Recently completed expansions and renovations:

• Stephens Memorial Hospital in Norway: New ER four years ago

• Rumford Hospital: New ER last year

• Maine General Hospital: Its two facilities in Waterville and Augusta each opened new ERs several months ago.

Expansion plans approved by the state:

• St. Mary’s Regional Medical Center: State has approved a $8.5 million plan (the cheapest currently on the boards in Maine) to triple its ER space. The hospital plans to fund-raise the money.

• Mid Coast Hospital in Brunswick: State has approved a plan for a multi-million-dollar ER expansion.

• Maine Medical Center in Portland: State has approved a plan to nearly double its ER capacity.

Expansion plans being discussed:

• Central Maine Medical Center: Will seek formal approval from the state early next year to expand its ER. The plan is for a $15 million to $20 million project; the hospital will use some money it already has and borrow the rest.

• Mercy Hospital in Portland: Renovated its ER two years ago and is discussing plans to expand.

Maine’s ER emergency

LEWISTON – It’s just after noon on a recent Monday, and St. Mary’s Regional Medical Center’s emergency room has just gotten slammed.

Two trauma patients. A guy from a car accident. A handful of mentally ill patients and addicts. People with various illnesses, injuries and levels of pain.

A man in jeans and an open-back johnny walks unsteadily down the hall. From a corner bed, a woman’s staccato snores are drowned out every few minutes by the sound of a man retching.

In a curtained cubicle at the far end of the ER, Florence Doe, 84, and her daughter, Diane, patiently wait for a doctor. Florence had been feeling sick and weak that morning. After she passed out, an ambulance brought her in.

“I’ve been here a couple of times this year,” said Florence, who’d been a nurse during World War II . “They give very good care. Very good care.”

Good care is what St. Mary’s prides itself on. But 17 years after it built its current ER, and about seven years after the department’s last expansion, the hospital says it needs a bigger, better place if that level of care is to continue.

It plans to spend – and has gotten state approval for – $8.5 million to triple the size of its ER.

And the Lewiston hospital isn’t alone.

• Less than two miles away, Central Maine Medical Center – struggling with its own 17-year-old facility – says it will seek state approval next year for an ER expansion.

• In Portland, Maine Medical Center plans to nearly double the size of its ER, while Mercy Hospital renovated its ER two years ago and is discussing plans to expand again.

• In Norway, Stephens Memorial Hospital got a new ER four years ago, while Rumford Hospital got theirs last year.

• Maine General Hospital overhauled and expanded two ERs – one for Augusta and one for Waterville – several months ago.

More patients come in every day, Maine hospital officials say. There are greater mental health issues. More medical technology to consider. Increasing demands for privacy.

They need the space, they say. Now.

During its worst days – days just slightly busier than that recent Monday – St. Mary’s moves its least serious patients from the ER back into the waiting room. It has 21 beds and sometimes that’s just not enough.

“The actual need is there,” said Nurse Manager Anita Lalonde.

Gurneys in the hall

On average, U.S. hospitals get 383 ER visits for every 1,000 area residents, according to the Maine Hospital Association. New England averages 439. Maine averages 540, ranking it fourth in the nation per capita.

And the number is growing.

Emergency room visits rose 26 percent between 1993 and 2003, according to a national survey. Local hospitals say their ER visits increase up to 8 percent every year.

National experts say a shortage of primary care may be to blame. Or a lack of health insurance. Or an aging population. No one really knows for sure.

In Maine, experts believe substance abuse and mental health crises are sending a greater number of people to the ER.

“Our behavior population has increased, my gosh, I don’t know how many fold. Maybe four or five,” said Marge Powell, a longtime nurse at St. Mary’s. “Some of it is truly sick, sick stuff. I’ve seen a psychotic child at 4 (years old).”

Maine experts also say high quality emergency care – and the immediate availability of that care – may be leading some patients to use the ER instead of a family doctor, even though ER visits are often more expensive.

“Consumer expectations have increased,” said Mary Mayhew, vice president of the Maine Hospital Association. “People don’t necessarily want to wait to get into a doctor’s office or squeezed into an appointment.”

But the ER’s popularity causes problems for both hospitals and patients. When an ER gets busy, wait times skyrocket. When people rely on expensive emergency care, health-care costs skyrocket.

Right now, capacity is the biggest problem, local hospitals say. When an ER can’t handle a sudden influx of people, patient privacy and medical care can suffer.

At Central Maine Medical Center, for example, patients end up lying on gurneys in the hall.

CMMC’s emergency room was built in 1990 to handle about 25,000 visits a year. It now gets 52,000 and is full “almost every day, usually by midday,” said spokesman Chuck Gill. The hospital wants to spend about $15 million to $20 million to expand the ER.

“We don’t want to get to the point where we’re not providing good care,” said Peggy McRae, nurse manager for the emergency department. (While still commonly referred to as ERs, most hospitals now call them emergency departments, reflecting their growth in size and the types of problems they treat – from sprained ankles to psychiatric patients.)

Of central Maine’s six hospitals, four have either built a new ER, dramatically expanded or plan to. The fifth, Bridgton Hospital, just opened its doors in 2002.

The sixth, Franklin Memorial in Farmington, has no immediate plans for an expansion, but officials expect the issue will come up.

“In the long-term plan, in the next three-to-five-year plan, it’s being looked at, that’s for sure,” said George Long, nursing manager for Franklin Memorial.

Rising costs

While expansions may help hospitals keep up with patient demand for ER services, there is a question of cost. When a hospital does a building project, patients often end up paying in the form of higher hospital bills.

Consumers for Affordable Healthcare, a Maine-based advocacy group, hasn’t tracked ER expansions in particular, but it does watch hospital expansions in general.

“That’s an issue we very much care about because it drives up costs,” said Policy Director Hilary Schneider.

Before hospitals spend millions to dramatically expand their ERs, she’d like the hospital industry to find out exactly why ER visits are increasing. She’d like to see doctors’ offices – many of which are now hospital-owned – provide an on-call doctor so patients don’t have to go to an ER after business hours. And she’d like to see ERs refer non-emergency patients to local primary care doctors rather than treating them, as long as the patients can wait.

She believes those changes could help ease the burden on ERs, without the expense of major expansions.

“Hospitals are a billion-dollar, several-billion-dollar industry,” she said. “They should be able to figure out this issue.”

In an effort to control health-care costs, Maine does require hospitals to seek state approval for any large building project. Four hospitals applied this year. Three of them asked for ER expansions.

All of the ER projects – at Mid Coast Hospital in Brunswick, Maine Medical Center and St. Mary’s – were approved. Each will cost between $8.5 million and $25 million.

St. Mary’s plans to triple its ER space with a design that calls for 30 exam rooms instead of 16 curtained areas, a second triage room, a separate ambulance bay for psychiatric patients and a decontamination suite. The current ER was built in 1990 to handle up to 25,000 visits a year. The hospital now gets about 30,000. The new ER will accommodate 37,000.

At $8.5 million, it’s the cheapest expansion of the three approved this year. The hospital will fund-raise the money, and officials say they won’t pass down the cost to patients.

“I don’t think it (the cost) will impact patients, especially those here,” nurse manager Anita Lalonde. “But they should be entitled to the very best possible care.”

CMMC will seek formal approval for its expansion early next year. To pay for the $15-million-to-$20-million project, the hospital will use some of the money it already has and borrow the rest.

“We need to have the facilities that match the demand for our services,” said Gill. “With the wrong facility we can’t guarantee patient safety and quality of care.”

Hospitals say they’ve tried to work around their ER issues, tried to put off expensive expansions.

Because primary care physicians seemed to be lacking in the area – a problem that draws patients to the ER – both CMMC and St. Mary’s routinely recruit family practice doctors to Lewiston-Auburn. Because non-emergency cases can quickly clog an emergency room, CMMC and St. Mary’s also offer separate fast-track areas for sprains, colds and other minor health issues.

They say they’ve also tried to nudge ER patients toward primary care doctors. At St. Mary’s, for example, the ER gives patients a card with the number of its physician referral line. The goal: Get ER patients to follow up with, and sign up with, a regular doctor.

“We do our best to get them out of that groove and get them into primary care,” said spokesman Russ Donahue.

But hospitals say demand still outpaces their ER capacity. Expansion, they believe, is their last best option.

“We probably should have done it five years ago,” said Gill at CMMC.

‘It’s always been busy when we’ve been here.’

Back at St. Mary’s, the ER quiets down.

It’s just after 1 p.m. and patients with minor problems have been treated and sent home. Three of the five psychiatric exam rooms have been cleared. The two trauma patients have been moved.

Of the 10 or so ER patients left, some are waiting for tests, some are waiting for doctors and a few, including Florence Doe, are waiting to be admitted. After examining her, Florence’s doctor still isn’t completely sure why she passed out.

As she and her daughter, Diane, wait for her to be moved upstairs, they talk about the hospital. Florence had visited the ER twice in six months, once for pneumonia and once for the flu.

“They get right at you,” she said.

Although she’s never had to wait long or go back to the waiting room during an ER rush, Florence and her daughter said they would support an expansion.

“It’s always been busy when we’ve been here,” Diane said.

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