Review by Chet Schrader
Column organized by Evan Schwarz
Washington University in St. Louis
Division of Emergency Medicine
Institute of Medicine. IOM Report: the future of emergency care in the United States health system. Acad Emerg Med. Oct 2006;13(10):1081-1085.
Every day Emergency Physicians encounter a growing crisis in emergency care. Overcrowded emergency departments (EDs), ambulance diversions, boarding of patients, and inability to find specialists to participate in patient care are among the problems pushing emergency care to its limits. In September 2003, the Institute of Medicine’s Committee on the Futures of Emergency Care published a series of reports – Hospital-Based Emergency Care: At the Breaking Point, Emergency Medical Care At the Crossroads, and Emergency Care for Children: Growing Pains – that examined and gave recommendations to the growing crisis in emergency care in the United States.
A rapidly growing number of ED visits (from 90.3 million in 1993 to 113.9 visits in 2003) and a coinciding decrease in hospitals over the same time period has resulted in the problem of ED overcrowding. ED overcrowding leads to the practice of boarding patients in the ED – holding patients in the ED until an inpatient bed is available. This practice reduces the services, expertise and equipment that would be available if the patient were in an inpatient department as well as likely contributes to an increase in patient morbidity and mortality.
ED overcrowding has also increased the practice of ambulance diversions. According to the IOM, “half a million times each year – an average of once every minute – an ambulance carrying an emergency patient is diverted from an ED that is full and sent to one that is farther away… Each diversion adds precious minutes to the time before a patient can be wheeled into an ED and be seen by a doctor, and these delays may in fact mean the difference between life and death for some patients.”
The rapid development of the emergency care system has in fact left a highly fragmented and disorganized system of care. Differing EMS areas in one population center, ineffective communication between EMS, police and fire departments, and a similar lack of communication between EDs and EMS, has led to poor regional flow of patients often resulting in patients being brought to facilities that are not ideal for their individual needs. In addition, there are not any nationwide standards for EMS personnel, and no single agency is responsible for development or oversight for emergency and trauma care leading to very little accountability for system breakdowns and difficulty determining where breakdowns even occur.
While emergency and trauma physicians are expected to see all patients who come to the emergency department, it has become increasingly difficult to find specialists to see patients. The shortage of on-call specialists is thought to be related to decreased reimbursement due to the high number of uninsured patients while at the same time assuming additional liability by treating patients with potentially risky procedures with whom the physician has no prior relationship. It is notable that insurance premiums for physicians who serve as on-call specialists are higher than those who do not. Finally, disruption of private practice and family life is an additional burden placed on specialists vital to the emergency care system.
Another area identified by the IOM report is lack of preparedness of emergency care to handle a disaster. With already crowded EDs and hospitals acting near capacity, a major disaster with numerous casualties would place an additional burden on an already overburdened system. The IOM identifies funding as a primary deficiency, stating “hospital grants from the Bioterrorism Hospital Preparedness Program were typically between $5,000 and $10,000 – not enough to equip even one critical-care room” and that “emergency service providers… received only 4 percent of the $3.38 billion distributed by the Homeland Security Department for emergency preparedness.” With this lack of funding, few emergency personnel have received training in preparing and responding to a disaster.
Pediatric care had special emphasis in the IOM report, as the different medical needs of the pediatric population were identified. Although children make up 27% of all ED visits, emergency departments are ill-prepared to deal with the different physiologic responses, need for different equipment and medication doses, as well as specialized mental health needs that are required to care for these patients. Out of necessity to care for sick children, many rural Ends and EMS personnel are without specific pediatric training.
While identifying the problems faced by the emergency care system, the IOM report also recommended a multi-pronged strategy for improving emergency care. By improving hospital efficiency and patient flow, hospitals could eliminate bottlenecks in admissions thereby reducing crowding and enhancing patient care while potentially reducing costs. The IOM urged hospitals to employ tools developed by engineering and operations research and to develop information technology to track and coordinate flow and communications.
The IOM also calls for a regionalized system with a single federal agency to lead emergency and trauma care. With regionalization of systems EMS, EDs, and hospitals can communicate and coordinate activities and ensure that patients can be routed to hospitals with appropriate resources.
With increased federal funding, the emergency care system could further research appropriate methods to organize emergency care, and, more importantly, ensure that greater funding goes to disaster preparedness. The IOM states “Congress should consider providing greater reimbursements to the large safety-net hospitals and trauma centers that bear a disproportionate amount of the cost of taking care of uninsured patients.”
Finally, a special emphasis should be made to improve the quality of care to emergency pediatric patients. While developing standards and protocols in triage, prehospital EMS, and disaster preparedness, pediatric concerns should be identified. In addition, emergency care workers should be properly trained and comfortable in treating pediatric patients.
With the identification of the crisis facing emergency care, and the proposed solutions offered by the Institute of Medicine’s Committee on the Futures of Emergency Care reports, we have the opportunity to develop an emergency care system that ensures high-quality and reliable care for all.
For the full report please go to www.nap.edu.