Recently, the Institute of Medicine convened a panel to study the
state of emergency medal care in the U.S. In an article in the
"Perspectives" section of the New England Journal of Medicine
— an important platform for discussions of national health policy — a
member of that panel presents highlights from its report.
The author first reviews some startling facts: From 1994 to 2004,
the number of hospitals and emergency departments decreased, the
latter by 9%, while the number of ED visits increased by more than 1
million a year. Annual ED visits now number about 110 million — more
than one for every three people in the U.S. The author notes the
shortage of nurses, insufficient coverage by on-call specialists, and
unexpected consequences of EMTALA as a preface to five
recommendations from the IOM report.
- Emergency care, now the province of at least three federal agencies,
should be assigned to a single agency within the Department
of Health and Human Services in order to minimize duplication
of effort, increase accountability, and centralize fiscal support.
- A focused needs-assessment should be undertaken, which would
also highlight areas for future research.
- State governments should regionalize prehospital and
hospital-based emergency care so as to reduce
duplication of effort and provide emergency patients
with the right care at the right time.
- "Boarding" of patients in the ED should end. As it is
unlikely that hospitals will do this on their own,
federal agencies should take both fiscal and regulatory
action to ensure that this goal is met.
- To strengthen disaster response, steps should be taken to
ensure that the day-to-day emergency and trauma care
system is integrated, efficient, and functional. The
author notes that only 4% of federal disaster funds
earmarked for "first responders" in 2002 and 2003
actually went to emergency services.
A call to Congress to fulfill the vision enunciated in the IOM
report provides an appropriate conclusion.
Comment: The perspective’s brevity does not allow the
complexity and interplay of the multiple issues that affect
emergency care to come to the fore. These include a growing
elderly population, an increase in poverty, the changing nature
of medical practice, and a focus on disaster response. And as
improving emergency care is essentially a health policy issue,
the fiscal model to support it should accompany any call for
reform of the current system. If careful consideration is not
given to these facets of the problem, the IOM report may languish
as simply a cry for help. The IOM’s 2000 report on patient
safety ("To Err is Human") garnered national attention and prompted
action. This report deserves no less.
— J. Stephen Bohan, MD, MS, FACP, FACEP
Published in Journal Watch Emergency Medicine September 27,
2006
