Hospital-Based Emergency Care: At the Breaking Point

Hospital-Based Emergency Care: At the Breaking Point (Free Executive Summary)
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Free Executive Summary
ISBN: 978-0-309-10173-8, 424 pages, 6 x 9, hardback (2007)
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Hospital-Based Emergency Care: At the Breaking
Point
Committee on the Future of Emergency Care in the
United States Health System
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Today our emergency care system faces an epidemic of crowded emergency
departments, patients boarding in hallways waiting to be admitted, and daily ambulance
diversions. Hospital-Based Emergency Care addresses the difficulty of balancing
theroles of hospital-based emergency and trauma care, not simply urgent and lifesaving
care, but also safety net care for uninsured patients, public health surveillance, disaster
preparation, and adjunct care in the face of increasing patient volume and limited
resources. This new book considers the multiple aspects to the emergency care system in
the United States by exploringits strengths, limitations, and future challenges. The wide
range of issues covered includes:&#8226 The role and impact of the emergency
department within the larger hospital and health care system.&#8226 Patient flow and
information technology.&#8226 Workforce issues across multiple disciplines.&#8226
Patient safety and the quality and efficiency of emergency care services.&#8226 Basic,
clinical, and health services research relevant to emergency care.&#8226 Special
challenges of emergency care in rural settings.Hospital-Based Emergency Care is one
of three books in the Future of Emergency Care series. This book will be of particular
interest to emergency care providers, professional organizations, and policy makers
looking to address the deficiencies in emergency care systems.
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Hospital-Based Emergency Care: At the Breaking Point
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Summary
Hospital-based emergency and trauma care is critically important to the
health and well-being of Americans. In 2003, nearly 114 million visits were
made to hospital emergency departments (EDs)—more than one for every
three people in the United States. About one-quarter of those visits were
due to unintentional injuries, the leading cause of death for people aged 1
through 44. While most Americans encounter the ED only rarely, they count
on it to be there when they need it.
Over the last several decades, the role of hospital-based emergency and
trauma care has evolved. EDs continue to focus on their traditional mission of
providing urgent and lifesaving care, but have taken on additional responsibilities to meet the needs of communities, providers, and patients. Today, their
complex role also encompasses safety net care for uninsured patients, public
health surveillance, disaster preparedness, and serving as an adjunct to community physician practices. In some rural communities, the hospital ED may
be the main source of health care for a widely dispersed population. While the
demands on emergency and trauma care have grown dramatically, however,
the capacity of the system has not kept pace. Balancing these roles in the face
of increasing patient volume and limited resources has become increasingly
challenging. The situation is creating a widening gap between the quality of
emergency care Americans expect and the quality they actually receive.
STUDY CHARGE
The Institute of Medicine’s (IOM) Committee on the Future of Emergency Care in the United States Health System was formed in September
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HOSPITAL-BASED EMERGENCY CARE
2003 to examine the emergency care system in the United States; explore
its strengths, limitations, and future challenges; describe a desired vision of
the system; and recommend strategies for achieving that vision. The committee was also tasked with taking a focused look at the state of pediatric
emergency care, prehospital emergency care, and hospital-based emergency
and trauma care. This is the third of three reports presenting the committee’s
findings and recommendations in these three areas. Summarized below are
the committee’s findings and recommendations for meeting the challenge of
high demand for emergency care and achieving the vision of a 21st-century
emergency care system.
THE CHALLENGE OF HIGH DEMAND AND
INADEQUATE SYSTEM CAPACITY
Between 1993 and 2003, the population of the United States grew by
12 percent, hospital admissions increased by 13 percent, and ED visits rose
by more than 2 million per year from 90.3 to 113.9 million—a 26 percent
increase (see Figure ES-1). Not only is ED volume increasing, but patients
coming to the ED are older and sicker and require more complex and timeconsuming workups and treatments. Moreover, during this same period,
the United States experienced a net loss of 703 hospitals, 198,000 hospital
beds, and 425 hospital EDs, mainly in response to cost-cutting measures
Number of Hospitals Reporting ED Visits versus Increase in ED Visits
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
4,500
5,000
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
0.0
20.0
40.0
60.0
80.0
100.0
120.0
Total U.S. Hospitals Reporting ED Visits Total ED Visits (millions)
Hospitals Reporting ED Visits
ED Visits (millions)
2-1
New
April10
FIGURE ES-1 Hospital emergency departments versus numbers of visits.
SOURCE: AHA, 2005b; McCaig and Burt, 2005.
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Hospital-Based Emergency Care: At the Breaking Point
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SUMMARY
and lower reimbursements by managed care, Medicare, and other payers.
By 2001, 60 percent of hospitals were operating at or over capacity.
The high demand for hospital-based emergency and trauma care reflects
several trends. First, EDs have become one of the nation’s principal sources
of care for patients with limited access to other providers, including the 45
million uninsured Americans. Indeed, the Emergency Medical Treatment
and Active Labor Act of 1986 prevents hospitals from restricting access for
uninsured patients by requiring hospitals to provide a medical screening
examination to all patients and to stabilize or transfer patients as needed.
With limited access to community-based primary and specialty care, many
turn to the emergency system when in medical need, often for conditions
that have worsened because of a lack of regular primary care.
Medicaid beneficiaries also turn to the ED. In fact, Medicaid enrollees
visit the ED at a higher rate than any other category of patient (81 visits
per 100 enrollees)—double the rate of the uninsured population and nearly
four times that of privately insured patients. Although Medicaid enrollees
are insured, the low rates of provider reimbursement in many states limit
the number of office-based practitioners who are willing to accept them as
patients.
In addition, the ED often serves as primary care provider, a role for
which it is not optimally designed. Rather, the ED is designed for rapid,
high-intensity responses to acute injuries and illnesses. Physicians in the ED
face constant interruptions and distractions, and typically lack access to the
patient’s full medical records. Because nonemergency patients are usually
low triage priorities, they often experience extremely long wait times as they
are passed over for more urgent cases.
Costs are another concern. When an ED is not busy, the cost of treating
an additional nonemergency patient is probably quite low. But while the
literature on this issue is mixed, a number of studies suggest that nonemergency care in the ED is more costly than that in alternative settings. Indeed,
ED charges for minor problems have been estimated to be two to five times
higher than those of a typical office visit. When the ED is at full capacity,
treating additional patients who could be cared for in a different environment means fewer resources—physicians, nurses, ancillary personnel, equipment, and time and space—available to respond to emergency cases.
By law, the front door of the ED is always open. When a hospital’s inpatient beds are full, as is frequently the case, ED providers cannot transfer
the most severely ill and injured patients to an inpatient unit. As a result,
ED patients who require hospitalization begin to back up in the ED. The
aggregate result of this imbalance between public demand and hospital capacity is an epidemic of overcrowded EDs, frequent “boarding” of patients
waiting for inpatient beds, and ambulance diversion:
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HOSPITAL-BASED EMERGENCY CARE
• Overcrowding—ED overcrowding is a nationwide phenomenon, affecting rural and urban areas alike. In one study, 91 percent of EDs responding to a national survey reported overcrowding as a problem; almost 40
percent reported that overcrowding occurred daily. Overcrowding induces
stress in providers and patients, and can lead to errors and impaired overall
quality of care.
• Boarding—A consequence of crowded EDs is the practice of boarding—holding a patient who needs to be admitted in the ED until an inpatient
bed becomes available. It is not unusual for patients in a busy hospital ED
to be boarded for 48 hours or more. In a nationwide survey of nearly 90
EDs across the country, conducted on a typical Monday evening, 73 percent
of hospitals reported boarding two or more patients. Boarding not only
compromises the patient’s hospital experience, but also adds to an already
stressful work environment for physicians and nurses and enhances the
potential for errors, delays in treatment, and diminished quality of care.
• Ambulance diversion—Another consequence of crowding is ambulance diversion—when EDs become saturated to the point that patient safety
is compromised, ambulances are diverted to alternative hospitals. Once a
safety valve to be used in extreme situations, this has now become a commonplace event. A recent study reported that 501,000 ambulances were
diverted in 2003, an average of 1 per minute. According to the American
Hospital Association, nearly half of all hospitals, and close to 70 percent
of urban hospitals, reported time on diversion in 2004. Ambulance diversion can lead to catastrophic delays in treatment for seriously ill or injured
patients. It also frequently leads to treatment in facilities with inadequate
expertise and resources appropriate to the patient’s severity of illness, placing the patient at significant risk.
FINDINGS AND RECOMMENDATIONS
This section presents the committee’s key findings and recommendations
for meeting the challenge of increased demand and inadequate capacity and
improving the quality of hospital-based emergency and trauma care. These
findings and recommendations address the need to enhance operational efficiency, the use of information technology, the burden of uncompensated
care, inadequate disaster preparedness, the emergency care workforce, and
the need for research in emergency care.
Enhanced Operational Efficiency
Hospital EDs and trauma centers have little control over external forces
that contribute to crowding, such as increasing numbers of uninsured or
the growing severity of patients’ conditions. There is, however, a great deal
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SUMMARY
they can do to manage the impact of these forces. Innovations in industrial
engineering that have swept through other sectors of the economy, from
banking to air travel to manufacturing, have failed to take hold in health
care delivery—a sector of the economy that now consumes 16 percent of
the nation’s gross domestic product and is growing at twice the rate of
inflation.
Tools derived from engineering and operations research have been directed successfully at the problem of hospital efficiency in general and ED
crowding in particular. A wide range of tools have been developed and tested
for addressing patient flow—defined as the movement of patients through
the hospital system—generally with good success. Efficient patient flow can
increase the volume of patients treated and discharged and minimize delays
at each point in the delivery process while improving the quality of care.
For example, while controlled studies have yet to be conducted, a growing body of experience suggests that using queuing theory to smooth the
peaks and valleys of patient admissions can eliminate bottlenecks, reduce
crowding, improve patient care, and reduce costs. The committee recommends that hospital chief executive officers adopt enterprisewide operations
management and related strategies to improve the quality and efficiency of
emergency care (4.2).1
A particularly promising technique for managing patient flow is the
use of clinical decision units (CDUs), also known as observation units. The
technique was developed as a means of monitoring patients with chest pain
who had a low to intermediate probability of acute myocardial infarction
(AMI). By observing patients for up to 23 hours, ED staff were able to
rule out many patients at risk of AMI while using fewer resources than
would have been consumed if these same patients had been admitted to the
intensive care unit (ICU) or an inpatient telemetry unit. Today, the Centers
for Medicare and Medicaid Services (CMS) reimburses CDU stays for only
three conditions: chest pain, asthma, and congestive heart failure. Because
of the demonstrated success of CDUs, the committee recommends that the
Centers for Medicare and Medicaid Services remove current restrictions on
the medical conditions that are eligible for separate clinical decision unit
payment (4.1).
Incentives to Reduce Crowding and Boarding
While hospitals can use many approaches to reduce crowding and
boarding, there are limited financial incentives for them to do so. Hospitals
1The committee’s recommendations are numbered according to the chapter of the main
report in which they appear. Thus, for example, recommendation 2.1 is the first recommendation in Chapter 2.
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HOSPITAL-BASED EMERGENCY CARE
are not reimbursed for differences in costs that are often associated with
admissions from the ED. Further, hospitals do not face significant negative
financial consequences for operating crowded EDs. In 2004, following a July
2002 alert that tied treatment delays to more than 50 hospital deaths, the
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
instituted new guidelines that would have required accredited hospitals
to take serious steps to reduce crowding, boarding, and diversion. Under
industry pressure, however, these requirements were withdrawn and replaced with a weaker standard. The committee recommends that the Joint
Commission on Accreditation of Healthcare Organizations reinstate strong
standards designed to sharply reduce and ultimately eliminate emergency
department crowding, boarding, and diversion (4.4). Furthermore, because
the practices of boarding and diversion are so antithetical to quality medical
care, the strongest possible measures should be taken to eliminate them. The
committee recommends that hospitals end the practices of boarding patients
in the emergency department and ambulance diversion, except in the most
extreme cases, such as a community mass casualty event. The Centers for
Medicare and Medicaid Services should convene a working group that includes experts in emergency care, inpatient critical care, hospital operations
management, nursing, and other relevant disciplines to develop boarding
and diversion standards, as well as guidelines, measures, and incentives for
implementation, monitoring, and enforcement of these standards (4.5).
Leadership in Improving Hospital Efficiency
Beyond the use of incentives, the committee looks to hospital executives, including both chief executive officers (CEOs) and midlevel managers,
to provide visionary leadership in promoting the use of patient flow and
operations management approaches to improve hospital efficiency. Hospital
leaders should be open to learning from the experiences of industries outside
of health care, and should be bold and creative in applying these and other
new ideas. To foster the development of hospital leadership in improving
hospital efficiency, the committee recommends that training in operations
management and related approaches be promoted by professional associations; accrediting organizations, such as the Joint Commission on Accreditation of Healthcare Organizations and the National Committee for Quality
Assurance; and educational institutions that provide training in clinical,
health care management, and public health disciplines (4.3).
Use of Information Technology
Opportunities to improve patient flow, operational efficiency, and
quality of care can be enhanced by appropriate information technologies.
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SUMMARY
Hospitals, however, lag behind other industries in the use of information
technologies, particularly those used to support process management.
Information technologies have broad application to hospitals and health
systems, but their use involves unique needs and approaches in emergency
care. Information is critically important for rapid decision making in emergency and trauma care. But emergency physicians are all too often deprived
of critical patient information; indeed, it has been said that EDs operate
on information “fumes.” The following information technologies could
significantly enhance emergency care: (1) dashboard systems that track and
coordinate patient flow, (2) communications systems that enable ED physicians to link to patients’ records or providers, (3) clinical decision-support
programs that improve decision making, (4) documentation systems for collecting and storing patient data, (5) computerized training and information
retrieval, and (6) systems to facilitate public health surveillance. Given their
demonstrated effectiveness in the emergency care setting, the committee
recommends that hospitals adopt robust information and communications
systems to improve the safety and quality of emergency care and enhance
hospital efficiency (5.1). The committee recognizes that the appropriate
prioritization of and investment in these approaches will vary based on each
institution’s resources and needs.
The Burden of Uncompensated Care
In most hospitals, if reimbursements fail to cover ED and trauma
costs, these costs are subsidized by admissions that originate in the ED.
But uncompensated care can be an extreme burden at hospitals that have
large numbers of uninsured patients. Many hospital ED and trauma center
closures are attributed to financial losses associated with emergency and
trauma care. Public hospitals and tertiary medical centers bear a large share
of this burden, as surrounding community hospitals often transfer their most
complex, high-risk patients to the large safety net hospitals for specialized
care. Often, the condition of these patients has deteriorated considerably
since their arrival at the referring hospital. Hospitals receive Disproportionate Share Hospital (DSH) payments from both Medicare and Medicaid to
compensate for these losses, but these payments are inadequate for hospitals
with large safety net populations. As a result, the emergency and trauma
care safety net system is at risk in many regions. To ensure the continued
viability of a critical public safety function, the committee recommends
that Congress establish dedicated funding, separate from Disproportionate
Share Hospital payments, to reimburse hospitals that provide significant
amounts of uncompensated emergency and trauma care for the financial
losses incurred by providing those services (2.1).
The committee believes that accurate determination of the optimal
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HOSPITAL-BASED EMERGENCY CARE
amount of funding to allocate for this purpose, which could run into the
hundreds of millions of dollars, is beyond its expertise, but that the government must begin to address this issue immediately. The committee therefore
recommends that Congress initially appropriate $50 million for the purpose,
to be administered by the Centers for Medicare and Medicaid Services
(2.1a). The Centers for Medicare and Medicaid Services should establish
a working group to determine the allocation of these funds, which should
be targeted to providers and localities at greatest risk; the working group
should then determine funding needs for subsequent years (2.1b).
Inadequate Disaster Preparedness
On September 10, 2001, the cover story of U.S. News and World Report described an emergency care system in critical condition as a result of
demands far in excess of its capacity. While the article focused on the dayto-day problems of diversion and boarding, the events of the following day
brought home a frightening realization to many: If we cannot take care of
our emergency patients on a normal day, how will we manage a large-scale
disaster? More than 4 years after the terrorist attacks of 2001, Hurricane
Katrina revealed how far we have is to go in this regard. While Katrina was
unusual in its size and scope, the capacity of the emergency care system to
respond effectively even to smaller disasters is very much in question.
Surge Capacity
Hospitals in many large cities are operating at or near full capacity. A
multiple-car highway crash can create havoc in an ED. Few hospitals have
the capacity to handle a major mass casualty event. One reason for this
lack of capacity is the small amount of funding for bioterrorism and other
emergency threats that has gone directly to hospitals. For example, hospital
grants from the Health Resources and Services Administration’s Bioterrorism Hospital Preparedness Program in 2002 were typically between $5,000
and $10,000—insufficient to equip even one critical care room.
Training
Training for ED workers in disaster preparedness is also deficient. In
2003, hospital training varied widely among staff: 92 percent of hospitals
trained their nursing staff in responding to at least one type of threat, but
residents and interns received any such training at only 49 percent of hospitals (although this represented an improvement over the situation prior
to the terrorist attacks of 2001).
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SUMMARY
Protection of Hospitals and Staff
Protecting hospitals and their staff from biological or chemical events
poses extraordinary challenges. The outbreak of severe acute respiratory
syndrome (SARS) in Toronto in 2003 revealed the difficulties associated
with containing even a small outbreak—particularly when health professionals themselves become both victims and spreaders of disease. One of
the most important tools in such an event is negative pressure rooms that
prevent the spread of airborne pathogens. Unfortunately, the number of such
rooms is limited, and they are generally restricted to a handful of tertiary
hospitals in each major population center. The committee believes that this
lack of adequate negative pressure suites is a critical vulnerability of the
current system, and that the existing capacity could be quickly overwhelmed
by either a terrorist event or a major outbreak of avian influenza or some
other airborne disease, posing an extreme danger to hospital workers and
patients.
Staff must also be protected through appropriate personal protective
equipment. Current training and equipment in this regard are inadequate. In
2005, the Occupational Safety and Health Administration developed guidelines for use of personal protective equipment, but more needs to be done.
Approaches to Improve Disaster Preparedness
To address the above concerns about surge capacity, training, and
protection of hospitals and staff, the committee recommends that Congress
significantly increase total preparedness funding in fiscal year 2007 for
hospital emergency preparedness in the following areas: strengthening and
sustaining trauma care systems; enhancing emergency department, trauma
center, and inpatient surge capacity; improving emergency medical services’
response to explosives; designing evidence-based training programs; enhancing the availability of decontamination showers, standby intensive care
unit capacity, negative pressure rooms, and appropriate personal protective
equipment; and conducting international collaborative research on the civilian consequences of conventional weapons terrorism (7.3).
In addition, to further address the need for competency in disaster
medicine across disciplines, the committee recommends that all institutions
responsible for the training, continuing education, and credentialing and
certification of professionals involved in emergency care (including medicine, nursing, emergency medical services, allied health, public health, and
hospital administration) incorporate disaster preparedness training into
their curricula and competency criteria (7.2).
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10 HOSPITAL-BASED EMERGENCY CARE
The Emergency Care Workforce
Emergency care is delivered in an inherently challenging environment,
often requiring providers to make life-and-death decisions with little time
and information. Emergency care providers wage battles on many fronts, including scheduling diagnostic tests; obtaining timely laboratory results and
drugs; getting patients admitted to the hospital; finding specialists willing
to come in during the middle of the night; and finding psychiatric centers,
skilled nursing facilities, or specialists who are willing to accept referrals.
ED staff often confront violence and deal with an array of social problems
that confound their attempts to heal their patients. As a result, providers on
the front lines of emergency care are increasingly exhausted, stressed out,
and frustrated by the deteriorating state of emergency care and the safety
net it supports.
On-Call Specialists
One of the most troubling trends is the increasing difficulty of finding
specialists to take emergency call. Providing emergency call has become
unattractive to many specialists in critical fields such as neurosurgery and
orthopedics. Specialists have difficulty collecting payment for on-call services, in part because many emergency and trauma patients are uninsured;
nearly 80 percent of specialists in one survey had difficulty obtaining payment for such services. Liability concerns also discourage many specialists
from taking emergency call. Procedures performed on emergency patients
are inherently risky and expose specialists to an increased likelihood of litigation. Patients are often sicker, and emergency procedures are frequently
performed in the middle of the night or on weekends, when the hospital’s
staffing and capabilities are not at their peak. A national survey of neurosurgeons found that 36 percent had been sued by patients seen through the ED.
These factors drive premiums for physicians who take emergency call well
above those for physicians who do not. The problem has been exacerbated
by recently revised guidelines under the Emergency Medical Treatment and
Active Labor Act that make it easier for on-call physicians to limit their
emergency practices.
Hospitals are using a number of different strategies to stabilize the
services of on-call physicians. One promising approach is to regionalize the
services of certain on-call specialties so that every hospital need not maintain
on-call services for every specialty. Such regionalization would rationalize
the limited supply of specialists by ensuring coverage at key tertiary and
secondary locations based on actual need, replacing the current haphazard
approach that is based on many factors other than need. For example, one
county is developing a communitywide cooperative that will contract collec-
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SUMMARY 11
tively for the services of certain specialists. The committee recommends that
hospitals, physician organizations, and public health agencies collaborate to
regionalize critical specialty care on-call services (6.1).
Exposure of Emergency Providers to Medical Malpractice Claims
As noted above, physicians providing emergency and trauma care face
extraordinary exposure to medical malpractice claims—far greater than
those not providing such care. Safety net providers are especially affected
by the liability problem: as on-call panels diminish at community hospitals,
these hospitals increasingly export their sickest patients to the large safety
net hospitals, which have no choice but to accept them. The result is even
higher concentrations of uninsured, high-risk patients. Protections must be
instituted so that emergency providers and EDs do not become the dumping
ground for the liability crisis. Although the public is largely unaware of the
situation, this crisis has already seriously eroded the capacity of emergency
and trauma care across many cities. Therefore, the committee recommends
that Congress appoint a commission to examine the impact of medical
malpractice lawsuits on the declining availability of providers in high-risk
emergency and trauma care specialties, and to recommend appropriate state
and federal actions to mitigate the adverse impact of these lawsuits and
ensure quality of care (6.2).
The Rural Workforce
Rural EDs face persistent shortages of emergency and trauma physicians, as well as on-call specialists. With such shortages likely to continue,
it is important to find alternative ways of enhancing emergency services
in rural areas. One approach is to increase collaboration between rural
hospitals and regional academic health centers to foster training, resource
sharing, and coordination of care. The committee recommends that states
link rural hospitals with academic health centers to enhance opportunities
for professional consultation, telemedicine, patient referral and transport,
and continuing professional education (6.6).
Need for Emergency Care Research
Although emergency medicine and trauma surgery are relatively young
specialties, researchers have made important contributions to both basic science and clinical practice that have dramatically improved emergency care
and have resulted in significant advances in general medicine. Examples are
assessment and management of cardiac arrest, including the development
and refinement of guidelines for cardiopulmonary resuscitation (CPR), the
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12 HOSPITAL-BASED EMERGENCY CARE
pharmacology of resuscitation, understanding and treatment of hemorrhagic shock, and electrocardiogram (EKG) analysis of ventricular fibrillation.
Because emergency care and trauma care are young fields, however, they
are not strongly represented in the political infrastructure of the National
Institutes of Health (NIH), its various institutes, and its study sections. As a
result, scant resources are allocated to advance the science of such care, and
few training grants are offered to develop researchers who want to focus
on emergency care. For example, only .05 percent of NIH training grants
awarded to medical schools goes to departments of emergency medicine—an
average of only $51.66 per graduating resident. In contrast, internal medicine receives approximately $5,000.00 per graduating resident.
The current uncoordinated approach to organizing and funding emergency and trauma care has been inadequate. There are well-defined emergency and trauma care research questions that would benefit from a coordinated and well-funded research strategy. Therefore, the committee
recommends that the Secretary of the Department of Health and Human
Services conduct a study to examine the gaps and opportunities in emergency and trauma care research, and recommend a strategy for the optimal
organization and funding of the research effort (8.2).
This study should include consideration of training of new investigators, development of multicenter research networks, funding of General Clinical Research
Centers that specifically include an emergency and trauma care component,
involvement of emergency and trauma care researchers in the grant review and
research advisory processes, and improved research coordination through a
dedicated center or institute (8.2a).
Congress and federal agencies involved in emergency and trauma care research
(including the Department of Transportation, the Department of Health and
Human Services, the Department of Homeland Security, and the Department
of Defense) should implement the study’s recommendations (8.2b).
ACHIEVING THE VISION OF A 21ST-CENTURY
EMERGENCY CARE SYSTEM
Hospital-based emergency and trauma care is part of an interdependent
system of emergency services; thus optimizing such care requires improvements in both hospital-based care and the larger system. To that end, the
committee developed a vision for the future of emergency care that centers
around three goals: coordination, regionalization, and accountability. Many
elements of this vision have been advocated previously; however, progress
toward achieving these elements has been derailed by deeply entrenched
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SUMMARY 13
parochial interests and cultural attitudes, as well as funding cutbacks and
practical impediments to change. Concerted, cooperative efforts at all levels
of government—federal, state, regional, local—and the private sector are
necessary to finally break through and achieve this vision.
Coordination
One of the most long-standing problems with the emergency care
system is that services are fragmented. Prehospital emergency medical services (EMS), hospitals, trauma centers, and public health have traditionally
worked in silos. For example, public safety and EMS agencies often lack
common radio frequencies and protocols for communicating with each
other during emergencies. Similarly, emergency care providers lack access
to patient medical histories that could be useful in decision making.
Ensuring that each patient is directed to the most appropriate setting,
including a level I trauma center when necessary, requires that many elements within the regional system—community hospitals, trauma centers,
and particularly prehospital EMS—coordinate the regional flow of patients
effectively. In addition to improving patient care, coordinating the regional
flow of patients is a critical tool in reducing overcrowding in EDs.
Unfortunately, only a handful of systems around the country coordinate transport effectively at the regional level. Short of formally instituting
diversion, there is typically little information sharing between hospitals and
EMS regarding overloaded EDs and trauma centers and the availability of
ED beds, operating suites, equipment, trauma surgeons, and critical specialists—information that could be used to balance the load among EDs and
trauma centers regionwide. Too often a hospital’s location places it in a
logistical situation in which it is overloaded with emergencies and trauma
cases while an ED several blocks away may be working at a comfortable
50 percent capacity. There is little incentive for ambulances to drive by a
hospital to take patients to a facility that is less crowded.
The benefits to patients of better regional coordination have been demonstrated. The technologies needed to facilitate such coordination exist, and
police and fire departments are ahead in this regard. The main impediment
appears to be entrenched interests and a lack of vision to motivate change
in the current system.
The committee envisions a system in which all patients receive wellplanned and coordinated emergency care services. Dispatch, EMS, ED providers, public safety, and public health should be fully interconnected and
united in an effort to ensure that each patient receives the most appropriate
care, at the optimal location, with the minimum delay. From the standpoint
of patients, delivery of emergency care services should be seamless.
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14 HOSPITAL-BASED EMERGENCY CARE
Regionalization
Because not all hospitals within a community have the personnel and
resources to support the delivery of high-level emergency care, critically ill
and injured patients should be directed specifically to those facilities with
such capabilities. That is the goal of regionalization. There is substantial
evidence that the use of regionalization of services to direct such patients
to designated hospitals with greater experience and resources improves
outcomes and reduces costs across a range of high-risk conditions and procedures. Thus the committee supports further regionalization of emergency
care services. However, use of this approach requires that prehospital providers, as well as patients and caregivers, be clear on which facilities have
the necessary resources. Just as trauma centers are categorized according
to their capabilities (i.e., level I–level IV/V), a standard national approach
to the categorization of EDs that reflects their capabilities is needed so the
categories will be clearly understood by providers and the public across all
states and regions of the country. To that end, the committee recommends
that the Department of Health and Human Services and the National Highway Traffic Safety Administration, in partnership with professional organizations, convene a panel of individuals with multidisciplinary expertise
to develop an evidence-based categorization system for emergency medical
services, emergency departments, and trauma centers based on adult and
pediatric service capabilities (3.1).
This information, in turn, could be used to develop protocols that
would guide EMS providers in the transport of patients and improve the
regional coordination of patient flow. These protocols should be based on
current and emerging evidence about the appropriate models for transport
given the patient’s condition and location, and should include protocols
that, given appropriate information about the status of facilities, direct
patients to less crowded local EDs rather than to the highest-level center.
Therefore, the committee also recommends that the National Highway Traffic Safety Administration, in partnership with professional organizations,
convene a panel of individuals with multidisciplinary expertise to develop
evidence-based model prehospital care protocols for the treatment, triage,
and transport of patients (3.2).
Accountability
Without accountability, participants in the emergency care system
need not accept responsibility for failures and can avoid making changes
to improve the delivery of care. Accountability has failed to take hold in
emergency care to date because responsibility is dispersed across many different components of the system, so it is difficult even for policy makers to
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SUMMARY 15
determine where system breakdowns occur and how they can subsequently
be addressed.
To build accountability into the system, the committee recommends
that the Department of Health and Human Services convene a panel of
individuals with emergency and trauma care expertise to develop evidencebased indicators of emergency and trauma care system performance (3.3).
Because of the need for an independent, national process with the broad
participation of every component of emergency care, the federal government should play a lead role in promoting and funding the development
of these performance indicators. The indicators developed should include
structure and process measures, but evolve toward outcome measures over
time. These performance measures should be nationally standardized so
that statewide and national comparisons can be made. Measures should
evaluate the performance of individual providers within the system, as well
as that of the system as a whole. Measures should also be sensitive to the
interdependence among the components of the system; for example, EMS
response times may be related to EDs going on diversion.
Using the measures developed through such a national, evidence-based,
multidisciplinary effort, performance data should be collected at regular
intervals from all hospitals and EMS agencies in a community. Public dissemination of performance data is crucial to driving the needed changes in
the delivery of emergency care services. Dissemination could take various
forms, including public report cards, annual reports, and state public health
reports. Because of the potential sensitivity of performance data, the data
should initially be reported in the aggregate rather than at the level of the
individual provider. Individual providers should have full access to their
own data so they can understand and improve their performance, as well as
contribute to the overall system. Over time, individual provider information
should become an important part of the public information on the system.
These performance measures should ultimately become the basis for pay-forperformance initiatives as those reimbursement techniques mature.
Achieving the Vision
States and regions face a variety of different situations, including the
level of development of trauma systems; the effectiveness of state EMS offices and regional EMS councils; and the degree of coordination among
fire departments, EMS, hospitals, trauma centers, and emergency management. Thus no single approach to enhancing emergency care systems will
achieve the goals outlined above. A number of different avenues should be
explored and evaluated to determine what types of systems are best able to
achieve the three goals. The committee therefore recommends that Congress
establish a demonstration program, administered by the Health Resources
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16 HOSPITAL-BASED EMERGENCY CARE
and Services Administration, to promote coordinated, regionalized, and accountable emergency care systems throughout the country, and appropriate
$88 million over 5 years to this program (3.5). Grants should be targeted
at states, which could develop projects at the state, regional, or local level;
cross-state collaborative proposals would also be encouraged. Over time,
and over a number of controlled initiatives, such a process should lead to
important insights about what strategies work under different conditions.
These insights would provide best-practice models that could be widely
adopted to advance the nation toward the committee’s vision for efficient,
high-quality emergency and trauma care.
Supporting System Integration
Reducing fragmentation at the state and local levels will require federal
leadership and support. Today, however, the federal agencies that support
and regulate emergency services mirror the fragmentation of emergency
services at the state and local levels. Prehospital EMS, hospital-based emergency care, trauma care, injury prevention and control, and medical disaster
preparedness are scattered across numerous agencies within the Department
of Health and Human Services, the U.S. Department of Transportation, and
the Department of Homeland Security.
Strong federal leadership for emergency and trauma care is at the heart
of the committee’s vision for the future, and continued fragmentation of responsibility at the federal level is unacceptable. A lead federal agency could
better move the emergency and trauma care system toward improved integration; unify decision making, including funding decisions; and represent
all emergency and trauma care patients, providers, and settings, including
prehospital EMS (both ground and air), hospital-based emergency and
trauma care, pediatric emergency and trauma care, rural emergency and
trauma care, and medical disaster preparedness. The committee therefore
recommends that Congress establish a lead agency for emergency and
trauma care within 2 years of this report. The lead agency should be housed
in the Department of Health and Human Services, and should have primary
programmatic responsibility for the full continuum of emergency medical
services and emergency and trauma care for adults and children, including medical 9-1-1 and emergency medical dispatch, prehospital emergency
medical services (both ground and air), hospital-based emergency and
trauma care, and medical-related disaster preparedness. Congress should establish a working group to make recommendations regarding the structure,
funding, and responsibilities of the new agency, and develop and monitor
the transition. The working group should have representation from federal
and state agencies and professional disciplines involved in emergency and
trauma care (3.6).
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Committee on the Future of Emergency Care
in the United States Health System
Board on Health Care Services
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NOTICE: The project that is the subject of this report was approved by the Governing Board
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This study was supported by Contract No. 282-99-0045 between the National Academy of
Sciences and the U.S. Department of Health and Human Services’ Agency for Healthcare
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Library of Congress Cataloging-in-Publication Data
Hospital-based emergency care : at the breaking point / Committee on the Future of
Emergency Care in the United States Health System, Board on Health Care Services.
p. ; cm. — (Future of emergency care series)
Includes bibliographical references and index.
ISBN-13: 978-0-309-10173-8 (hardback)
ISBN-10: 0-309-10173-5 (hardback)
1. Hospitals—Emergency services. 2. Emergency medical services. I. Institute of Medicine
(U.S.). Committee on the Future of Emergency Care in the United States Health System. II.
Series.
[DNLM: 1. Emergency Service, Hospital—United States. 2. Health Care Reform—United
States. WX 215 H8261 2007]
RA975.5.E5H67723 2007
362.11—dc22
2007000079
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Advising the Nation. Improving Health.
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COMMITTEE ON THE FUTURE OF EMERGENCY CARE
IN THE UNITED STATES HEALTH SYSTEM
GAIL L. WARDEN (Chair), President Emeritus, Henry Ford Health
System, Detroit, Michigan
STUART H. ALTMAN, Sol C. Chaikin Professor of National Health
Policy, Heller School of Social Policy, Brandeis University, Waltham,
Massachusetts
BRENT R. ASPLIN, Associate Professor of Emergency Medicine,
University of Minnesota and Department Head, Regions Hospital
Emergency Department, St. Paul
THOMAS F. BABOR, Chair, Department of Community Medicine and
Health Care, University of Connecticut Health Center, Farmington
ROBERT R. BASS, Executive Director, Maryland Institute for Emergency
Medical Services Systems, Baltimore
BENJAMIN K. CHU, Regional President, Southern California, Kaiser
Foundation Health Plan and Hospital, Pasadena
A. BRENT EASTMAN, Chief Medical Officer, N. Paul Whittier Chair of
Trauma, ScrippsHealth, San Diego, California
GEORGE L. FOLTIN, Director, Center for Pediatric Emergency Medicine,
Associate Professor of Pediatrics and Emergency Medicine, New York
University School of Medicine, Bellevue Hospital Center, New York
SHIRLEY GAMBLE, Chief Operating Officer, United Way Capital Area,
Austin, Texas
DARRELL J. GASKIN, Associate Professor, Department of Health Policy
and Management, Johns Hopkins Bloomberg School of Public Health,
Baltimore, Maryland
ROBERT C. GATES, Project Director, Medical Services for Indigents,
Health Care Agency, Santa Ana, California
MARIANNE GAUSCHE-HILL, Clinical Professor of Medicine and
Director, Prehospital Care, Harbor-UCLA Medical Center, Torrance,
California
JOHN D. HALAMKA, Chief Information Officer, Beth Israel Deaconess
Medical Center, Boston, Massachusetts
MARY M. JAGIM, Internal Consultant for Emergency Preparedness
Planning, MeritCare Health System, Fargo, North Dakota
ARTHUR L. KELLERMANN, Professor and Chair, Department of
Emergency Medicine and Director, Center for Injury Control, Emory
University School of Medicine, Atlanta, Georgia
WILLIAM N. KELLEY, Professor of Medicine, Biochemistry &
Biophysics, University of Pennsylvania School of Medicine, Philadelphia
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vi
PETER M. LAYDE, Professor and Interim Director, Health Policy Institute
and Co-Director, Injury Research Center, Medical College of Wisconsin,
Milwaukee
EUGENE LITVAK, Professor of Health Care and Operations Management
Director, Program for Management of Variability in Health Care
Delivery, Boston University Health Policy Institute, Massachusetts
RICHARD A. ORR, Associate Director, Cardiac Intensive Care Unit,
Medical Director, Children’s Hospital Transport Team of Pittsburgh
and Professor, University of Pittsburgh School of Medicine, Children’s
Hospital of Pittsburgh, Pennsylvania
JERRY L. OVERTON, Executive Director, Richmond Ambulance
Authority, Virginia
JOHN E. PRESCOTT, Dean, West Virginia University School of
Medicine, Morgantown
NELS D. SANDDAL, President, Critical Illness and Trauma Foundation,
Bozeman, Montana
C. WILLIAM SCHWAB, Professor of Surgery, Chief, Division of
Traumatology and Surgical Critical Care, Department of Surgery,
University of Pennsylvania Medical Center, Philadelphia
MARK D. SMITH, President and CEO, California Healthcare
Foundation, Oakland
DAVID N. SUNDWALL, Executive Director, Utah Department of Health,
Salt Lake City
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vii
SUBCOMMITTEE ON HOSPITAL-BASED EMERGENCY CARE
BENJAMIN K. CHU (Chair), Regional President, Southern California,
Kaiser Foundation Health Plan and Hospital, Pasadena
STUART H. ALTMAN, Sol C. Chaikin Professor of National Health
Policy, Heller School of Social Policy, Brandeis University, Waltham,
Massachusetts
BRENT R. ASPLIN, Associate Professor of Emergency Medicine,
University of Minnesota and Department Head, Regions Hospital
Emergency Department, St. Paul
JOHN D. HALAMKA, Chief Information Officer, Beth Israel Deaconess
Medical Center, Boston, Massachusetts
MARY M. JAGIM, Internal Consultant for Emergency Preparedness
Planning, MeritCare Health System, Fargo, North Dakota
KENNETH W. KIZER, President, Chief Executive Officer, and Chairman,
Medsphere Systems Corporation, Aliso Viejo, California
PETER M. LAYDE, Professor and Interim Director, Health Policy Institute
and Co-Director, Injury Research Center, Medical College of Wisconsin,
Milwaukee
EUGENE LITVAK, Professor of Health Care and Operations Management
Director, Program for Management of Variability in Health Care
Delivery, Boston University Health Policy Institute, Massachusetts
JOHN R. LUMPKIN, Senior Vice President, The Robert Wood Johnson
Foundation, Princeton, New Jersey
W. DANIEL MANZ, Director, Emergency Medical Services Division,
Vermont Department of Health, Burlington
JOHN E. PRESCOTT, Dean, West Virginia University School of
Medicine, Morgantown
C. WILLIAM SCHWAB, Professor of Surgery, Chief, Division of
Traumatology and Surgical Critical Care, Department of Surgery,
University of Pennsylvania Medical Center, Philadelphia
JOSEPH L. WRIGHT, Executive Director, Child Health Advocacy
Institute, Children’s National Medical Center; Professor of Pediatrics,
Emergency Medicine & Community Health, George Washington
University Schools of Medicine and Public Health, Washington, District
of Columbia; and State EMS Medical Director for Pediatrics, Maryland
Institute for Emergency Medical Services Systems, Baltimore
Study Staff
ROBERT B. GIFFIN, Study Co-Director and Senior Program Officer
SHARI M. ERICKSON, Study Co-Director and Program Officer
MEGAN MCHUGH, Senior Program Officer
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viii
BENJAMIN WHEATLEY, Program Officer
ANISHA S. DHARSHI, Research Associate
SHEILA J. MADHANI, Program Officer
CANDACE TRENUM, Senior Program Assistant
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ix
Reviewers
This report has been reviewed in draft form by individuals chosen
for their diverse perspectives and technical expertise, in accordance with
procedures approved by the National Research Council’s Report Review
Committee. The purpose of this independent review is to provide candid
and critical comments that will assist the institution in making its published
report as sound as possible and to ensure that the report meets institutional
standards for objectivity, evidence, and responsiveness to the study charge.
The review comments and draft manuscript remain confidential to protect
the integrity of the deliberative process. We wish to thank the following
individuals for their review of this report:
E. JOHN GALLAGHER, Department of Emergency Medicine, Albert
Einstein College of Medicine, Montefiore Medical Center, Bronx,
New York
KRISTINE M. GEBBIE, Center for Health Policy, Columbia University
School of Nursing, New York, New York
LEWIS R. GOLDFRANK, Department of Emergency Medicine, New York
University School of Medicine, New York University Medical Center
and Bellevue Hospital Center, New York
JERRIS R. HEDGES, School of Medicine, Oregon Health & Science
University, Portland
GARY JOHNSON, Department of Family Medicine, University of Nevada
School of Medicine, Reno
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REVIEWERS
D. RANDY KUYKENDALL, Emergency Medical and Trauma Services
Section, Health Facilities & Emergency Medical Services Division,
Colorado Department of Public Health & Environment, Colorado
Springs
RONALD V. MAIER, Department of Surgery, Harborview Medical
Center, Seattle, Washington
MITCHELL T. RABKIN, Harvard Medical School, Beth Israel Deaconess
Medical Center, Boston, Massachusetts
SARA ROSENBAUM, Department of Health Policy, School of Public
Health and Health Services, The George Washington University Medical
Center, Washington, District of Columbia
ALEX B. VALADKA, Department of Neurological Surgery, University of
Texas Medical School at Houston
Although the reviewers listed above have provided many constructive
comments and suggestions, they were not asked to endorse the conclusions
or recommendations nor did they see the final draft of the report before its
release. The review of this report was overseen by Enriqueta C. Bond, Burroughs Wellcome Fund, and Don E. Detmer, American Medical Informatics
Association. Appointed by the National Research Council and the Institute
of Medicine, they were responsible for making certain that an independent
examination of this report was carried out in accordance with institutional
procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring
committee and the institution.
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xi
Foreword
The state of emergency care affects every American. When illness or
injury strikes, Americans count on the emergency care system to respond
with timely and high-quality care. Yet today, the emergency and trauma care
that Americans receive can fall short of what they expect and deserve.
Emergency care is a window on health care, revealing both what is right
and what is wrong with the care delivery system. Americans increasingly
rely on hospital emergency departments because of the skilled specialists
and advanced technologies they offer. At the same time, the increasing use
of the emergency care system represents failures of the larger health care
system—the growing numbers of uninsured Americans, the limited alternatives available in many communities, and the inadequate preventive care
and chronic care management received by many. The resulting demands on
the system can degrade the quality of emergency care and hinder the ability
to provide urgent and lifesaving care to seriously ill and injured patients
wherever and whenever they need it.
The Committee on the Future of Emergency Care in the United States
Health System, ably chaired by Gail Warden, set out to examine the emergency care system in the United States; explore its strengths, limitations, and
future challenges; describe a desired vision of the emergency care system;
and recommend strategies required to achieve that vision. Their efforts build
on past contributions of the National Academies, including the landmark
National Research Council report Accidental Death and Disability: The
Neglected Disease of Modern Society in 1966, Injury in America: A Continuing Public Health Problem in 1985, and Emergency Medical Services
for Children in 1993.
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xii FOREWORD
The committee’s task in the present study was to examine the full scope
of emergency care, from 9-1-1 and medical dispatch to hospital-based
emergency and trauma care. The three reports produced by the committee—
Hospital-Based Emergency Care: At the Breaking Point, Emergency Medical Services at the Crossroads, and Emergency Care for Children: Growing
Pains—provide three different perspectives on the emergency care system.
The series as a whole unites the often fragmented prehospital and hospitalbased systems under a common vision for the future of emergency care.
As the committee prepared its reports, federal and state policy makers
were turning their attention to the possibility of an avian influenza pandemic. Americans are asking whether we as a nation are prepared for such
an event. The emergency care system is on the front lines of surveillance
and treatment. The more secure and stable our emergency care system is,
the better prepared we will be to handle any possible outbreak. In this
light, the recommendations presented in these reports take on increased
urgency. The guidance they offer can assist all of the stakeholders in emergency care—the public, policy makers, providers, and educators—to chart
the future of emergency care in the United States.
Harvey V. Fineberg, M.D., Ph.D.
President, Institute of Medicine
June 2006
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xiii
Preface
Emergency care has made important advances in recent decades: emergency 9-1-1 service now links virtually all ill and injured Americans to
immediate medical response; organized trauma systems transport patients
to advanced, life-saving care within minutes; and advances in resuscitation
and lifesaving procedures yield outcomes unheard of just two decades ago.
Yet just under the surface, a growing national crisis in emergency care is
brewing. Emergency departments (EDs) are frequently overloaded, with
patients sometimes lining hallways and waiting hours and even days to be
admitted to inpatient beds. Ambulance diversion, in which overcrowded
EDs close their doors to incoming ambulances, has become a common,
even daily problem in many cities. Patients with severe trauma or illness
are often brought to the ED only to find that the specialists needed to treat
them are unavailable. The transport of patients to available emergency care
facilities is often fragmented and disorganized, and the quality of emergency
medical services (EMS) is highly inconsistent from one town, city, or region
to the next. In some areas, the system’s task of dealing with emergencies is
compounded by an additional task: providing nonemergent care for many of
the 45 million uninsured Americans. Furthermore, the system is ill prepared
to handle large-scale emergencies, whether a natural disaster, an influenza
pandemic, or an act of terrorism.
This crisis is multifaceted and impacts every aspect of emergency
care—from prehospital EMS to hospital-based emergency and trauma care.
The American public places its faith in the ability of the emergency care
system to respond appropriately whenever and wherever a serious illness
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xiv PREFACE
or injury occurs. But while the public is largely unaware of the crisis, it is
real and growing.
The Institute of Medicine’s Committee on the Future of Emergency
Care in the United States Health System was convened in September 2003
to examine the emergency care system in the United States, to create a vision
for the future of the system, and to make recommendations for helping the
nation achieve that vision. The committee’s findings and recommendations
are presented in the three reports in the Future of Emergency Care series:
• Hospital-Based Emergency Care: At the Breaking Point explores
the changing role of the hospital ED and describes the national epidemic
of overcrowded EDs and trauma centers. The range of issues addressed
includes uncompensated emergency and trauma care, the availability of
specialists, medical liability exposure, management of patient flow, hospital
disaster preparedness, and support for emergency and trauma research.
• Emergency Medical Services at the Crossroads describes the development of EMS over the last four decades and the fragmented system
that exists today. It explores a range of issues that affect the delivery of
prehospital EMS, including communications systems; coordination of the
regional flow of patients to hospitals and trauma centers; reimbursement
of EMS services; national training and credentialing standards; innovations
in triage, treatment, and transport; integration of all components of EMS
into disaster preparedness, planning, and response actions; and the lack of
clinical evidence to support much of the care that is delivered.
• Emergency Care for Children: Growing Pains describes the special
challenges of emergency care for children and considers the progress that has
been made in this area in the 20 years since the establishment of the federal
Emergency Medical Services for Children (EMS-C) program. It addresses
how issues affecting the emergency care system generally have an even
greater impact on the outcomes of critically ill and injured children. The
topics addressed include the state of pediatric readiness, pediatric training
and standards of care in emergency care, pediatric medication issues, disaster preparedness for children, and pediatric research and data collection.
THE IMPORTANCE AND SCOPE OF EMERGENCY CARE
Each year in the United States approximately 114 million visits to EDs
occur, and 16 million of these patients arrive by ambulance. In 2002, 43
percent of all hospital admissions in the United States entered through the
ED. The emergency care system deals with an extraordinary range of patients, from febrile infants, to business executives with chest pain, to elderly
patients who have fallen.
EDs are an impressive public health success story in terms of access to
Copyright © National Academy of Sciences. All rights reserved.
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PREFACE xv
care. Americans of all walks of life know where the nearest ED is and understand that it is available 24 hours a day, 7 days a week. Trauma systems
also represent an impressive achievement. They are a critical component of
the emergency care system since approximately 35 percent of ED visits are
injury-related, and injuries are the number one killer of people between the
ages of 1 and 44. Yet the development of trauma systems has been inconsistent across states and regions.
In addition to its traditional role of providing urgent and lifesaving care,
the emergency care system has become the “safety net of the safety net,”
providing primary care services to millions of Americans who are uninsured
or otherwise lack access to other community services. Hospital EDs and
trauma centers are the only providers required by federal law to accept,
evaluate, and stabilize all who present for care, regardless of their ability to
pay. An unintended but predictable consequence of this legal duty is a system
that is overloaded and underfunded to carry out its mission. This situation
can hinder access to emergency care for insured and uninsured alike, and
compromise the quality of care provided to all. Further, EDs have become
the preferred setting for many patients and an important adjunct to community physicians’ practices. Indeed, the recent growth in ED use has been
driven by patients with private health insurance. In addition to these responsibilities, emergency care providers have been tasked with the enormous
challenge of preparing for a wide range of emergencies, from bioterrorism
to natural disasters and pandemic disease. While balancing all of these tasks
is difficult for every organization providing emergency care, it is an even
greater challenge for small, rural providers with limited resources.
Improved Emergency Medical Services:
A Public Health Imperative
Since the Institute of Medicine (IOM) embarked on this study, concern about a possible avian influenza pandemic has led to worldwide
assessment of preparedness for such an event. Reflecting this concern,
a national summit on pandemic influenza preparedness was convened by
Department of Health and Human Services Secretary Michael O. Leavitt
on December 5, 2005, in Washington, D.C., and has been followed by
statewide summits throughout the country. At these meetings, many of
the deficiencies noted by the IOM’s Committee on the Future of Emergency Care in the United States Health System have been identified as
weaknesses in the nation’s ability to respond to large-scale emergency
situations, whether disease outbreaks, naturally occurring disasters, or
continued
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xvi PREFACE
FRAMEWORK FOR THIS STUDY
This year marks the fortieth anniversary of the publication of the
landmark National Academy of Sciences/National Research Council report
Accidental Death and Disability: The Neglected Disease of Modern Society.
That report described an epidemic of automobile-related and other injuries,
and harshly criticized the deplorable state of trauma care nationwide. The
report prompted a public outcry, and stimulated a flood of public and private initiatives to enhance highway safety and improve the medical response
to injuries. Efforts included the development of trauma and prehospital EMS
systems, creation of the specialty in emergency medicine, and establishment
of federal programs to enhance the emergency care infrastructure and build
a research base. To many, the 1966 report marked the birth of the modern
emergency care system.
Since then, the National Academies and the Institute of Medicine
(IOM) have produced a variety of reports examining various aspects of
the emergency care system. The 1985 report Injury in America called for
expanded research into the epidemiology and treatment of injury, and led to
the development of the National Center for Injury Prevention and Control
within the Centers for Disease Control and Prevention. The 1993 report
Emergency Medical Services for Children exposed the limited capacity of the
emergency care system to address the needs of children, and contributed to
the expansion of the EMS-C program within the Department of Health and
Human Services. It has been 10 years, however, since the IOM examined
any aspect of emergency care in depth. Furthermore, no National Academies
report has ever examined the full range of issues surrounding emergency
care in the United States.
acts of terrorism. During any such event, local hospitals and emergency
departments will be on the front lines.Yet of the millions of dollars going
into preparedness efforts, a tiny fraction has made its way to medical
preparedness, and much of that has focused on one of the least likely
threats—bioterrorism.The result is that few hospital and EMS professionals have had even minimal disaster preparedness training; even fewer
have access to personal protective equipment; hospitals, many already
stretched to the limit, lack the ability to absorb any significant surge in
casualties; and supplies of critical hospital equipment, such as decontamination showers, negative pressure rooms, ventilators, and intensive
care unit beds, are wholly inadequate. A system struggling to meet the
day-to-day needs of the public will not have the capacity to deal with a
sustained surge of patients.
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PREFACE xvii
That is what this committee set out to do. The objectives of the study
were to (1) examine the emergency care system in the United States; (2)
explore its strengths, limitations, and future challenges; (3) describe a desired vision for the system; and (4) recommend strategies for achieving this
vision.
STUDY DESIGN
The IOM Committee on the Future of Emergency Care in the United
States Health System was formed in September 2003. In May 2004, the
committee was expanded to comprise a main committee of 25 members
and three subcommittees. A total of 40 main and subcommittee members,
representing a broad range of expertise in health care and public policy,
participated in the study. Between 2003 and 2006, the main committee and
subcommittees met 19 times; heard public testimony from nearly 60 speakers; commissioned 11 research papers; conducted site visits; and gathered
information from hundreds of experts, stakeholder groups, and interested
individuals.
The magnitude of the effort reflects the scope and complexity of emergency care itself, which encompasses a broad continuum of services that
includes prevention and bystander care; emergency calls to 9-1-1; dispatch
of emergency personnel to the scene of injury or illness; triage, treatment,
and transport of patients by ambulance and air medical services; hospitalbased emergency and trauma care; subspecialty care by on-call specialists;
and subsequent inpatient care. Emergency care’s complexity can also be
traced to the multiple locations, diverse professionals, and cultural differences that span this continuum of services. EMS, for example, is unlike any
other field of medicine—over one-third of its professional workforce consists of volunteers. Further, EMS has one foot in the public safety realm and
one foot in medical care, with nearly half of all such services being housed
within fire departments. Hospital-based emergency care is also delivered by
an extraordinarily diverse staff—emergency physicians, trauma surgeons,
critical care specialists, and the many surgical and medical subspecialists
who provide services on an on-call basis, as well as specially trained nurses,
pharmacists, physician assistants, nurse practitioners, and others.
The division into a main committee and three subcommittees made it
possible to break down this enormous effort into several discrete components. At the same time, the committee sought to examine emergency care as
a comprehensive system, recognizing the interdependency of its component
parts. To this end, the study process was highly integrated. The main committee and three subcommittees were designed to provide for substantial
overlap, interaction, and cross-fertilization of expertise. The committee
concluded that nothing will change without cooperative and visionary lead-
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Hospital-Based Emergency Care: At the Breaking Point
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xviii PREFACE
ership at many levels and a concerted national effort among the principal
stakeholders—federal, state, and local officials; hospital leadership; physicians, nurses, and other clinicians; and the public.
The committee hopes that the reports in the Future of Emergency Care
series will stimulate increased attention to and reform of the emergency
care system in the United States. I wish to express my appreciation to the
members of the committee and subcommittees and the many panelists who
provided input at the meetings held for this study, and to the IOM staff for
their time, effort, and commitment to the development of these important
reports.
Gail L. Warden
Chair
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xix
Acknowledgments
The Future of Emergency Care series benefited from the contributions
of many individuals and organizations. The committee and Institute of
Medicine (IOM) staff take this opportunity to recognize and thank those
who helped in the development of the reports in the series.
A large number of individuals assembled materials that helped the committee develop the evidence base for its analyses. The committee appreciates
the contributions of experts from a variety of organizations and disciplines
who gave presentations during committee meetings or authored papers that
provided information incorporated into the series of reports. The full list
of presenters is provided in Appendix C. Authors of commissioned papers
are listed in Appendix D.
Committee members and IOM staff conducted a number of site visits
throughout the course of the study to gain a better understanding of certain aspects of the emergency care system. We appreciate the willingness
of staff from the following organizations to meet with us and respond to
questions: Beth Israel Deaconess Medical Center, Boston Medical Center,
Children’s National Medical Center, Grady Memorial Hospital, Johns
Hopkins Hospital, Maryland Institute for EMS Services Systems, Maryland
State Police Aviation Division, Richmond Ambulance Association, and
Washington Hospital Center.
We would also like to express appreciation to the many individuals
who shared their expertise and resources on a wide range of issues: Karen
Benson-Huck, Linda Fagnani, Carol Haraden, Lenworth Jacobs, Tom
Judge, Nadine Levick, Ellen MacKenzie, Dawn Mancuso, Rick Murray, Ed
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xx ACKNOWLEDGMENTS
Racht, Dom Ruscio, Carol Spizziri, Caroline Steinberg, Rosemary Stevens,
Peter Vicellio, and Mike Williams.
This study received funding from the Josiah Macy, Jr. Foundation, the
National Highway Traffic Safety Administration (NHTSA), and three agencies within the Department of Health and Human Services: the Agency for
Healthcare Research and Quality (AHRQ), the Centers for Disease Control
and Prevention (CDC), and the Health Resources and Services Administration (HRSA). We would like to thank the staff from those organizations
who provided us with information, documents, and insights throughout the
project, including Drew Dawson, Laurie Flaherty, Susan McHenry, Gamunu
Wijetunge, and David Bryson of NHTSA; Dan Kavanaugh, Christina
Turgel, and David Heppel of HRSA; Robin Weinick and Pam Owens of
AHRQ; Rick Hunt and Bob Bailey from CDC’s National Center for Injury
Prevention and Control; and many other helpful members of the staffs of
those organizations.
Important research and writing contributions were made by Molly
Hicks of Keene Mill Consulting, LLC. Karen Boyd, a Christine Mirzayan
Science and Technology Fellow of the National Academies, and two student
interns, Carla Bezold and Neesha Desai, developed background papers.
Also, our thanks to Rona Briere, who edited the reports, and to Alisa
Decatur, who prepared them for publication.
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xxi
Contents
SUMMARY 1
Study Charge, 1
The Challenge of High Demand and Inadequate System Capacity, 2
Findings and Recommendations, 4
Achieving the Vision of a 21st-Century Emergency Care System, 12
1 INTRODUCTION 17
A Growing National Crisis, 19
Impact on Quality and Patient Safety, 23
Purpose of This Study, 27
Study Scope, 29
Study Approach, 30
A Note about Terminology, 31
Organization of the Report, 32
2 THE EVOLVING ROLE OF HOSPITAL-BASED
EMERGENCY CARE 37
Imbalance between Demand and Capacity, 38
The Emergency Department as a Core Component of
Community Ambulatory Care, 42
Reimbursement for Emergency and Trauma Care, 52
Challenges of Care for Mental Health Conditions and
Substance Abuse, 59
Rural Emergency Care, 65
Summary of Recommendations, 70
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xxii CONTENTS
3 BUILDING A 21ST-CENTURY EMERGENCY CARE SYSTEM 81
The Goal of Coordination, 82
The Goal of Regionalization, 87
The Goal of Accountability, 94
Current Approaches, 102
A Proposal for Federal, State, and Local Collaboration
through Demonstration Projects, 107
Need for System Integration and a Federal Lead Agency, 110
Summary of Recommendations, 124
4 IMPROVING THE EFFICIENCY OF HOSPITAL-BASED
EMERGENCY CARE 129
The ED in the Context of the Health Care Delivery System, 129
Understanding Patient Flow through the Hospital System, 131
Impediments to Efficient Patient Flow in the ED, 135
Strategies for Optimizing Efficiency, 139
Overcoming Barriers to Enhanced Efficiency, 152
Summary of Recommendations, 160
5 TECHNOLOGY AND COMMUNICATIONS 165
Information Technology in the Health Care Delivery System, 167
Information Technology in the Emergency Department, 171
New Clinical Technologies, 190
Barriers to the Adoption of Information Technology, 194
Prioritizing Investments in Emergency Care Information
Technology, 200
Summary of Recommendations, 202
6 THE EMERGENCY CARE WORKFORCE 209
Physicians, 210
Nurses and Other Critical Providers, 229
Enhancing the Supply of Emergency Care Providers, 236
Building Core Competencies, 238
Addressing the Issue of Provider Safety, 240
Increasing Interprofessional Collaboration, 243
Addressing the Shortage of Rural Emergency Care Providers, 247
Summary of Recommendations, 251
7 DISASTER PREPAREDNESS 259
Defining Disaster, 260
Critical Hospital Roles in Disasters, 265
Challenges in Rural Areas, 281
Federal Funding for Hospital Preparedness, 283
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CONTENTS xxiii
Summary of Recommendations, 285
8 ENHANCING THE EMERGENCY CARE RESEARCH BASE 291
Emergency Medicine Research, 293
Trauma and Injury Control Research, 304
Barriers to Emergency Care Research, 311
Summary of Recommendations, 315
APPENDIXES
A Committee and Subcommittee Membership 321
B Biographical Information for Main Committee and
Hospital-Based Emergency Care Subcommittee 323
C List of Presentations to the Committee 337
D List of Commissioned Papers 343
E Statistics on Emergency and Trauma Care Utilization 345
F Historical Development of Hospital-Based Emergency and
Trauma Care 353
G Recommendations and Responsible Entities from the
Future of Emergency Care Series 365
INDEX 383
Copyright © National Academy of Sciences. All rights reserved.
This executive summary plus thousands more available at http://www.nap.edu
Hospital-Based Emergency Care: At the Breaking Point
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Copyright © National Academy of Sciences. All rights reserved.
This executive summary plus thousands more available at http://www.nap.edu
Hospital-Based Emergency Care: At the Breaking Point
http://books.nap.edu/catalog/11621.html
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This executive summary plus thousands more available at http://www.nap.edu
Hospital-Based Emergency Care: At the Breaking Point
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