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VITAL SIGNSERs in need of first aid
U.S. emergency-care system is ill prepared for disaster: study

By Kristen Gerencher, MarketWatch
Last Update: 6:04 PM ET Jun 15, 2006

SAN FRANCISCO (MarketWatch) -- Stretched to its limit, U.S. emergency medical care is in poor shape to handle disasters and needs to expand capacity, improve coordination before and after patients arrive and address the special needs of children, according to a new report.

Overcrowded hospital emergency departments increasingly are at a "breaking point" and have to divert ambulances to less-pressed facilities, adding time and potential risks to patients' plights, according to a series of three reports from the National Academies of Sciences' Institute of Medicine (IOM). A panel of experts surveyed the state of hospital-based ER care, out-of-hospital emergency medical services and pediatric emergency care. Patients can waits hours and sometimes days to get a hospital bed, and ambulances are turned away from full ERs 500,000 times a year.

Disjointed medical first-response systems add to the burden, and the common practice of "boarding" patients by leaving them in hallways to wait for an open bed needs to change, the report said. Part of the problem is that demand is outpacing supply. Visits to emergency departments have grown significantly from 1993 to 2003 but capacity has declined. There were nearly 114 million emergency visits in 2003, up 26% from 90.3 million a decade earlier, the report said. Over those 10 years the number of hospitals dropped by 703, the number of beds fell 198,000 and the number of emergency departments declined by 425.

At the same time, emergency departments are expected to do more with less, both by girding for natural and manmade disasters and keeping up with demographic changes such as the coming increase in baby-boomer visits, said Dr. Marianne Gausche-Hill, an IOM committee member and emergency physician at Harbor-UCLA Medical Center in Torrance, Calif. "There's a fragmentation of services," she said. "In addition to funding, what's needed is coordination of services, regionalization of services and some accountability to see how we're doing to take the steps necessary to improve things even more."

Building surge capacity

As the number of Americans without health insurance has grown to 45.5 million, some ERs function as a medical home for uninsured patients who don't have regular doctors, putting the facilities under increased financial and logistical strain.

They also are a last resort for insured patients whose coverage is skimpy or who get sick when their regular source of care isn't available, such as at night and on the weekends, and for patients whose doctors order tests to be performed there, said Dr. Brian Keaton, an emergency physician with Summa Health System in Akron, Ohio, who was not involved in the study. Emergency departments also are on the front line of public-health surveillance and disaster response, and the safety net is fraying, said Keaton, who's also president-elect of the American College of Emergency Physicians.

The IOM report highlighted all the right issues, he said. "Surge capacity is a big deal every day. It's really a big deal every Friday night," Keaton said. "[Emergency departments] are significantly challenged from a capacity standpoint....backing up with admitted patients who can't get to the floors."

"When we multiply that out and look at the ability to take care of a high-casualty event, whether it's [a potential pandemic of] bird flu, a terrorism event or a natural disaster, the surge capacity isn't there."

Gausche-Hill agreed. "You want to be able to expand and contract as needed, and that can only happen if there's good coordination." Only 4% of the $3.4 billion emergency preparedness funds distributed by the U.S. Department of Homeland Security made it to emergency medical services in 2002 and 2003, the report said.

Prescribing changes

The scenario may seem bleak. But hospitals can help control patient flow and free up beds during predictably peak times by canceling certain elective surgeries or moving patients awaiting discharge into chairs in a public area, Gausche-Hill said. "Creating some capacity within the system is going to be a multiprong approach, but I think it can be done." All through the process -- whether it's 911 call centers, police, fire departments or paramedics -- priority needs to be given to emergency communications so they're modern, reliable and compatible between counties and agencies, Keaton said. Different radio technology sometimes doesn't allow emergency workers to talk to each other, creating an onerous dispatch system, he said. "We need to break down some silos and take a look at the way we do things and bring some resources to the table, and quite frankly we need to do it now before we have to take care of the baby boomers," Keaton said.

When it comes to serving pediatric needs, large metro areas often have children's hospitals with cutting-edge treatments and technology. But many other areas remain vastly underserved. The majority of kids go to general hospitals for emergencies, which often don't have specially trained staff or the appropriate equipment, according to the report. Children comprise 27% of emergency-department visits, but only 6% of ERs have all the supplies necessary to handle pediatric cases, the study said.

"Using equipment on a [newborn] is very different from a five-year-old is very different from an adolescent," Gausche-Hill said.

"We need to make some inroads there." "Because critically ill and injured children are really a rare event, many practitioners don't have the experience level and aren't able to maintain skills to care for those kids," she added. "We're going to have to develop different strategies to maintain the competency of our work force."

While well-trained physicians can offer quality care to anyone in the ER, kids have specific needs that many hospitals don't attend to on a regular basis, Keaton said. "They don't have medications in the smaller doses you need because they don't usually take care of kids. In a crisis, whether it be disaster mode or pandemic influenza or things like that, every emergency department will have to take care of children, and they should be prepared for that."

Also harming emergency medicine is a dwindling number of specialists such as neurosurgeons and orthopedic surgeons who are willing to be on-call for emergencies, the report said. Some say they have trouble getting paid for their services while others are turned off by the hours or high costs of liability insurance required to work in such a high-risk environment.

Overall, the report underscores that Americans have the right to emergency care under federal law, but there's no consensus on how to fund it, Keaton said.

On one hand, he said, the U.S. holds it in such esteem that hospitals are required to evaluate all patients who show up at an emergency department and provide treatment if needed. "At the same time, we value it so much we refuse to pay for it," Keaton said. "It's really a very interesting, frustrating dichotomy in terms of how we value that service."

In addition to increasing funding for hospital disaster preparedness, the report recommended Congress establish a pool of at least $50 million to reimburse hospitals for uncompensated emergency and trauma care. Another $88 million should be granted over five years for projects devoted to promoting greater coordination and regionalization, and Congress should allocate $37.5 million annually for the next five years to bolster the Emergency Medical Services for Children Program, the IOM reports concluded.

Kristen Gerencher is a reporter for MarketWatch in San Francisco.