Stress on the System
Such financial difficulties have led to the closing of scores of emergency departments, which places more pressure on the remaining facilities.
Hospitals aren't inclined to give up inpatient beds to admit patients from the emergency department, who may pay at Medicaid rates or not at all, Dr. Kellermann said.
“Right now, all the incentives are to leave the patient in the ED so that they can keep admitting electives. You are financially penalized for making the right decision for patient care, because it is the wrong decision for your business,” he said.
The IOM committee also concluded that the emergency care system is not equipped to cope with a large-scale emergency.
“You've got to ask yourself, 'If our emergency departments are struggling to handle their daily and nightly load of 911 calls, how in the world are they going to handle a mass casualty event following a terrorist strike, an outbreak of infectious disease, or a natural disaster?” Dr. Kellermann said.
Federal funding for emergency preparedness has been and remains inadequate, the committee found. In 2002 and 2003, emergency care providers received 4% of $3.38 billion in first-responder funding distributed by the Department of Homeland Security—although emergency medical services personnel make up one-third of first responders. That has left EMS providers with scant training or planning to deal with a disaster situation.
Time to Act
The committee's findings show that emergency departments cannot continue to operate without more financial support, said Dr. Rick Blum, president of the American College of Emergency Physicians.
“Hospitals must be reimbursed for the significant amounts of uncompensated emergency and trauma care they provide,” he said in a statement.
Dr. Blum called for Congress to hold hearings on the state of emergency medicine and to pass the Access to Emergency Medical Services Act, introduced in the House last September and in the Senate in May 2006. The legislation targets several problems addressed in the report, including boarding, the lack of on-call specialists, and poor reimbursement for emergency care services.
Although emergency care on the whole is deeply troubled, the IOM committee found that there are islands of excellence—a select few facilities that have developed innovative approaches to dealing with the problems that all emergency departments face. Those islands provide a starting point on which to build a better system, committee members said.
“Our goal should be for these islands to coalesce and eventually blanket the United States with an emergency care system that has no holes,” Dr. Eastman said.
The panel envisioned a new regionalized system to coordinate care, so that patients are only taken to facilities that are appropriate and prepared to care for them, he said.
“Where there is no vision, the people perish,” Dr. Kellermann said. “Our committee has described a vision for a coordinated, regionalized, and accountable emergency care system. It's time to act.”
Gaps Noted in EMS, Pediatric Services
Problems with the state of hospital-based emergency care received the most focus in the release of the Institute of Medicine reports, but two accompanying reports highlight systemic issues with emergency medical services and pediatric emergency care.
Ambulance and other emergency medical services suffer from fragmentation that has led to critical problems in efficiency, efficacy, and coordination, according to the committee's report on emergency medical services.
The system is severely lacking in data to drive, or even gauge, performance. What few data do exist point to wide variations between communities, said committee member Shirley Gamble, chief operating officer for United Way Capital Area of Austin, Tex.
“There is as much as a 10-fold difference by community in survival rates for sudden cardiac arrest,” she said.
The committee also found that the patchwork nature of emergency medical services creates barriers to communication among emergency medical service providers and between those providers and emergency departments.
Children represent 27% of the country's 110 million emergency visits, but they often inappropriately receive adult-sized care, according to a committee report on emergency care for children.
“Many hospitals and EMS agencies may lack smaller-size medical equipment that is needed to care for these patients, and many providers receive limited training in pediatric emergency care,” said Dr. Marianne Gausche-Hill, director of prehospital care at Harbor-UCLA Medical Center in Torrance, Calif. Also, many medications used in the emergency department are given to children off-label, Dr. Gausche-Hill said, because they have not been approved by the Food and Drug Administration for pediatric use.