University of Iowa Health Care tackles growing demand for emergency care

IOWA CITY — The number of Eastern Iowans needing or wanting emergency care has soared over the last two decades — as has the severity of the health issues patients are facing — cramping emergency rooms, crowding wait rooms and compelling hospitals to expand, renovate and build.

That includes University of Iowa Health Care, which in the spring will increase its emergency room count to three — including its main-campus ER west of the Iowa River in Iowa City; the former Mercy Hospital ER east of the river in Iowa City it acquired through a bankruptcy sale this year; and an ER attached to the new North Liberty hospital nearing completion.

“The emergency department at North Liberty will treat the same types of patients with the same spectrum of disease that we currently see at our university and downtown campus locations,” said Hans House, director of emergency medicine services at the UIHC North Liberty campus. “We will be ready for patients of all ages, including children.”

On the main UIHC campus — which has taken the brunt of the area’s ER-visit spike, given its ability to treat the sickest and highest-acuity patients — the emergency room is undergoing a $37 million renovation and expansion, phase I of which wrapped this month.

After the full expansion and renovation anticipated by next winter, the main UIHC ER will have more than a dozen additional treatment rooms — bringing it to nearly 60 beds — a new triage area and more space for assessing and treating pediatric patients and those with mental health needs.

The project aims to improve the department’s capacity, efficiency and patient experience — which has suffered due to long wait times and other crowding issues.

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“It's just overwhelming at times,” UIHC Emergency Departmental Executive Officer Andrew Nugent told The Gazette about the university’s ER traffic. “And it really depends on the amount that is coming from outside institutions. Being the tertiary center, we take an enormous number of transfers into the hospital. … There are days when everybody's trying to send us patients because they're all sick, and we're the only place that can handle a lot of these things.”

The university’s most recent Board of Regents report on its emergency room use showed wait times rose about 40 percent from 2018 to 2022, while its emergency room-to-emergency room transfers from other hospitals to the UI climbed 33 percent during the period. The average length of stay in the UI ER increased from under 4.5 hours to over five.

While a typical wait time at the UIHC ER is between one to two hours, the wait time at the former Mercy ER — now called UI Medical Center Downtown — often is only minutes.

Adding that space to its emergency repertoire — in addition to the new North Liberty emergency room — will allow the university to better triage its patients based on severity and specific needs.

“We can kind of work synergistically to get the sickest patients here” at the main campus ER, Nugent said.

‘In the hallway quite a bit’

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The first phase of the main campus ER project was focused on a south and vertical expansion — moving a relatively new “crisis stabilization unit” from the seventh floor of the John Pappajohn Pavilion to the second floor of the emergency department, where many with mental health needs first present.

“This move is designed to improve the speed and effectiveness of the care we provide patients experiencing a mental health emergency, as well as enhance efficiencies for staff,” according to a UIHC summary of the upgrade.

The upgrade also created a new adolescent-specific stabilization unit. That, according to the university, will streamline treatment for pediatric patients having a mental health crisis and allow the university to care for them in a “much more humane way.”

“One of the side effects of boarding and overcrowding is that our patients are in the hallway quite a bit,” Nugent said. “And so hopefully this alleviates that. Our mental health patients will have rooms. And they're being specifically built so they're safe for mental health patients but can be used multi-functionally.”

Both of those new units are opening this month, when phase II of the ER expansion is beginning — creating a larger pediatric emergency space on the north side that will include two resuscitation rooms, a procedure room and a triage room.

“And we’re going to have a waiting room for the kids, which is great — so they don’t have to be next to the adults that are sick and coughing, or vice versa,” he said.

On a 60-acre plot in North Liberty, the university’s new $525.6 million, 469,000-square-foot hospital aims to absorb some of the visits to the main UIHC ER. The university expects 55,000 visits there this year — up 140 percent from the about 23,000 visits 25 years ago.

And while the new hospital itself will house the UI Department of Orthopedics and Rehabilitation and lean heavily toward orthopedics care, its ER will be capable of responding to any type of emergency.

“This will be a fully functional emergency department with the same equipment, technologies and capabilities available at the downtown campus (emergency department),” according to Ali Harmon, director of emergency medicine and transport services in the UI Department of Emergency Medicine. “It will be available to anyone needing emergency treatment.”

The new North Liberty ER will have 14 emergency care rooms, including two for behavioral health patients; a designated trauma and resuscitation room; haz-mat space for patients needing to decontaminate from hazardous materials; an isolation room for patients with infectious diseases; and board-certified ER doctors and nurses.

The North Liberty emergency department will be designated a Level 4 trauma center — providing advanced trauma care and life support “in preparation for transfer to a facility that provides tertiary-level care and a broader scope of surgical, specialty, and subspecialty services.”

Patients needing that higher level of care will be transferred to the UIHC main campus ER, designated a level 1 trauma center, or to the Downtown Campus, a level 3 trauma center.

“The North Liberty ED won’t include all the specialty care teams on-site that we have on the university campus,” Harmon said. “That’s really what impacts a trauma center’s level designation. For patients who come to the North Liberty ED needing subspecialty care, we’ll transfer those patients to the university campus or downtown campus, depending on the care they need.”

‘Spreading out of the community visits’

Although UIHC doesn’t have much control over where patients decide to go for emergency care — aside from educating them on which site is most appropriate for their specific need — ER doctors now will be able to coordinate transfers where necessary using an up-and-coming internal ambulance system, Nugent said.

That system hasn’t officially been announced or come online, but Nugent said the goal is to have it up and running before the spring opening of the North Liberty hospital.

“So that we can get people effectively from here to downtown, and then we’ll just add North Liberty to the system,” he said.

Patients can help and avoid transfer by doing “some self-selection” — heading, for example, to North Liberty for a broken bone, to the downtown campus for a high fever or to the main UIHC ER for trauma or a life-threatening issue.

“But if you’re really hurting, go to the closest spot, and that’s fine,” Nugent said. “Because then we’ll get you to the right spot.”

Once the university has its ER trio online, Nugent said he expects to see some “spreading out of the community visits.”

“I would see wait times hopefully go down for everyone at every location,” he said. “I think the number of admissions still coming to the main campus is going to be the same, if maybe not higher, because we're going to find out people are ill and getting seen faster.”

Part of the university’s ER crowding issue has to do with its inpatient bed capacity and the fact that so many of its emergency patients need to stay overnight. Where an average community hospital reports a 12 to 14 percent admission rate from its ER, the university’s ER admission rate is 33 percent, according to Nugent.

The university has 889 inpatient beds on its main campus, including 205 pediatric beds in its UI Stead Family Children’s Hospital; 234 beds at its downtown campus; and it will add up to 48 inpatient beds in North Liberty. The hospital also is planning a new 842,000-gross-square-foot inpatient tower costing more than $1 million, including multiple floors of 48 beds each.

But completion of that tower will take years.

“So we're still going to have some of those issues where we need to get people admitted,” Nugent said. “We don't know the impact of moving some of our inpatient capacity out to North Liberty, and we're getting better at sending some downtown, so hopefully that evens out a little bit.

“But I don't want to have to wait for a new inpatient tower to make everything better,” he said. “So we're constantly working on the efficiency of things.”

Other expansion

Although the university is planning significant upgrades to the downtown campus it acquired from Mercy Iowa City — with expectations to spend “far” more than $25 million over time — initial plans include roofing upgrades and operating room renovations.

“I think, first of all, they’ve got to get the building in shape,” Nugent said about the prospect of expanding the downtown ER. “And then they’ll probably have some discussions about whether they need to expand or not.”

UI Health Care isn’t the only hospital system in the area addressing emergency room crowding and wait times.

Mercy Medical Center in Cedar Rapids in 2020 opened the state’s first free-standing ER — by converting its Hiawatha MercyCare Urgent Care location into an extension of its emergency department.

That ER is open every hour of every day of the year — offering on-site radiology, lab and pharmaceutical services. And earlier this month, Mercy Cedar Rapids opened its second freestanding ER — this one in Marion — outfitted with 12 exam rooms, two trauma rooms, lab and imaging services, and a helipad.

“Like the Mercy Hiawatha ER, patients at the Marion location that require additional hospital intervention will be transferred free of charge to Mercy’s downtown location based on well-developed protocols and in partnership with local ambulance services,” according to hospital officials.

UnityPoint Health-St. Luke’s Hospital, 1026 A Ave. NE in Cedar Rapids, also opened a Marion ER in August. The 10,000-square-foot ER was built inside an existing building at 3301 Armar Dr., just off Marion Boulevard near the border of Cedar Rapids and Marion.

St. Luke’s identified Marion “as an ideal location due to its fast-growing population and community expansion projections,” Dr. Sarah Hoper, the medical director for its new Marion ER, told a correspondent for The Gazette earlier this year.

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