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Emergency Care: A System in Crisis

Highlights from a recent Institute of Medicine report on the state of emergency medicine in the U.S.

Recently, the Institute of Medicine convened a panel to study the state of emergency medal care in the U.S. In an article in the "Perspectives" section of the New England Journal of Medicine — an important platform for discussions of national health policy — a member of that panel presents highlights from its report.

The author first reviews some startling facts: From 1994 to 2004, the number of hospitals and emergency departments decreased, the latter by 9%, while the number of ED visits increased by more than 1 million a year. Annual ED visits now number about 110 million — more than one for every three people in the U.S. The author notes the shortage of nurses, insufficient coverage by on-call specialists, and unexpected consequences of EMTALA as a preface to five recommendations from the IOM report.

• Emergency care, now the province of at least three federal agencies, should be assigned to a single agency within the Department of Health and Human Services in order to minimize duplication of effort, increase accountability, and centralize fiscal support.
  
• A focused needs-assessment should be undertaken, which would also highlight areas for future research.
  
• State governments should regionalize prehospital and hospital-based emergency care so as to reduce duplication of effort and provide emergency patients with the right care at the right time.
  
• "Boarding" of patients in the ED should end. As it is unlikely that hospitals will do this on their own, federal agencies should take both fiscal and regulatory action to ensure that this goal is met.
  
• To strengthen disaster response, steps should be taken to ensure that the day-to-day emergency and trauma care system is integrated, efficient, and functional. The author notes that only 4% of federal disaster funds earmarked for "first responders" in 2002 and 2003 actually went to emergency services.
  

A call to Congress to fulfill the vision enunciated in the IOM report provides an appropriate conclusion.

Comment: The perspective’s brevity does not allow the complexity and interplay of the multiple issues that affect emergency care to come to the fore. These include a growing elderly population, an increase in poverty, the changing nature of medical practice, and a focus on disaster response. And as improving emergency care is essentially a health policy issue, the fiscal model to support it should accompany any call for reform of the current system. If careful consideration is not given to these facets of the problem, the IOM report may languish as simply a cry for help. The IOM’s 2000 report on patient safety ("To Err is Human") garnered national attention and prompted action. This report deserves no less.

— J. Stephen Bohan, MD, MS, FACP, FACEP

Published in Journal Watch Emergency Medicine September 27, 2006

Citation(s):

Kellerman AL. Crisis in the emergency department. N Engl J Med 2006 Sep 28; 355:1300-3.

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• Medline abstract (Free)