The Institute of Medicine Committee on the Future of Emergency Care in the U.S. Health System
Findings and Recommendations
Gail L. Warden
Henry Ford Health System
Chair, Committee on the Future of Emergency Care in the U.S. Health System
Board on Health Care Services
Institute of Medicine
The National Academies
Subcommittee on Health
Committee on Ways and Means
U.S. House of Representatives
July 27, 2006
Good morning Madame Chair and members of the Subcommittee. My name is Gail Warden and I am President Emeritus of Henry Ford Hospital in Detroit, Michigan. I served as chair of the Institute of Medicine’s Committee on the Future of Emergency Care in the U.S. Health System.
The Institute of Medicine, or IOM as it is commonly called, was established in 1970 under the charter of the National Academy of Sciences to provide independent, objective, evidence-based advice to the government, health professionals, the private sector, and the public on matters relating to medicine and health care.
The Institute of Medicine’s Committee on the Future of Emergency Care was formed in September 2003 to examine the full scope of emergency care; explore its strengths, limitations and challenges; create a vision for the future of the system; and make recommendations to help the nation achieve that vision. Over 40 national experts from fields including emergency care, trauma, pediatrics, health care administration, public health, and health services research participated on the Committee or one of its subcommittees. The Committee produced three reports – one on prehospital emergency medical services (EMS), one on hospital-based emergency care, and one on pediatric emergency care. These reports provide complimentary perspectives on the emergency care system, while the series as a whole offers a common vision for the future of emergency care in the U.S.
This study was requested by Congress and funded through a Congressional appropriation, along with additional sponsorship from the Josiah Macy Jr. Foundation, the Agency for Healthcare Research and Quality, the Health Resources and Services Administration, the Centers for Disease Control and Prevention, and the National Highway Traffic Safety Administration.
I will briefly summarize the Committee’s findings and recommendations, giving particular attention to those that relate to hospital-based emergency care.
Emergency and trauma care are 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 1 for every 3 people in the U.S. While many Americans need emergency care only rarely, everyone counts on it to be available when needed.
Emergency care has made important strides over the past 40 years: emergency 9-1-1 service now links virtually all ill and injured Americans to an emergency medical response; EMS systems arrive to transport patients to advanced, life-saving care; and scientific advances in resuscitation, diagnostic testing, trauma and emergency medical care yield outcomes unheard of just two decades ago. Yet just beneath the surface, a growing crisis in emergency care is brewing; one that could imperil everyone’s access to care.
Emergency Department Crowding
The number of patients visiting EDs has been growing rapidly. There were 113.9 million ED visits in 2003, for example, up from 90.3 million a decade earlier. At the same time, the number of facilities available to deal with these visits has been declining. Between 1993 and 2003, the total number of hospitals in the United States decreased by 703, the number of hospital beds dropped by 198,000, and the number of EDs fell by 425. The result has been serious overcrowding. If the beds in a hospital are filled, patients cannot be transferred from the ED to inpatient units. This can lead to the practice of “boarding” patients—holding them in the ED, often in beds in hallways, until an inpatient bed becomes available. It is not uncommon for patients in some busy EDs to board for 48 hours or more. These patients have limited privacy, receive less timely services, and do not have the benefit of expertise and equipment specific to their condition that they would get within the inpatient department.
Another consequence of overcrowding has been a striking increase in the number of ambulance diversions. Once considered a safety valve to be used only in the most extreme circumstances, diversions are now commonplace. Half a million times each year—an average of once every minute—an ambulance carrying an emergency patient is diverted from an ED that is full and sent to one that is farther away. Each diversion adds precious minutes to the time before a patient can be wheeled into an ED and be seen by a doctor, and these delays may mean the difference between life and death for some patients. Moreover, the delays increase the time that ambulances are unavailable for other patients.
Few systems around the country coordinate the regional flow of emergency patients to hospitals and trauma centers effectively because most fail to take into account such things as the levels of crowding and the differing sets of medical expertise available at each hospital. Indeed, in most cases, the only time an ED passes along information concerning its status to EMS agencies is when it formally goes on diversion and refuses to take further deliveries of patients. As a result, the regional flow of patients is managed poorly and individual patients may have to be taken to facilities that are not optimal given their medical needs.
Adding to the fragmentation is the fact that there is tremendous variability around the country in how emergency care is handled. There are more than six thousand 9-1-1 call centers around the country and depending on their location, they may be operated by the police department, the fire department, the city or county government, or some other entity. There is no single agency in the federal government that oversees the emergency and trauma care system. Instead, responsibility for EMS and hospital-based emergency and trauma care is scattered among many different agencies and federal departments, including Health and Human Services, Transportation, and Homeland Security. Because responsibility for the system is so fractured, there is very little accountability. In fact, it is often difficult even to determine where system breakdowns occur and why.
Shortage of On-Call Specialists
Emergency and trauma doctors can be called on to treat nearly any type of injury or illness, so it is important for them to be able to consult with specialists in various fields. It has become increasingly difficult, however, for hospitals to find specialists willing to be on call for the ED. The resulting shortage of on-call specialists in EDs can have dire and sometimes tragic results.
There are many reasons why specialists are often unwilling to be on-call in EDs. Many specialists find that they have difficulty getting paid for services provided in the ED because many emergency and trauma patients are uninsured. Specialists are also deterred by the additional liability risk of working in the ED. Many of the procedures performed in EDs are inherently risky and physicians rarely have an existing relationship with emergency patients. The result is that insurance premiums for doctors who serve as on-call specialists in the ED are higher than for those who do not. Finally, many specialists find the demands of providing on-call services too disruptive to their private practices and their family lives.
Lack of Preparedness for Disasters
Unfortunately, the nation’s emergency care system is very poorly prepared to handle disasters. The difficulties begin with the already overcrowded nature of the system. With hospitals in many large cities operating at or near full capacity, even a multiple-car highway crash can create havoc in an ED. A major disaster with many casualties is something that most hospitals have limited capacity to handle.
Much of the problem, though, is due to a simple lack of funding. Hospital grants from HRSA’s National Bioterrorism Hospital Preparedness Program are small —not enough to equip even one critical-care room. Although emergency service providers are a crucial part of the response to any disaster, they received only 4 percent of the $3.38 billion distributed by the Homeland Security Department for emergency preparedness in 2002 and 2003. Due to this lack of funding, few hospital and EMS personnel have received even minimal training in how to prepare for and respond to a disaster. Few hospitals have negative-pressure units, for instance, which are crucial for isolating victims of airborne diseases, such as the avian flu. Nor do many hospitals have the appropriate personal protective equipment to keep their staffs safe when dealing with an epidemic or other disaster.
Shortcomings in Pediatric Emergency Care
Children who are injured or ill have different medical needs than adults with the same conditions. They have different heart rates, blood pressures, and respiratory rates, and these change as children grow. They often need equipment that is smaller than what is used for adults, and they require medication in much more carefully calculated doses. They have special emotional needs as well, often reacting very differently to an injury or illness than adults. Unfortunately, although children make up 27 percent of all visits to the ED, many hospitals and EMS agencies are not well equipped to handle these patients.
To improve the nation’s emergency care system and deal with the growing demands placed on it, the Committee recommends a broad strategy for reform, beginning with a new vision for the future of emergency care
A Vision for the Future of Emergency Care
The Committee believes the challenges that exist in the system today can best be addressed by building a nationwide network of regionalized, coordinated, and accountable emergency care systems. They should be coordinated in the sense that, from the patient’s point of view, delivery of emergency services should be seamless. To achieve this, the various components of the system—9-1-1 and dispatch, ambulances and EMS workers, hospital EDs and trauma centers, and the specialists supporting them—must be able to communicate continuously and coordinate their activities. When an ambulance picks up a patient, for example, the EMS personnel gather information on the patient, and the information is automatically passed on to the ED before the ambulance even arrives.
The system should be regionalized in the sense that neighboring hospitals, EMS, and other agencies work together as a unit to provide emergency care to everyone in that region. A patient should be taken to the optimal facility within the region based on his or her condition and the distances involved. In case of a stroke, for example, a patient might be better served by going to a hospital that is slightly farther away but that specializes in treatment of strokes.
Finally, the system should be accountable, which means that there must be a way of determining the performance of the different components of the system and reporting that performance to the public. This will require the development of well-defined standards and methods to collect data and measure performance against those standards.
To promote the development of these systems, the Committee recommends two important roles for Congress. First, Congress should establish a federally funded demonstration program to develop and test various approaches to regionalize delivery of prehospital and hospital-based emergency care. Second, Congress should designate a lead agency for emergency care in the federal government to increase accountability, minimize duplication of efforts, and fill important gaps in federal support of the system.
The Committee recommends that states actively promote regionalized emergency care services. This will help insure that the right patient gets to the right hospital at the right time, and help hospitals retain sufficient on-call specialist coverage. Disaster planning at the local and regional level would take place within the context of these regionalized systems so that patients get the best care possible in the event of a disaster. Integrating communications systems would improve coordination of services across the region; not only during a major disaster but on a day-to-day basis.
Improving Efficiency and Patient Flow
Tools developed from engineering and operations research have been successfully applied to a variety of businesses, from banking and airlines to manufacturing companies. These same tools have been shown to improve the flow of patients through hospitals, increasing the number of patients that can be treated while minimizing delays in their treatment and improving the quality of their care. For example, smoothing the peaks and valleys of patient admissions has the potential to eliminate bottlenecks, reduce crowding, improve patient care, and reduce cost. Another promising tool is the clinical decision unit, or 23-hour observation unit, which helps ED staff determine whether certain ED patients require admission. Hospitals should use these tools as a way of improving hospital efficiency and, in particular, reducing ED crowding.
At the same time hospitals should increase their use of information technologies with such things as dashboard systems that track and coordinate patient flow and communications systems that enable ED physicians to link to patients’ records from other providers. Such increased use of information technologies will not only lead to greater hospital efficiency but will increase safety and improve the quality of emergency care.
Since there are few financial incentives for hospitals to reduce crowding, the Joint Commission on the Accreditation of Healthcare Organizations should put into place strong standards on ED crowding, boarding, and diversion. In particular, the practices of boarding and ambulance diversion should be eliminated except in the most extreme circumstances, such as a community mass-casualty event.
Increasing Resources for Emergency Care
Increased funding could help improve the nation’s emergency care system in a number of ways. More research is needed, for instance, to determine the best ways to organize the delivery of emergency care services, particularly prehospital EMS. And, given that many closings of hospitals and EDs can be attributed to financial losses from the delivery of emergency and trauma services, Congress should provide additional funding to large safety-net hospitals and trauma centers that bear a disproportionate amount of the cost of taking care of uninsured patients.
Another area in which more funding is needed is disaster preparedness. To date, despite their importance in any response to disaster, the various components of the emergency care system have received very little of the funding that Congress has dispensed for disaster preparedness. In part this is because the money tends to be funneled through public safety agencies that often consider medical care to be a low priority. Therefore, Congress should make significantly more disaster-preparation funds available to the emergency system through dedicated funding streams.
Paying Attention to Children
Finally, as these various improvements are made to the nation’s emergency care system, it will be important to keep pediatric patients in mind in all aspects of emergency care. The needs of pediatric patients should be taken into account in developing standards and protocols for triage and transport of patients; in developing disaster plans; in training emergency care workers, to ensure that they are competent and comfortable providing emergency care to children; and in conducting research to determine which treatments and strategies are most effective with children in various emergency situations.
The Committee believes that the nation’s emergency care system is in serious peril. If the system’s ability to respond on a day-to-day basis is already compromised to a serious degree, how will it respond to a major medical or public health emergency? Strong measures must be taken by Congress, the states, hospitals, and other stakeholders to lead the emergency care system into the future. The Committee’s recommendations provide concrete recommendations for action.
Thank you for the opportunity to testify. I would be happy to address any questions the Subcommittee might have.