Emergency rooms confront a crisis of patient arrivals

2-year study finds care often delayed

WASHINGTON -- A half-million times a year, or about once every minute, ambulances carrying sick patients are turned away from full emergency rooms and sent to others farther away, according to a national study.

It's a symptom of how the nation's emergency-care system is overcrowded and overwhelmed, ``at its breaking point," said an investigation by the Institute of Medicine, part of the National Academies, which advises the government on health issues.

``The safety net . . . has large holes," a coauthor, Dr. A. Brent Eastman, chief medical officer at ScrippsHealth in San Diego, said yesterday. ``You may not be caught and saved when your life depends on it."

How many people die as a result? The two-year inquiry did not issue an answer; there is little tracking of how emergency patients fare after a frantic 911 call or a race to the hospital. But there are troubling clues. For example, in some cities, emergency workers save half of the victims of cardiac arrest, but in other places, they save merely 5 percent.

This crisis report involves just day-to-day emergencies. Emergency rooms are far from ready to handle the mass casualties that a bird-flu epidemic or a terrorist strike would bring, the institute said yesterday in a three-volume report.

``If you can barely get through the night's 911 calls, how on earth can you handle a disaster?" asked a coauthor of the report, Dr. Arthur Kellerman, Emory University's emergency medicine chief.

Even a school bus crash would qualify as a disaster, but though children make up more than one-quarter of all emergency-room visits, only 6 percent of emergency departments have all the supplies needed, such as child-sized equipment to treat pediatric emergencies, and few have doctors trained in children's care, the Institute of Medicine panel found.

The inquiry by the independent scientific group provides a rare look at the problem's scope, and recommends urgent steps for health organizations and local and federal officials to start fixing it.

At the root of the crisis: Demand for emergency care is surging, even as the capacity for hospitals, ambulance services, and other emergency workers to provide it is dropping.

There were almost 114 million emergency-room visits in 2003, up from 90 million a decade earlier. Only about half were true medical emergencies. When the poor and uninsured cannot get healthcare anywhere else, they go to emergency rooms, which must treat them regardless of ability to pay.

``It is the only medical care to which Americans have a legal right," said Kellerman, adding that what constitutes an emergency is different to a doctor than to a desperate patient. Last week, he treated a woman who arrived in an emergency room after running out of some crucial medication and being turned away by four clinics.

Yet lack of reimbursement for emergency-room care is one reason some emergency departments go out of business. In the past decade, the total number of US hospitals decreased by 703, and the number of emergency rooms by 425. And the total number of hospital beds dropped nationwide by 198,000, also because of a trend toward cheaper outpatient care.

That in turn means long waits in crowded emergency rooms for hospital rooms to open up. Once stabilized, patients can lie on gurneys in emergency-room hallways, not just for hours but for as long as two days. The new report found that on a typical Monday evening, three-quarters of hospitals reported that at least two patients were boarded in the halls.

Even getting to the emergency room is a gamble, the report found, because the emergency medical services system -- including ambulances and paramedics -- is fragmented. How well-trained and prompt local paramedics are varies greatly; there are no nationwide standards. Many ambulance services cannot effectively communicate with hospitals or other first responders because they use radio equipment from the 1970s.

The first item on the recommendation list is a call for states and hospitals to set up regionally coordinated emergency systems that manage patient flow to avoid overcrowding, as airports direct flight traffic. They would direct ambulances not necessarily to the nearest emergency room, but to the one best equipped to treat each patient's condition.

Other recommendations:

Congress should establish a pool of $50 million to reimburse hospitals for unpaid emergency care provided to the poor and uninsured.

Congress should ensure that more disaster-preparedness funding goes to the hospitals and emergency workers who will provide that care. First responders, such as ambulance and paramedic services, have received 4 percent of that money to date. And typical government grants to hospitals for biological terrorism preparation are $5,000 to $10,000 -- not enough to equip one critical-care room.

Hospitals should stop diverting ambulances and boarding patients in the hallways.

``I didn't say work on it. We said they must end it. This is simply unacceptable," Kellerman said.

The American College of Emergency Physicians called the report groundbreaking, but said Congress must heed recommendations to fund improvements. 

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