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U.S. Emergency Medicine on the Critical List

Three reports find the system barely coping day-to-day

WEDNESDAY, June 14, 2006 (HealthDay News) -- The U.S. emergency medical system is in critical condition and on life support -- overburdened, under-funded, and highly fragmented, according to three new reports released Wednesday by the Institute of Medicine (IOM).

According to the reports, ambulances are being turned away from emergency departments and patients can wait hours or even days for a hospital bed. And, as it stands, the system is currently unprepared to handle overloads of patients from disasters such as hurricanes, bombings, or disease outbreaks, the authors contended.

"These reports reinforce something we have known for a long time," said one expert, Dr. Rick Blum, president of the American College of Emergency Physicians. "The challenges facing emergency medicine are reimbursement, overcrowding, ambulance diversion and lack of on-call specialists."

Gail Warden, chairman of the IOM's Hospital-Based Emergency Care Committee that did the reports, noted that "there has not been an in-depth study of emergency medicine done in 40 years."

His team's report finds the U.S. system in a precarious state. "Emergency rooms, in most cases, are overcrowded with long waits for patients to be admitted," Warden said. "Ambulances are frequently diverted to another hospital, because the primary one is overflowing. There is a lack of specialists to provide care in many emergency rooms. The transport of ambulances to emergency medical services is often fragmented, disorganized and inconsistent. In many cases, pediatric care falls short because emergency rooms are not prepared to care for children in the way that they should be."

To help solve these problems, Congress needs to earmark money to ensure that emergency departments, trauma centers and medical first responders are fully equipped and ready to deliver fast and appropriate care, the IOM reports concluded.

They are calling for action to reduce crowding in emergency rooms, boost the number of specialists involved in emergency care, and get all emergency medical services to work as a team, steering patients to the most appropriate facilities.

The reports in the The Future of Emergency Care series include: Emergency Care Services at the Crossroads, Emergency Care for Children: Growing Pains and Hospital-Based Emergency Care: At the Breaking Point.

Why the crisis? The IOM, which is part of the National Academies, reported that:

  • Insufficient funding and uncompensated care have taken a toll on the capacity of the emergency medical system. Significant cuts in federal funds for emergency medical response in the early 1980s left first-responder services to develop haphazardly across the country. Many ambulance services use out-of-date communications equipment that hinders their ability to coordinate with hospitals and other first-responders in their areas.
  • In 2003, emergency departments saw nearly 114 million patients -- a 26 percent increase over the previous decade -- but during the same 10 years the United States lost 703 hospitals and 425 emergency departments, one report noted.
  • A growing number of uninsured Americans are looking to emergency departments as their health care "safety net," and much of this care is never paid for.
  • Emergency departments are also playing key roles in disaster response, but in 2002 and 2003, emergency medical services received just 4 percent of the $3.38 billion doled out for emergency preparedness by the U.S. Department of Homeland Security.

The reports urges Congress to allocate $50 million to reimburse hospitals for uncompensated emergency and trauma care and to increase funding to provide hospitals with resources needed to handle disaster situations.

That proposal will make up only about a third of the actual costs, noted Warden, who is president emeritus of the Henry Ford Health Care System, in Detroit.

"The request is basically to get it on the record to get some dialogue going, recognizing that it might take a few years to get some of these things addressed. But at the same time we had to make the point that the resources going into emergency medicine fall way short of what is needed," he said.

The reports also urged federal legislators to earmark $88 million over five years for projects designed to test ways to promote greater coordination and regionalization of emergency care; and another $37.5 million each year for the next five years to the Emergency Medical Services for Children Program, to address shortfalls in pediatric emergency care.

Blum said the reports highlight what those in emergency medicine have long known.

"As a nation, we have to figure out how we are going to care for 47 million uninsured people," Blum said. "Emergency departments really have to bear a disproportionate part in caring for these folks and it has resulted in the infrastructure of emergency care to be extremely limited."

"The current climate, where 50 percent of emergency care is uncompensated, is not financially viable," Blum said. "So, while the number of emergency visits has gone up dramatically over the past 10 years, the actual of emergency departments has declined -- that's not a sustainable trend."

For his part, Warden believes all the players in emergency medicine must come together to try to solve these issues. Many of the problems cited in the IOM reports have been endemic in emergency medicine for a long time, he said, but increased volume of patients has tipped the scale and caused the current crisis.

"There has been no concerted effort to really look at these issues and try to figure out what kinds of strategies are necessary to look at these problems in depth, and this is what we have done in these studies," Warden said.

The crisis in emergency medicine crisis is symptomatic of broader stresses in the U.S. health care system, Blum added.

"For emergency medicine, we are just trying to figure out how to get through the next day in our crowed emergency departments," he said. "We are not focused on the big picture of health care reform. We are focused on the day-to-day realities of trying to care for people with declining resources and having to care for more and more patients."

More information

For more on efforts to improve U.S. emergency care, head to the American College of Emergency Physicians.

SOURCES: Gail Warden, chairman, Hospital-Based Emergency Care Committee, Institute of Medicine, and president emeritus, Henry Ford Health Care System, Detroit; Rick Blum, M.D., president, American College of Emergency Physicians, Washington, D.C., June 14, 2006, report, Institute of Medicine
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