U.S. Emergency Rooms Unprepared for Major Trouble

WASHINGTON, June 15 ? The nation's emergency care system is woefully ill-prepared to handle a natural disaster, disease outbreak, or terrorist attack, according to three reports released by the Institute of Medicine today.

"With hospitals in many large cities operating at or near full capacity, even a multiple-car highway crash can create havoc in an emergency department," warned the authors of the reports, led by Gail Warden, M.H.A., president emeritus of the Henry Ford Health System in Detroit. "A major disaster with many casualties is something that many hospitals have limited capacity to handle,"

One report focused on hospital-based emergency care, another on pediatric emergency care, and the third on challenges to the nation's emergency service system overall. Collectively, the reports are titled The Future of Emergency Care. Key problems discussed in the reports include the following:

Overcrowding

Demand for emergency care grew by 26% between 1993 and 2003, but at the same time the nation lost 425 emergency departments and 198,000 hospital beds, according to the report Hospital-Based Emergency Care: At the Breaking Point.

"The result has been serious overcrowding," the report said. This can lead to the practice of "boarding" patients-holding them in the emergency department, often in beds in hallways, until an inpatient bed becomes available. It is not uncommon for patients to be boarded for 48 hours or more, the report said.

Another consequence of overcrowding has been an increase in the number of ambulances diverted away from an emergency department that is full and sent to one farther away. "Once considered a safety valve to be used only in the most extreme circumstances, such diversions are now commonplace," the report said. Ambulances are diverted half a million times each year-an average of almost once every minute, according to the report.

"Each diversion adds precious minutes to the time before a patient can be wheeled into an emergency department and be seen by a doctor, and these delays may in fact mean the difference between life and death for some patients," the report said.

Fragmentation

There are neither national standards for training emergency medical service personnel nor any national accreditation of the institutions that train them, according to the report Emergency Medical Services at the Crossroads.

In addition, federal oversight of the emergency care system is scattered across multiple federal departments, including Health and Human Services, Transportation, and Homeland Security, the report said.

"Because responsibility for the system is so fractured, it has very little accountability. In fact, it can be difficult even to determine where system breakdowns occur and why," the report said.

Lack of Disaster Preparedness

Few hospital and emergency medical service personnel have received even minimal training in how to respond to a natural disaster or terrorist attack, the report authors said.

In addition, most emergency departments lack the equipment and supplies necessary to deal with such an event. They also lack protective equipment to keep first responders to a natural disaster or terrorist attack safe, they said.

The authors blame this lack of preparedness on scanty funding. They point out that, of the .38 billion distributed by Homeland Security for emergency preparedness in 2002 and 2003, only 4% went to emergency service providers.

"In general, of the billions of federal dollars being spent on disaster preparedness, only a tiny fraction is spent on medical preparedness, and much of that is focused on one of the least likely threats-bioterrorism," the authors said.

Other Problems

Few emergency departments are adequately supplied and staffed to treat children, according to the report Emergency Care for Children: Growing Pains.

For example, only 6% of emergency departments have all the supplies necessary for handling pediatric emergencies, and only about half of departments had at least 85% of the essential supplies, the report said.

In addition, many emergency departments, particularly those in rural areas, lack doctors and nurses with specialized pediatric training, the report said.

Finally, emergency departments suffer from a shortage of other on-call specialists, such as neurosurgeons, the authors said. Many specialists find the demands of providing on-call emergency services disruptive to their regular practices and family life, and the insurance premiums are prohibitively high, they said. To achieve this, the various components of the system-9-1-1 and dispatch, ambulances and EMS workers, hospital EDs and trauma centers, and the specialists supporting them-must be able to communicate continuously and coordinate their activities.

Key recommendations the authors made include:

• The federal government should create national standards for emergency care performance measurement and national protocols for the treatment, triage, and transport of patients.
• The federal government should consolidate the fragmented oversight of the emergency service system into a single agency in the Department of Health and Human Services.
• Hospitals should reduce overcrowding by using management tools developed by other industries, such as banks and airlines, to improve efficiency. One such tool, queuing theory, has the potential to eliminate bottlenecks in patient admissions, the authors said.
• The emergency care system of the future should be highly coordinated. To achieve this, the various components of the system - 911, dispatch, ambulances, EMS workers, hospital emergency departments, trauma centers, and the specialists supporting them must be able to communicate continuously and coordinate their activities.
• The system should be regionalized in the sense that neighboring hospitals, EMS, and other agencies work together as a unit to provide emergency care to everyone in that region.
• The Department of Health and Human Services should conduct its own study of the gaps in emergency care and come with strategies for closing the gaps, which may include a center or institute for emergency care research.

The reports call for a series of 10 demonstration sites to put these ideas into practice and test them to determine which strategies work best under various conditions.