The State of Emergency Care Today & Tomorrow, Part 1

Friday, June 15, 2007

By now I m sure all of you ve seen at least a summary of the IOM (Institute of Medicine) report on the future of emergency care in the United States. Actually, there were three reports. One addressed EMS and emergency services, another looked at pediatric emergency services and the third, at hospital-based emergency care.

For those who haven t seen anything on these reports, I m sure you could guess that they weren t glowing pronouncements of our success at tackling the needs of our diverse patient populations. It should come as no surprise to any health-care professional, whether they work in the field or in hospitals, that we have problems. In every atmosphere, we re struggling to get to the people who need care and give them the care they need.

The reports, Hospital Based Emergency Care: At the Breaking Point, Emergency Medical Services at the Crossroads and Emergency Care for Children: Growing Pains, included the following key findings:

Definite problems

ED overcrowding: Many emergency departments and trauma centers are overcrowded. Again, this is no surprise to most of us. We see proof of this in our daily practice. We wait for rooms to place our patients in and we are diverted from the hospitals our patients prefer or the hospitals we believe our patients should transferred to.

The report makes the following statements on this issue:

• Demand for emergency service is rising. Emergency department visits grew by 26 percent between 1993 and 2003.
• In this same period, the number of emergency departments declined by 425 nationwide and the number of available hospital beds declined by 198,000.

These two statements lead into discussions of how patients back up in EDs and trauma centers because no beds are available, with patients often being held 48 hours or more. With these patients stuck in emergency services, ambulances are diverted (an average of once every minute) to hospitals that may be far away from the ambulance provider s service area. In 2003 alone, ambulances were diverted more than 500,000 times.

Lack of collaboration: Emergency care is very fragmented. The report made the following points:

• Cities and regions are often served by multiple 9-1-1 call centers;
• There is no effective coordination among EMS agencies, EDs and trauma centers;
• EMS is not in sync with public safety agencies and public health departments;
• There are no national standards for training and certification for EMS personnel; and
• Federal responsibility for oversight of emergency and trauma care is scattered among multiple agencies.

The result of all of this is that multiple entities are trying to resolve problems without the coordination of all of the people and systems involved.

Lack of on-call specialists: Critical specialists are often unavailable to provide emergency and trauma care.

• Three-quarters of hospitals report difficulty finding specialists to take emergency and trauma calls.
• Key specialists are in short supply. For example, the number of practicing neurosurgeons decreased between 1990 and 2002, whereas the number of trauma visits increased.
• On-call specialists often treat emergency patients without compensation because the patients lack insurance.
• These same specialists face higher medical liability than physicians who don t provide on-call coverage.

Ill-prepared for disaster: Our ability to handle large-scale disasters should be measured by our ability to fulfill the daily needs of our patients. If we can t meet their daily needs, it would follow that a disaster would overwhelm our systems. The reports made the following points:

• With many EDs over capacity, there is little surge capacity;
• EMS received only 4 percent of the DHS first responder funding;
• Non-fire-based EMS received an average of less than one hour of training in disaster response; and
• Both hospital and emergency department personnel lack PPE needed to effectively respond to chemical, biological or nuclear threats.

Ill-prepared for pediatric emergencies: EMS and EDs are not well equipped to handle pediatric care.

• Most children receive emergency care in general hospitals rather than in centers that specialize in pediatric care. Thus, it s less likely that specialized equipment and personnel are available for these patients.
• Children make up 27 percent of all ED visits. Conversely, only 6 percent of EDs have the necessary supplies for pediatric emergencies.
• Many of the drugs and devices we use have not been adequately tested on or for children.
• Although children are more vulnerable in disasters, planning for them has been largely overlooked.

Possible solutions

The reports make the following recommendations in response to these findings:

Create a regionalized, accountable system: The reports call for 9-1-1 call centers, ambulance services and EDs to coordinate their activities and integrate their communications to ensure seamless emergency and trauma services. Congress should enact programs to identify and test alternative strategies for achieving this vision. The federal government should support the development of national standards for emergency care performance measurement, categorization of emergency care facilities and protocols for the treatment, triage and transport of prehospital patients.

Create a lead agency: The federal government should consolidate functions related to emergency care into a single agency in the Department of Health and Human Services.

End ED boarding & diversion: Hospitals should reduce crowding by improving hospital efficiency and patient flow with operational management methods and information technologies. The Joint Commission on the Accreditation of Healthcare Organizations should reinstate strong standards for ED boarding and diversion. The Centers for Medicare and Medicaid Services should develop payment and other incentives to discourage boarding and diversion.

Increase funding for emergency care: Congress should appropriate $50 million for hospitals that provide large amounts of uncompensated emergency and trauma care. Funding should be increased for the emergency medical component of preparedness both for EMS and hospitals, particularly to provide adequate PPE, training and planning.

Advocate for emergency care research: Federal agencies should target additional research funding to prehospital emergency services and pediatric emergency care. DHHS should conduct a study of the research needs and gaps in emergency care and determine the best strategy for closing the gaps, which may include a center or institute for emergency care research.

Promote EMS workforce standards: States should strengthen the EMS workforce by requiring national accreditation of paramedic education programs, accepting national certification for state licensure and adopting common EMS certification levels.

Enhance the pediatric focus: EDs and EMS agencies should have pediatric coordinators to ensure appropriate equipment, training and services for children. Pediatric concerns should be explicit in disaster planning. More research is needed to determine the appropriateness of many medical treatments, medications and medical technologies for the care of children. Congress should increase funding for the federal EMS for Children Program to $37.5 million per year for five years.

This is a lot of information. In part 2, I ll discuss what it all it boils down to and what I ve observed.