Breaking point: Report calls for Congressional rescue of hospital emergency departments

Article Outline

• More I.T. in the ED
• A crisis in unfunded trauma care
• More research dollars for emergency care

The trends in patient demand and bed availability bode ill for US emergency departments (EDs), leading an influential panel of medical experts to call for Congressional aid.

Between 1993 and 2003 ED visits rose by 26%, from 90.3 to 113.9 million. During the same period the US lost 703 hospitals, 198,000 hospital beds and 425 hospital EDs.

It’s no surprise, then, that by the year 2001 some 60% of US hospitals were operating at their capacities, or exceeding them. The results of such trends are clear and painful: ED crowding and diversion.

In recognition of these challenges, and a changing world in which EDs may find themselves on the front lines during terrorist attacks and natural disasters like Hurricane Katrina, the Institute of Medicine devoted a subcommittee to Hospital-Based Emergency Care: At the Breaking Point. In this committee’s own words:

“These findings and recommendations address the need to enhance operational efficiency, the burden of uncompensated care, the use of information technology, inadequate disaster preparedness, the emergency care workforce, and research needs in emergency care.”

Ignoring these challenges will imperil the country’s emergency systems when they’re most needed, said subcommittee member Mary Jagim, RN, internal consultant for emergency preparedness planning, MeritCare Health System, Fargo, ND.

“With the emergency care system, we have developed a skyscraper built on stilts,” Jagim said. “We have piled and piled on things that it was not originally designed to do. In order to meet any type of catastrophic event a strong foundation is the most essential component and right now we don’t have that.”

The subcommittee made several recommendations to improve hospital efficiency, including improving management strategies and implementing financial penalties for hospital EDs that remain crowded. The panel said the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) should reinstate strong standards that address ED crowding, boarding and diversion. A JCAHO spokeswoman, when asked for comment, said the organization was still reviewing the reports.

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More I.T. in the ED 

Another recommendation for improving efficiency called for increased adoption of information technology–such as dashboard systems to track and coordinate patient flow–to improve the rapid decisionmaking capabilities and patient flow of EDs.

“There really are some hopeful new information technologies that focus on patient flow, understanding where the patients are, and making timely handoffs,” said Carmela Coyle, a senior vice president for policy with the American Hospital Association. “The goal is to make sure patients are moving through the system as efficiently as possible.”

However, some researchers, such as University of Pennsylvania sociologist Ross Koppel, PhD, cautioned that some new technologies used in hospitals aren’t specifically designed for EDs, and in their present state can hinder as much as they help.

“The vendors are more interested in building their market share than improving their software. What they need to do is spend some real hours in a real emergency room setting, watching doctors and nurses work, so their systems respond to the needs of the real world.”

The subcommittee recognized that hospitals have come under increasing strains because so much of their ED care is uncompensated, especially for hospitals in areas with large numbers of uninsured patients. In addition to existing Disproportionate Share Hospital payments from Medicaid and Medicare, the subcommittee recommended that Congress immediately establish dedicated funding to reimburse hospitals for their uncompensated emergency and trauma care.

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A crisis in unfunded trauma care 

Failure to take such actions would lead to further ED and trauma center down-sizing and closures as hospitals seek to cut costs, said Dr. Arthur Kellermann, chairman of the Department of Emergency Medicine and director of the Center for Injury Control, Emory University School of Medicine, Atlanta, Georgia. Kellermann himself has had to deal with fewer hospital beds.

“I want to get mad at my hospital administrators, but they have to have the hospital in the black at the end of the year so it can function the year after that,” he said.

If crowding is the business-as-usual state of US EDs, what will happen when a terrorist attack, hurricane or pandemic strains the system? Funding to beef up EDs for such events is poor, the subcommittee noted, with typical hospital grants from the Health Resources and Services Administration’s Bioterrorism Hospital Preparedness Program ranging from $5,000 to $10,000.

The subcommittee recommended that Congress significantly increase disaster preparedness funding for emergency centers in a number of areas, including strengthening trauma centers and boosting surge capacity.

The subcommittee also recognized the inherently difficult working conditions of emergency physicians: limited time to make critical decisions, stress, a never-ending stream of patients and exhaustion. But perhaps the most troubling trend, the subcommittee said, was the increasing difficulty of finding specialists, such as neurosurgeons and orthopedic surgeons, to take emergency on-call duty.

Dr. Brent King, chairman of the Department of Emergency Medicine at The University of Texas Medical School at Houston, explained the problem for specialists: a one-in-three chance of not collecting payment, high liability and extremely risky cases.

“These factors, combined, clearly impact their willingness to cover an emergency case,” King said.

The subcommittee sought to address the malpractice issue by recommending that Congress examine the impact of medical malpractice lawsuits on the availability of specialists in US trauma and emergency centers, and to take steps to mitigate their effect.

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More research dollars for emergency care 

Finally, the report calls for more funding to address a disparity in research funding for emergency care, noting that just .05% of National Institutes of Health training grants awarded to medical schools go to departments of emergency medicine. Internal medicine departments, by comparison, receive nearly 100 times the amount of funding per graduating resident.

“The potential power to improve human health with a focus applied to general emergency care research–not only emergency medicine, but trauma care, nursing, EMS – is probably one of the greatest opportunities we will have that will come out of this report,” Kellermann said. “It is low-hanging fruit. We can make an enormous impact very quickly with a very focused research agenda. … About $95 billion, that’s billion with a B, dollars are spent on research in the federal government every year on human health. If you take that number, probably less than 1-10th of 1% is being devoted now to emergency care. That is pretty astounding.”