IOM Report: AAEM/RSA Supports Increased Funding for Emergency Care and Solutions to Ease Overcrowding

By Brian Potts

The nation's emergency medical system as a whole is overburdened, under funded, and highly fragmented, says a new report from the Institute of Medicine. On June 14th, the Institute of Medicine (IOM) released their three-part report entitled "The Future of Emergency Care in the U.S. Health System." The study was completed over two years by a 40-member panel of health care experts. They focused on three areas of emergency care: hospital-based emergency care, pre-hospital emergency medical system and pediatric emergency care.

This report shows that Congress must provide better support for our nation's emergency departments and the emergency care system. Findings show the demand for emergency care is rising, even as the capacity of hospitals, ambulance services and other emergency workers to provide it is falling. Emergency department overcrowding, ambulance diversions and uninsured/under funded patients threaten an already perilous situation. The panel recommended that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) reinstate strong guidelines to reduce crowding, boarding, and diversion. They called on the Centers for Medicare and Medicaid Services to convene a working group to develop standards to address these problems. Moreover, the system is ill-prepared to handle surges from disasters such as hurricanes, bombings, or disease outbreaks.

The Emergency Medical Treatment and Active Labor Act (EMTALA) requires that every emergency department patient receive a screening exam and stabilizing treatment if necessary regardless of the ability to pay. Fulfilling this unfunded mandate has led to some emergency departments going out of business or physicians not receiving compensation for treating these patients. To address these funding deficiencies, Congress should establish a pool of at least $50 million to reimburse hospitals for uncompensated emergency and trauma care, the reports concludes.

To further increase the availability of specialists in EDs, the report also calls on Congress to find a way to mitigate the effect of medical malpractice suits on services provided to patients in the EDs. They recommend that Congress appoint a commission to examine the impact of medical malpractice lawsuits on the declining availability of providers in high-risk emergency and trauma care specialties and to then propose appropriate state and federal actions to mitigate the adverse impact of these lawsuits and ensure quality of care.

Another central recommendation is that the emergency care system of the future should be highly coordinated, regionalized, and accountable, with one lead federal agency consolidating many of the government programs that deal with emergency and trauma care. In addition, Congress should allocate $88 million to be disbursed as grants over five years for projects designed to test ways to promote greater coordination and regionalization of emergency care.

Finally, AAEM/RSA would like to stress the importance of EM residency training to obtain board certification in EM and also the need for an increase in EM research funding. As stated in AAEM's mission statement, "A specialist in Emergency Medicine is a physician who has achieved, through personal dedication and sacrifice, certification by either the American Board of Emergency Medicine (ABEM) or the American Osteopathic Board of Emergency Medicine (AOBEM)." Patients deserve to receive high quality care from board certified emergency physicians when they seek care in an emergency department. Also, federal NIH research training grants and fellowship funding should be increased for emergency medicine. If total funding is divided by the number of residents training in each field, the IOM study mentions that internal medicine receives over $5,000 NIH funding per resident while emergency medicine gets $50 per resident. This imbalance should be addressed.

Below is a summary of IOM findings and recommendations that AAEM/RSA created from the three reports: "Hospital-Based Emergency Care: At the Breaking Point", "Emergency Medical Services At the Crossroads", "Emergency Care for Children: Growing Pains" and other resources.

To discuss the IOM report and other current issues with AAEM/RSA members: https://ssl18.pair.com/aaemorg/members/forums/

More information on this report can be found at:
http://www.iom.edu/CMS/3809/16107/35007.aspx

To download an IOM Report Brief:
http://www.iom.edu/CMS/3809/16107/35007/35014.aspx

Summary of IOM findings and recommendations:

FINDINGS

Emergency departments are overcrowded

• Demand for services increasing, number of hospital beds decreasing.
• Admitted patients boarding in ED contributes to crowding.
• Ambulances often diverted from overcrowded EDs.

Emergency care is fragmented

• EMS agencies do not effectively coordinate their services with EDs and trauma centers, so regional flow of patients is poorly managed.
• EMS does not communicate effectively with other public safety/health agencies.
• Federal responsibility for oversight of the emergency and trauma care system is scattered across multiple agencies.

Access to on-call specialists is crisis

• Three quarters of hospitals report difficulty finding specialists to take emergency and trauma calls.
• On-call specialists often treat emergency patients without compensation due to high levels of uninsurance, and also face higher medical liability exposure than those who do not provide on-call coverage.

Emergency care system is ill-prepared to handle a major disaster

• Many EDs are at or over capacity, so there is little surge capacity for a major event.
• Although they represent a third of the nation's first responders, EMS received only 4 percent of Department of Homeland Security first responder funding in 2002 and 2003 .

EMS and many EDs are not well equipped to handle pediatric care

• Children make up 27 percent of all ED visits, but only 6 percent of EDs in the U.S. have all of the necessary supplies for pediatric emergencies.
• While children have increased vulnerability, disaster planning has largely overlooked their needs.

RECOMMENDATIONS

Create a coordinated, regionalized, accountable system

• The entire emergency system should coordinate activities and develop integrated and interoperable communications and data systems to ensure seamless emergency and trauma services.
• Dispatch, EMS , ED providers, public safety, and public health should be fully interconnected and united in an effort to ensure that each patient receives the most appropriate care, at the optimal location, with the minimum delay.
• Hospitals, physician organizations, and public health agencies collaborate to regionalize critical specialty care on-call services.
• Congress should enact a demonstration program ($88 million over 5 years) for regionalization of emergency services.
• Federal government should support development of national standards for: emergency care performance measurement; categorization of hospital facilities; and protocols for prehospital care.

Create a lead government agency for emergency care

• Emergency care functions that are currently scattered among multiple federal agencies should be consolidated into one single agency within the Department of Health and Human Services (DHHS) within two years.

Stop ED boarding and diversion

• Hospitals should reduce crowding by improving hospital efficiency and patient flow, by using operational management and robust information and communications systems.
• JCAHO should reinstate standards for ED boarding and diversion and have hospitals end the practices of boarding patients in the ED and ambulance diversion, except in extreme cases, such as a community mass casualty event.
• The Centers for Medicare and Medicaid Services should develop payment and other incentives to discourage hospitals from boarding and diversion.

Increase funding for emergency care

• Congress should appropriate $50 million for "safety-net" hospitals providing large amounts of uncompensated emergency and trauma care.
• Funding should be increased by Congress for the emergency medical component of disaster preparedness—both EMS and hospital-based.

Enhance emergency care research

• Federal agencies should target research funding to prehospital and pediatric emergency care.
• DHHS should conduct study to determine research needs/gaps in emergency care.

Enhance pediatric presence throughout emergency care

• EDs and EMS agencies should have pediatric coordinators to ensure appropriate equipment, training, and services for children.
• More research to determine appropriateness of many medical treatments and medical technologies for children.
• EMS agencies and hospitals integrate family-centered care into emergency care practice.
• Congress should increase funding for the Emergency Medical Services for Children Program to $37.5 million each year for 5 years.