IOM Recommends Steps for Fixing Problems in Emergency Care

Half a million times a year - about once every minute - an ambulance carrying a sick patient is turned away from a full emergency room and sent to another one farther away.

It's a sobering symptom of how the nation's emergency-care system is overcrowded and overwhelmed, "at its breaking point," concludes a major investigation by the influential Institute of Medicine.

That crisis comes from just day-to-day emergencies. Emergency rooms are far from ready to handle the mass casualties that a bird flu epidemic or terrorist strike would bring, the institute warned Wednesday 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 report co-author Dr. Arthur Kellerman, Emory University's emergency medicine chief.

That ERs are overburdened isn't new. But the probe by the IOM, an independent scientific group that advises the government, provides an unprecedented look at the scope of the problems - and recommends urgent steps for health organizations and local and federal officials to start fixing it.

Topping that list is a call for coordinating care so that ambulances don't waste potentially lifesaving minutes wandering from hospital to hospital in search of an ER with room. The idea is to set up regionalized systems that manage the flow much like airports direct flight traffic. That also should direct patients not just to the nearest ER but to the one best equipped to treat their particular condition - making sure stroke victims go to stroke centers, for example.

Other recommendations:

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

_Congress should ensure that more of the nation's disaster-preparedness funding goes to the hospitals and emergency workers who will provide that care. Typical government grants to hospitals for bioterrorism preparation are $5,000 to $10,000 - not enough to equip one critical-care room. When it comes to getting ready for a bird flu outbreak, few hospitals even have the ventilation equipment needed to isolate patients. And emergency medical services received only 4 percent of the $3 billion distributed by the Department of Homeland Security in 2002 and 2003 for emergency preparedness.

_The board that accredits the nation's hospitals should establish strong guidelines to reduce crowding and ambulance diversion.

At the root of the problem: 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. During the same time, the total number of U.S. hospitals decreased by 703, and the number of ERs by 425. And the total number of hospital beds nationwide dropped by 198,000, as hospitals strive toward more outpatient care - which in turn leaves fewer beds for ER patients to move into when they're seriously ill.

Too often, busy ERs stabilize those patients and then have to leave them lying on gurneys in the hallway for 48 hours or more until a room becomes available and they can be admitted to the hospital. That's not only a time of misery for the patient, but it means less timely care and potentially poorer care, without the specialized equipment and expertise available to inpatients, the report found.

Children have even scarcer help. They make up more than a quarter of all ER visits, yet one survey found only 6 percent of emergency departments had all the supplies needed, such as child-size equipment, to treat them.

Before getting to the hospital, the EMS system - emergency medical services that include ambulances and paramedics - is fragmented. How well-trained and prompt local paramedics are varies greatly; there are no nationwide standards. Many ambulance services can't even effectively communicate with hospitals or other first responders because of antiquated equipment.

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

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