Hospital emergency room makeovers on the rise

An 'unprecedented building spree, mirrored nationally and brought on by a variety of factors'

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With each passing year, it was getting more difficult to tell the difference between the waiting room at Sewickley Valley Hospital's emergency department and the one at the Greyhound bus depot.

That's not the view of some disgruntled patient. That's straight from the CEO's mouth.

"Sewickley was last renovated in 1976," said Norm Mitry, president and CEO of Heritage Valley Health System, which owns both Heritage Valley Beaver and Heritage Valley Sewickley, the new name for the former Sewickley Valley.

Both hospitals' ERs were undersized, overutilized -- and, ultimately, past their expiration dates, he said. That's why the nonprofit health system spent more than $26 million two years ago improving the hospitals and expanding the emergency departments.

If this story sounds familiar, that's because it is: Across southwestern Pennsylvania, emergency rooms have spent the last five years expanding, improving and, in many cases, rebooting from scratch.

It is, experts say, an unprecedented building spree, mirrored nationally and brought on by a variety of factors. But while hospitals say the construction was driven by a need to upgrade aging facilities, insurers and industry watchdogs worry about ER arms races, mainly because ER care for routine injuries is often four times the cost of the same care when it's dispensed at a doctor's office or urgent care clinic.


The rundown:

The West Penn Hospital in Bloomfield is reopening its emergency room next year, with 24 beds. In Monroeville, West Penn Allegheny Health System plans to expand its emergency trauma center capabilities at its Forbes Regional hospital, following a complete 2006 rebuild and a January 2011 expansion that added eight beds and four new physician triage rooms as well. Meanwhile UPMC's new Monroeville campus also will have a full-service ER, with 22 emergency bays.

Other suburbs have been getting new ERs, too. The Washington Hospital in Washington County opened a new, 24,000-square-foot emergency services wing in 2009, growing from 22 beds to 38, part of a larger $69 million expansion. Butler Memorial Hospital opened a new ER in 2008, 50 percent larger than the old one, followed by another 2010 facelift.

Indiana Regional Medical Center has redone its ER, adding 20 new beds and three trauma rooms. St. Clair Hospital in Mt. Lebanon spent $13.5 million on its 2008 emergency expansion. At WPAHS's Allegheny Valley Hospital, the emergency department was renovated in 2010, with a 20,000-square-foot addition, and at the system's Canonsburg General, the ER was rebuilt in 2006.

UPMC opened a new ER at its Passavant-Cranberry location in September 2008, triple the size of the old department. The health giant is also redoing emergency rooms at UPMC Presbyterian and Mercy.


'Woefully older' buildings

"A lot of the hospitals [were] just old, and a lot of the ERs just weren't functional," said Tom Aubel, spokesman for the Hospital Council of Western Pennsylvania, a lobbying group whose membership includes most of the region's non-UPMC facilities. "Our age of facility in Western Pennsylvania is woefully older than most other parts of the country."

The average "plant age" in the western half of the state, according to the council, is about 12 years old. ("Age of plant" is a financial rubric hospitals use to measure the age of all fixed assets). That doesn't sound terribly old, but nationally, the average is about 10 years, and on the West Coast, about nine years.

Even as the region's ER facilities aged, they decreased in number. Emergency departments at UPMC Braddock, UPMC South Side and WPAHS's Suburban campus in Bellevue disappeared in the last few years. The region also lost an ER in Aliquippa and one in Lawrenceville, via the buyout of the St. Francis system.

It's part of national trend, especially in urban areas: From 1990 to 2007, 933 out of 2,814 urban acute-care hospitals -- one-third -- eliminated their emergency departments or the hospitals closed altogether, according to research by the University of California San Francisco.

Couple the regional closures with an overall increase in ER admissions -- up about 2.3 percent from 2010 to 2011, which followed similar increases in previous years --and all of it added up to a need for upgrades, said Fred Peterson, the vice president of emergency management at the hospital council.

"There's no question there's been a lot of construction," he said. "Many hospitals are just reaching the age where they can't keep retrofitting. ...There's [a] growing mismatch between resources and demand."

With new ER space comes new expense -- not just the construction costs, but also the cost of staffing. Is it a cost that's necessary, especially at a time when "express" medical centers and urgent care clinics are gaining market share? How much of the construction is driven by need, and how much by a general arms race mentality?

"People in Butler are not likely to drive 20 miles or more" to another hospital just because they don't like the way the hospital's ER looks, said Kevin Stansbury, vice president of business development at Butler Memorial.

Yet in competitive markets, appearances can matter more.

"The health care consumer is a much more savvy consumer" than a few decades ago, said John Schrott, president of IKM Inc., the Downtown architecture firm that has planned several of the region's new ERs. "As designers, we want to create the best patient experience," from aesthetics to parking to functionality, he said.

Is there an element of keeping-up-with-the-Joneses to all of the ER upgrades?

"The administrative suite struggles with that all the time, and not just the regarding emergency facilities," Mr. Schrott said. But more important than the aesthetics of the place is whether the new ER actually works better, for both the patient and the employees.

At new, IKM-designed ERs, for example, nursing stations are no longer centralized. Instead, nurses are assigned to pods, which cuts down on the number of steps they have to take each day, reducing the time it takes to move from the nursing station to the supply closet, then back to the bed.

New ERs also try to cut down on average wait time for patient. What might have been an average 30-minute wait time for visitors at older facilities can be cut in half if the intake system is better designed.


'Somebody's going to pay'

While hospitals view the new ERs as necessary expenditures, they come at a cost that will ultimately be borne by taxpayers, patients and the employers that subsidize an insurance plan.

"When you're seeing an outlay of expenditures like this, somebody's going to pay," said Chris Whipple, executive director of the Pittsburgh Business Group on Health.

ER investments aren't a bad thing per se, and makeovers often improve efficiency and care, said Harold Miller, executive director of Pittsburgh's Center for Healthcare Quality and Payment Reform.

But those improvements can't mask the fact that ERs are an expensive place to get care to begin with and ought to be used as a last resort, not as the gateway to the health system. Some studies show as many as 40 percent of patients' ER visits are either unnecessary -- that is, they could have been more cheaply or effectively treated in another setting -- or preventable had the patient received better primary care on the front end, Mr. Miller said.

Hospitals, on the other hand, say they're simply reacting to the health care market's retail, on-demand trends, as well as the desires of insurers and other payers.

"There's been a transition in how we do medicine in acute care," said Thomas Pangburn, director of Heritage Valley's emergency services. "Rather than a triage unit -- now, the government and third-party payers don't appreciate that approach -- we've become a short-stay diagnostic unit."

ERs now have X-ray machines, CT scanners and other equipment that used to be located down the hall or on another floor. It makes for faster triage, Dr. Pangburn said, and fewer long ER layovers.

It also makes for a re-thinking of how hospitals operate, trying to manage increasing ER flow even as inpatient beds throughout the rest of the hospital go unfilled. Only one in five ER visits result in an impatient admission in this region -- or roughly 158,000 out of 753,000 ER visits in Allegheny County from 2009 to 2010 -- and total hospital bed occupancy rates in the region run at about 70 percent.


Bill Toland: btoland@post-gazette.com or 412-263-2625.


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