American ERs unprepared for emergency care needs

Alex Bloom

While the United States may be one of the world’s richest and most technologically advanced countries, it is not the place to get injured.

A report released last month by the Institute of Medicine declared that emergency rooms in the United States are overcrowded, under-funded, and ill-equipped to deal with the nation’s emergency care needs.

The report was the product of the Institute of Medicine’s Committee on the Future of Emergency Care. Convened in 2003, the committee found that emergency rooms have a declining number of beds, an increasingly poor waiting time for patients, and a poorly coordinated ambulance system.

Results also included a declining number of on-call specialists, limited pediatric equipment to deal with injured children, and emergency rooms inadequately prepared to handle a major disaster.

All of these problems are adding up to put America’s emergency care system, which is free for everyone, in dire straits.

“We really take care of everybody who comes in and we’re very, very proud of that, but we need help,” said Dr. Brent Eastman, the chief medical officer for the Scripps Health system in San Diego, and a member of the committee. “This safety net that we are providing today does have holes in it and it is tenuous.”

One of the largest problems facing emergency care is the declining number of hospital beds. While the number of emergency department visits grew by 26 percent between 1993 and 2003, the number of hospital beds declined by 198,000. That has resulted in patients being “boarded” in the emergency room until they can be moved to inpatient care. Some wait times have been 48 hours or more.

Dr. Eugene Litvak, professor of health care and operations management at the Boston University Health Policy Institute, has been studying the problem of boarding for years as the director of the Management of Variability in Health Care Delivery Program (MVP). He also served on the Institute of Medicine’s committee.

“Clinically, I think we have very, very good physicians,” said Litvak. “They are dedicated, smart, and well-trained, but they are put in an absolutely inappropriate position. This is why it is so terrible. The service quality is next to nothing.”

Litvak and MVP have argued that hospitals need to do a better job of scheduling elective surgeries. Poor scheduling creates peaks and dips in hospital visits, leading to overcrowded emergency rooms one day, and empty beds the next day.

Dr. Paul Biddinger, director of operations for the Department of Emergency Medicine at Massachusetts General Hospital, agreed with Litvak about the severity of the problem.

“The boarding problem is enormous,” said Biddinger. “It translates into decreased disaster preparedness.”

Biddinger said that MGH has employed a computer system with hospital beds so that they can track each and every bed in the hospital, knowing if they are in use and having them cleaned promptly when they are empty so they can be reused.

“So even though we have a limited number of beds, we use them as efficiently as possible,” said Biddinger.

Biddinger argued that hospitals do not have the financial incentive to add more beds, saying that hospital insiders were disappointed that no incentive system was added in the reports recommendations.

“It called for regulatory training to eliminate boarding and diversion, but it didn’t address the underlying problem — reimbursement to hospitals is structured in a way that it’s not financially possible for hospitals to add more beds,” said Biddinger.

The report also recommended that a regionalized system of emergency care be instituted to combat the problem of hospitals diverting ambulances upon arrival. Eastman noted that in 2003, ambulances were diverted 501,000 times — an average of once every minute.

“There are many places in this country where, because of the lack of regional care in this country, we would encounter preventable deaths,” said Eastman.

Dr. Eastman started in San Diego in 1984. Within a year of instituting his trauma system of regionalized care, he managed to reduce the preventable death rate from 22 percent to two percent or less, showing that the problem can be corrected with focus and cooperation.

“Our recommendations are absolutely doable but it is going to take the political will of … the leaders of this country to principally provide the funding for corrections to these problems,” said Eastman.

Without adequate funding, 94 percent of all hospitals will continue to lack proper pediatric care equipment and on-call specialists will remain in very short supply. Worse, emergency departments would stay very unprepared for a major disaster.

“These signs and symptoms — these are the tip of the iceberg, and it would not take a great deal to have a system implode in this country,” said Eastman.

Eastman also noted that healthcare providers make up only four percent of the Homeland Security budget.

“Healthcare providers have been largely overlooked,” said Eastman. “It’s as though it hasn’t occurred to anybody that somebody might get hurt, whether it’s a terrorist attack or a natural disaster like Katrina.”

It’s more than a matter of proper training. “We are very fortunate to have training in disaster preparedness,” said Biddinger. “All of our training, preparation and plans won’t create free beds when a disaster occurs. If we don’t have the free beds and we don’t have the capacity, that limits the emergency preparedness.”

Eastman quoted another committee member, Dr. Art Kellerman of Emory University School of Medicine, to sum up the problem facing emergency care.

“We value emergency care so much in this country that it’s the only medical care in this country that Americans have legal right to receive for free,” said Eastman. “But we value it so little that we aren’t willing to pay for it.”