For heart attacks and more, big ERs thump small ones

Heart attack patients admitted to hospitals after first being treated in giant emergency rooms are 25 percent less likely to die in the hospital than those treated in smaller ERs.

“It’s not like you can go and shop around for a hospital in the midst of a health crisis,” Keith Kocher, assistant professor of emergency medicine at the University of Michigan Medical School, said. “The bottom line for everyone is that it really does matter where you get your emergency care.”

In a nationwide study of emergency room performance, Kocher and other University of Michigan researchers analyzed the records of 17.5 million patients who were admitted to a hospital from an ER with eight high-risk conditions – particularly those where fast care is critical. 

In addition to heart attack, Kocher found similar differences in survival for respiratory failure, renal failure and sepsis. There was little or no difference for stroke or pneumonia.

“Is it about the protocols? The coordinating of care? The timeliness of the interventions provided? Familiarity with knowing how to care? We don’t know the answer,” Kocher said.

Overall about 3 percent of the studied patients died in the hospital. But those admitted from smaller ERs were about 10 percent more likely to die.

It wasn’t just the small ERs. Kocher found a “stepwise decline” in deaths for each increase in ER volume, from those admitting 1,000 patients per year to those admitting more than 15,000. The best performing hospitals were large, urban teaching centers.

An estimated 24,000 deaths could be prevented each year if all ERs performed at the highest standard.

The results were published Wednesday in the Annals of Emergency Medicine.

Robert Shesser, chair of the Department of Emergency Medicine at the George Washington University School of Medicine and Health Sciences, said that the likelihood of death has “little to do with the ER” and more to do with the hospital it's attached to.

He was not involved in the study.

“Small emergency departments tend to be in small hospitals. Small hospitals tend to not have the full range of services that a large hospitals have.” Shesser said. “If you took the same physician from a busy hospital to a remote one, that individual is going to have worse results in the smaller hospital.”

The role of emergency medical services is to direct patients to the closest hospital that best serves their needs. But if it is possible to choose a hospital, Shesser said its best to go where you’re well known. Otherwise, medical personnel have to start from scratch.

Without more research, Kocher said he could not recommend patients change how they seek medical care.

But it does raise “fresh questions” for policy makers and administrators.

“It’s clear that what ER and what hospital delivers your care can make a big difference on your outcome,” Kocher said. “We need to understand what that is to get hospitals up to a high performance level.”

Reach reporter Gavin Stern at or 202-408-2735. SHFWire stories may be used by any news organization that credits the SHFWire and gives the reporter a byline. 

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