Hospital-Based Emergency Care At the Breaking Point (2007) / Chapter Skim
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From page 1... ...
In some rural communities, the hospital ED may be the main source of health care for a widely dispersed population. While the demands on emergency and trauma care have grown dramatically, however, the capacity of the system has not kept pace.
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Moreover, during this same period, the United States experienced a net loss of 703 hospitals, 198,000 hospital beds, and 425 hospital EDs, mainly in response to cost-cutting measures Number of Hospitals Reporting ED Visits versus Increase in ED Visits 120.0 5,000 4,500 100.0 4,000 Hospitals Reporting ED Visits 3,500 80.0 ED Visits (millions) 3,000 2,500 60.0 2,000 40.0 1,500 1,000 20.0 500 0 0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Total U.S.
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From page 3... ...
The high demand for hospital-based emergency and trauma care reflects several trends. First, EDs have become one of the nation's principal sources of care for patients with limited access to other providers, including the 45 million uninsured Americans.
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These findings and recommendations address the need to enhance operational efficiency, the use of information technology, the burden of uncompensated care, inadequate disaster preparedness, the emergency care workforce, and the need for research in emergency care. Enhanced Operational Efficiency Hospital EDs and trauma centers have little control over external forces that contribute to crowding, such as increasing numbers of uninsured or the growing severity of patients' conditions.
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Efficient patient flow can increase the volume of patients treated and discharged and minimize delays at each point in the delivery process while improving the quality of care. For example, while controlled studies have yet to be conducted, a growing body of experience suggests that using queuing theory to smooth the peaks and valleys of patient admissions can eliminate bottlenecks, reduce crowding, improve patient care, and reduce costs.
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The committee recommends that hospitals end the practices of boarding patients in the emergency department and ambulance diversion, except in the most extreme cases, such as a community mass casualty event. The Centers for Medicare and Medicaid Services should convene a working group that includes experts in emergency care, inpatient critical care, hospital operations management, nursing, and other relevant disciplines to develop boarding and diversion standards, as well as guidelines, measures, and incentives for implementation, monitoring, and enforcement of these standards (4.5)
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From page 7... ...
Many hospital ED and trauma center closures are attributed to financial losses associated with emergency and trauma care. Public hospitals and tertiary medical centers bear a large share of this burden, as surrounding community hospitals often transfer their most complex, high-risk patients to the large safety net hospitals for specialized care.
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From page 8... ...
For example, hospital grants from the Health Resources and Services Administration's Bioterrorism Hospital Preparedness Program in 2002 were typically between $5,000 and $10,000 -- insufficient to equip even one critical care room. Training Training for ED workers in disaster preparedness is also deficient.
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In 2005, the Occupational Safety and Health Administration developed guidelines for use of personal protective equipment, but more needs to be done. Approaches to Improe Disaster Preparedness To address the above concerns about surge capacity, training, and protection of hospitals and staff, the committee recommends that Congress significantly increase total preparedness funding in fiscal year 2007 for hospital emergency preparedness in the following areas: strengthening and sustaining trauma care systems; enhancing emergency department, trauma center, and inpatient surge capacity; improving emergency medical services' response to explosives; designing evidence-based training programs; enhancing the availability of decontamination showers, standby intensive care unit capacity, negative pressure rooms, and appropriate personal protective equipment; and conducting international collaborative research on the civilian consequences of conventional weapons terrorism (7.3)
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The problem has been exacerbated by recently revised guidelines under the Emergency Medical Treatment and Active Labor Act that make it easier for on-call physicians to limit their emergency practices. Hospitals are using a number of different strategies to stabilize the services of on-call physicians.
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Therefore, the committee recommends 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 recommend appropriate state and federal actions to mitigate the adverse impact of these lawsuits and ensure quality of care (6.2)
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From page 12... ...
. This study should include consideration of training of new investigators, devel opment of multicenter research networks, funding of General Clinical Research Centers that specifically include an emergency and trauma care component, involvement of emergency and trauma care researchers in the grant review and research advisory processes, and improved research coordination through a dedicated center or institute (8.2a)
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From page 13... ...
Similarly, emergency care providers lack access to patient medical histories that could be useful in decision making. Ensuring that each patient is directed to the most appropriate setting, including a level I trauma center when necessary, requires that many elements within the regional system -- community hospitals, trauma centers, and particularly prehospital EMS -- coordinate the regional flow of patients effectively.
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, a standard national approach to the categorization of EDs that reflects their capabilities is needed so the categories will be clearly understood by providers and the public across all states and regions of the country. To that end, the committee recommends that the Department of Health and Human Services and the National Highway Traffic Safety Administration, in partnership with professional organizations, convene a panel of individuals with multidisciplinary expertise to develop an evidence-based categorization system for emergency medical services, emergency departments, and trauma centers based on adult and pediatric service capabilities (3.1)
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From page 15... ...
These performance measures should ultimately become the basis for pay-forperformance initiatives as those reimbursement techniques mature. Achieving the Vision States and regions face a variety of different situations, including the level of development of trauma systems; the effectiveness of state EMS offices and regional EMS councils; and the degree of coordination among fire departments, EMS, hospitals, trauma centers, and emergency management.
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From page 16... ...
The lead agency should be housed in the Department of Health and Human Services, and should have primary programmatic responsibility for the full continuum of emergency medical services and emergency and trauma care for adults and children, including medical 9-1-1 and emergency medical dispatch, prehospital emergency medical services (both ground and air) , hospital-based emergency and trauma care, and medical-related disaster preparedness.
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