus on sepsis would potentially improve nutrition and hygiene and lead to the initiation of timely treatment.
Sepsis is a life-threatening condition triggered by a systemic infection, caused by bacteria, virus or parasite that ultimately affects the function of vital organs. In the U.S., as many as 50 percent of patients had sepsis at the time of their death.24
Interestingly, most of these patients were admitted to the hospital with a diagnosis of sepsis and did not acquire the condition while hospitalized. The cost of treating sepsis is high, topping $24 billion in 2014, with nearly 25 percent of all hospital charges attributed to the treatment of sepsis.
Sepsis is a condition that does not discriminate, as it affects all age groups, socioeconomic groups and men and women alike.25 There are groups who are more vulnerable than others, such as newborns and the elderly. Those who suffer with chronic diseases or have a weakened immune system are also at greater risk.
Successful results rely on early detection and rapid treatment. Through recognition that sepsis is a discrete cause of death, better clinical practice guidelines stressing recognition in the community and the ER may reduce the overall number of deaths.
Prevention: Often the Best Medicine
Preparation and better discharge planning may reduce both the number of emergency room visits and subsequent disability experienced by patients. Those admitted to the hospital with sepsis may also enjoy better outcomes with better planning. You can also reduce your personal risks by implementing the following suggestions:
• Have an emergency plan in place before you encounter an emergency. Being forewarned is forearmed. This means you should know the hospital where you want to receive care before you need to visit an emergency room.
• Reduce or eliminate lifestyle choices that negatively affect health. Start by eliminating smoking and reducing your alcohol intake. A reduction or elimination of all processed foods and sodas, and exposure to toxic over-the-counter medications and chemically laden cleaning supplies help to reduce your toxic load.
Reduce your sugar and net carbohydrate intake to optimize your mitochondrial health and reduce your risk for insulin resistance, type 2 diabetes and cardiovascular disease.
• Embrace choices that reduce your risk. You feel better when you are healthy and give your body the nutrients it needs to repair cellular damage and support your immune system. Use this list to develop a plan of action:
Optimize your vitamin D through sensible sun exposure
Eat whole, organic and non-GMO produce
Eat organic, certified grassfed meats
Get at least eight hours of quality sleep each night
Stay hydrated with clean, pure water
Do cardiovascular, strength training and core exercises each week
Get as much movement into your days as possible; consider a standing desk if you have a desk job
Eat a diet high in healthy fats, including macadamia nuts, avocadoes, coconut oil, butter, eggs and olive oil
Use green cleaning supplies or make your own at home
Optimize your gut flora by eating fermented foods every day
Eat plenty of raw foods
Regularly walk barefoot to ground with the earth
• Take a proactive approach to your mental health. When asked about how they live so long, centenarians (people who live beyond age 100) list a positive attitude and staying mentally active among their top reasons for living a long and healthy life. Overwhelmingly they cite stress as the most important thing to avoid.
The Emotional Freedom Techniques (EFT) is a powerful way to minimize the impact of stress in your life. Exercise, yoga, meditation and connecting with family are other means of achieving the same goal.
• Take defensive steps if you need emergency care. While the primary goal of the medical staff at a hospital is to ensure your health and safety, they are also human. This means you may want to take steps to prevent inadvertent mistakes. Bring someone with you who will double check the medications given to you and advocate for you, ask questions and stay aware of treatments and testing.
Prepare a list of any medications, allergies, vitamins and over-the-counter medications you take, as well as any medical diagnoses you have. Keep this list with you. In this way you won't need to remember these details when you need emergency care.