More and more patients are leaving California emergencies prematurely as waiting times increase



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Emergency room patients are leaving more and more California hospitals against the advice of a doctor, and experts say cluttered emergency rooms are probably to blame.

In 2017, approximately 352,000 emergency room visits in California ended when patients left after seeing a doctor, but before the end of care. This represents a 57% increase, or 128,000 incidents, compared to 2012, according to data from the Office of Statewide Health Planning and Development.

Another 322,000 potential patients left the emergency without consulting a physician, compared with 315,000 of this type in 2012.

Several hospital administrators have stated that overcrowding was probably at the root of this trend. Emergency room trips to California have increased by almost 20%, or 2.4 million, from 2012 to 2017.

In addition, waiting times in emergencies have also increased for many during this period: in 2017, the median waiting time of patients before admission as hospital patients in hospitals from California was 336 minutes, more than 5:30. This represents a 15-minute increase over 2012, according to federal centers for Medicare and Medicaid services. The median waiting time for people discharged without admission to the hospital decreased by 12 minutes during this period, but it still exceeded two and a half hours in 2017.

Wait times in California remain above the national average. In 2017, the median duration of an emergency stay before admission for inpatients nationwide was 80 minutes lower than the median stay in California. Four states – Maryland, New York, New Jersey and Delaware – had even longer median wait times.


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Growth among early quit patients in California was faster than growth in the total number of consultations. About 2.4% of emergency department trips in 2017 resulted in an outpatient discharge in the opinion of a physician or abrupt cessation of care after consulting a physician, compared with 1.8% in 2012 .

"Most of the patients are sick but not seriously ill," said Dr. Steven Polevoi, medical director of the Emergency Department at the Helen Diller UCSF Medical Center in Parnassus Heights. "Emergency care is not always equivalent to fast care."

When a patient leaves the emergency after consulting a physician but before the latter authorizes him to leave, the Office of Planning and Development of Health in all of the state qualifies this meeting as "departure against medical advice or interrupted care". The definition includes meetings where a doctor explains the risks to the patient and asks the patient to sign a form, but also to cases in which the patient simply stops caring and leaves the door.

Patients who leave the emergency room too early "deliberately expose themselves to a higher risk of morbidity and even mortality," said Polevoi, a point taken up by other doctors.

Dr. Veronica Vasquez-Montez, Emergency Room Medical Director of the Good Samaritan Hospital in Los Angeles, said she was sometimes in a "difficult conversation" with sick patients who were planning to leave the ER. often evoking pressing responsibilities.

"If you die of it," she said to them, "you will not be good to anyone, you will not take care of yourself."

One of his recent patients was at high risk of major stroke, but insisted that he had to leave the emergency to take care of his pet.

"Guess why he came back? A major stroke, "said Vasquez-Montez, also clinical assistant professor at the Keck School of Medicine at the University of Southern California.

Compared to all emergency patients, those who went against the advice of a doctor were more likely to be men; people aged 20 to 39; and according to state figures, and on Medi-Cal, the government's program of insurance for the poor. They were also more likely to complain mainly of nonspecific symptoms such as chest pain or coughing.

The counties of Fresno, Shasta, Yuba, Kern, San Bernardino and Tulare had the highest proportion of emergencies in 2017, which resulted in the departure of the patients against the opinion of the community. a doctor or sudden stop of care. The figures indicate that each of these counties recorded more than 4% of patients in the emergency department.

Between 2012 and 2017, the number of emergencies in the Fresno County emergency rooms increased by nearly 95,000, or 37%. At Fresno Regional Medical Center, about 9% of emergencies ended with the departure of a patient too early, more than triple the rate recorded across the country.

The Regional Regional Medical Center is one of the most popular hospitals in the state. He recently put in place a "Provider at Triage" program that places caregivers in the reception area with patients, said Dr. Jeffrey Thomas, Chief Medical Officer and Hospital Quality Manager. . Internal hospital data now shows that less than 2% of patients go against medical advice or abruptly stop their care.

"When patients enter the emergency room themselves, they are seen for about 5 minutes by a registered nurse and, on average, by a provider within 30 minutes of arrival," Thomas said in a statement.

When a sick patient is about to leave the emergency room, the doctor must determine why he wants to go there, make sure that the patient is able to make an informed decision, involve the friends and the family, explain the course of treatment and, if nothing works. , hold fast follow-up care, said Dr. Jay Brenner, Medical Director of the Emergency Department of the Upstate University Hospital-Community Campus in New York and co-author of several studies on patients who are going against an opinion medical.

"When someone asks to leave," said Brenner, "this must be a priority that lies just below a cardiac arrest."

This story was produced by Kaiser Health News, which publishes California Healthline, an independent editorial service of the California Health Care Foundation.

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