In part 1 of this month s column, I outlined the findings and recommendations of the IOM reports on the state of emergency care. In general, the reports describe what all of us have been working with for a long time. Here are my observations:
ED & trauma center overcrowding
The bottom line is this isn t an ED or trauma center problem. It s a problem with the system a combination of inefficiencies in moving patients out of the hospital and too few beds for too many patients. This problem is compounded by the fact that inefficiencies in the general patient-care system are bringing patients to EDs who don t belong there. Let s break this down.
Hospitals have downsized due to several factors. For one, large numbers of patients have either no insurance or are publicly insured. Uninsured patients often can t pay for their services, and even publicly insured patients only reimburse the hospitals at a fraction of their cost for care, let alone their invoice for care.
In addition, shortages in personnel including nurses and physicians cause hospitals to pay premiums for available personnel or remove beds and services from their facilities. Also, although patients may be ready to leave the hospital, coordination with services to accommodate the needs of these patients on the outside are either insufficient or poorly coordinated. Patients who could have been moved home or into other specialized facilities are often left in the hospital.
How do we fix this? It s complicated.
The first answer is that all of us have to be willing to pay. Hospitals, and for that matter EMS, can t continue to work with public insurance (such as Medicare and Medicaid) reimbursing a fraction of our expenses. We all have to be ready to pay so that systems can handle the patients we need to care for.
Second, once we are paying the freight, allowing for investment in hospital and EMS systems adequate for our volumes, we must level the playing field for hospitals. All over the country, hospitals are looking to build or expand but are limited by boards that decide who can build or expand and who can t. I wonder if the system wouldn t benefit from more open competition and development.
Third, we must find a way to make the idea of becoming a nurse, a neurosurgeon or a paramedic more attractive to the young people in our colleges and universities. Salary, benefits and working conditions need to improve to attract young people with fresh ideas to help us resolve these issues.
Who are our patients?
All of us know that a large percentage of our patients don t need to be in the ED. Often, we re frustrated and blame the patient or guardian for this situation. Let s consider this for a moment. How many of you are parents? How many of you took your child to the ED for an earache instead of the doctor s office because your insurance covered it or because you were willing to pay to get your irritable child cared for?
The reality is that EDs fill up with lots of patients because the primary care system fails. Imagine that your child has an earache. You ve called the pediatrician and are told you can t get an appointment for two weeks. Your child has an earache now. In two weeks, it will either have passed or become something worse clearly unacceptable to any parent with a child in pain. You have nowhere else to turn but the ED. So the ED fills up with patients who could be treated elsewhere.
Here s another example of system failure that fills the ED: One of my sons recently injured his hand playing softball and his PPO gave him an appointment with a doctor. The appointment was subsequently cancelled, rescheduled for a week later and then cancelled again. He s still waiting. Others in his situation would have ended up in someone s ED. The system is broken.
Coordination of health services
We re also all aware that many of the patients we transport are not in need of ED services but clearly need something a doctor, a nurse specialist or other health service. Fixing this problem is complex and requires coordination of all health services with training for prehospital care providers that enables them to triage patients to the appropriate service. It s perhaps the most difficult of all of the issues facing us. We must coordinate the available services, the training of prehospital care systems and the providers within it to get patients where they need to be which often will not be the ED.
Here are my other responses to observations made in the reports:
Pediatric emergency care: Dealing with injured or ill children continues to be the most frightening experiences for many prehospital care providers. We have no confidence that our protocols or the facilities we transport them to are adequate for their needs. Research and development of protocols for children must be enhanced.
National standardization: We need to get off the dime here. All over the U.S., the best and brightest EMS professionals are writing standardized curricula and protocols for prehospital care. However, licensure of providers and protocols still vary greatly. At best, some states recognize other state s licensure or national certification. At worst, a state may require re-training of prehospital care providers to qualify to work in their state. We must standardize prehospital care so that is consistent with providers anywhere.
Federal leadership: The scattershot approach of current federal guidance is failing. We need to put all of these eggs in a single basket to prevent redundancy, waste and conflict. If we are to move forward, coordination and consistency are tantamount.
I know this month s column turned into the proverbial 10 lbs of stuff in a 5 lb bag, but it s important. The IOM report pointed out our problems, but it s up to us to collectively move forward. When you go to work tomorrow, think about the problems you re encountering. When you go to your next conference, listen to the ideas that address these concerns. If you have procedures that work in your area, make sure the rest of us hear about it.
And, most importantly, press your local and regional leaders to invest in a national resolution to these concerns. Press your elected officials to make EMS their concern. Work within your community to educate citizens about the variety of health services available and how to access them.
EMS and health care needs to and will change. As the dialogue continues, action must follow.