Why We Don't Rank Emergency Room Care

Another query I get time and again, most recently this morning, is why we don't rank hospital emergency departments. Funny, I don't recall anyone asking except emergency physicians, but it's a fair question—especially at a time when these departments are expected to deal immediately and capably with outbreaks of infectious disease and the aftermath of natural disasters and terrorist attacks, in addition to the usual gunshot wounds, car-crash victims, feverish babies, and accidental poisonings.

Let's get the quick and most obvious answer to the question out of the way. Your 10-year-old son, who has never met a tree he didn't want to climb, is on the ground, moaning, his leg bent at an unnatural angle. Or your father is sweating, his skin is gray, and he says he feels painful pressure in his chest—a possible heart attack. Minutes matter. Will knowing a hospital's emergency ranking help get your son or father better care?

No. The rescue crew has standing orders to take patients to the closest emergency room, and whether or not it is ranked in Best Hospitals or anywhere else is irrelevant. They will be diverted to another hospital only if the ER has a crush of urgent cases or there's a particular medical reason to take them elsewhere—perhaps a pediatric orthopedist who can expertly treat a child's compound fracture is on the premises at a hospital not much farther away.

Moreover, emergency care is local. The rankings are national. Say you live in Cincinnati. How are you helped by rankings showing that an ER at a hospital in St. Louis or Detroit outranks any ER close to you?

And even if we did decide to rank hospitals on the quality of their emergency care, what reasonably objective and meaningful standards would we apply? ER death rates, if they were available (they're not), would be impossible to interpret—how can an ER be blamed for not saving the victim of a stab wound to the heart? I have listened many times to directors of emergency services tell me why we should include their specialty. I give them the explanation above about the local nature of ER care, but I also tell them I don't know what yardsticks we would use anyway. I'll get back to you soon, each doc says confidently. None ever has.

Are we in a rut? Is there a fresh argument, backed up with data, that we aren't thinking about? Tell us. Our minds and ears are open.

Next: when good hospitals do bad things.