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I just read about the new Institute of Medicine report on America's emergency care system being "At The Breaking Point" and while I'm usually a big fan of the IOM's work my first impression is they blew it this time. (Let me first put out the disclaimer that I have not yet read the entire report.)

The report discusses the major problems in our hospital-based EDs, including overcrowding, people using the ED because they cannot access primary care, and the burden of uninsured patients. I'm with them so far. But their recommendation seems to be to throw money at the hospital ED system. Huh?! EDs are widely acknowledged to be the most expensive and least cost effective way to deliver care, especially primary care. So why would we sink more money into building more EDs and paying them to see more people (inefficiently)? Wouldn't it make a heckuva lot more sense to build up the primary care system, especially the Community Health Centers and other safety net providers who specialize in caring for uninsured and disenfranchised individuals, and who provide great care for the lowest cost? Then there'd be more access, so fewer people would seek care in the ED, they'd have less overcrowding and less "burden." I think the IOM needs to try again on this one.

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Join the dialogue here

Jun 15, 2006 2:56:45 PM
Nicole says

I read about this report in a Washington Post article. I agree, why take care of a symptom but ignore the disease that caused it?

Jun 17, 2006 9:31:50 AM
John Moorhead MD says

The IOM report actually hits the mark and the recommendations deserve thorough review. It should serve as a wake up call for the entire community. The report confirms what emergency providers experience firsthand. The system is fragmented and overwhelmed.
Emergency department crowding is primarily caused by increasing numbers of very sick patients in fewer EDs, needing admission to fewer hospital beds than existed 10 years ago.
Emergency physicians are among the most dedicated, best trained, action orientated professionals in any field. Emergency departments provide very efficient care but face a shortage of on-call physicians often required to complete emergency specialty care. Physician shortages, reimbursement and liability issues contribute to the unavailability of on-call specialists.
Not only is access to expected daily emergency care threatened, the system is dangerously unprepared for a major disaster.
Our healthcare system needs major reform both to provide access for all citizens to primary AND emergency care, and to make care more affordable.
The provision of emergency medical care needs to be regionalized, better-coordinated and accountable. Many of us participating in local reform initiatives do believe that the system will require additional resources to accomplish these goals. Federal, state and local leadership and our entire community needs to be involved in generating meaningful solutions. Lets get started!

Jun 18, 2006 11:38:30 AM
Jerris R. Hedges, MD says

The recent IOM report on Emergency Care and ensuing debate has raised some interesting philosophical discussions. The reality is that the Emergency Care System is about to implode and federal support is needed at this time. An essential, immediate fix is to shore up the hospital-based operations with additional hospital beds, more efficient hospital operations, and strengthened EDs and a stronger ED/EMS workforce. These changes are essential given the current deficiency in emergency resources needed by our growing and aging American population.

However, to look beyond the next 5-10 years, we do need to reconfigure and enhance our community-based healthcare delivery system. Such care must be reconfigured to be meaningful to the patient's and/or family's needs and life-styles; such delivery models can no longer be constructed for the convenience of the healthcare provider. Indeed, community-based care must begin to deliver more weekend and late evening care (if not on a 24/7 basis). Further, community-based care providers must provide an increasing share of the care to the under-insured, if such an effort is to truly help reduce the burden on America's EDs.

Much remains to be done here and the solution cannot be focused solely on strengthening the ED resources any more than it can be focused solely on building more community healthcare options. Indeed, the former is a temporizing measure and the latter holds long-term promise only if the ambulatory services delivered in the community more closely approximate those delivered in a modern ED (in terms of availability and coverage of the underinsured).

The IOM has done America a great service by drawing our attention to this growing threat to the healthcare of Americans. Now is not the time to debate the reality of this need. Now is the time to take emergency action and begin strengthening all aspects of the healthcare system.

Jerris Hedges, MD, MS

Jun 19, 2006 6:37:40 PM
Yogin Patel, MD MBA says

I wanted to thank you for initiating this dialogue regarding the Institute of Medicine’s recent report. This is an issue of paramount importance to the nation as a whole, and something that we, as healthcare professionals, must lead the debate in. With that being said, as an emergency medicine resident, I wanted to address some of your concerns about resource allocation.

On your next visit to an emergency department, take a look around. As our waiting rooms swell, and the wait times climb, and fewer specialists provide us with on-call support, and our malpractice costs soars, and our resources dwindle, the reality becomes all too clear. We do not have a looming emergency care crisis – the crisis is already here.

Nationally, the number of emergency department visits increased from 90.3 million to nearly 114 million from 1993 to 2003. At the same time, the number of emergency departments nationally decreased by 425, and the number of hospital beds fell by 198,000. When beds in the hospital are full, patients in the ED simply can not be transferred to inpatient beds. They can not receive the ongoing assessments and treatments they need, and as you alluded to, using emergency resources to provide this “inpatient” level of care is a gross misallocation of resources. Finally, as we “board” an increasing number of patients, we turn away ambulances with patients who may need life-saving stabilization.

Each day, there are more and more patients living with co-morbid conditions that will require complex medical assessments. I fully acknowledge that there is tremendous room for the expansion of preventative care in the United States. But this is a complex issue. Primary care clinics are simply not equipped to rapidly assess and treat critically ill patients. And frankly, more healthcare providers at Wal-Mart that can hand out prescriptions, is not the answer.

Our system is beyond the breaking point. Many lack access to care and emergency departments around the country are chronically under-funded and dangerously overcrowded. The system remains crippled and unprepared for major disasters (hurricanes, terrorist attacks or epidemics).

Emergency room physicians, nurses, technicians, and staff are among the most dedicated, well-trained, action-oriented professionals in any health care field. We aren’t used to crying “uncle”. And now that we, as a group of professionals, are asking for help, I would urge Congress would to listen. My hope is that the IOM report will promote dialogue. In the end, our experiences, our voices, and our patient’s stories are our greatest instruments of change.

Yogin Patel MD, MBA

Jun 20, 2006 8:44:33 AM
sweet lou says

I don't think anyone doubts the commitment level and effectiveness of EDs, or the obvious lack of funding hampering EDs across the nation. The key is that with the healthcare system in crisis, it is becoming increasingly important to ensure that EDs functions - as the name implies – only for emergency care. As it stands, too many people are using them for primary care as well, or are presenting with serious conditions that have escalated due to lack of basic treatment. When that happens, it drags down the effectiveness of ED care by clogging the waiting rooms and siphoning away the time of practitioners who should be focused solely on urgent care.

The end result is that highly trained “specialty” staff is being used in the role of primary care physicians, or to make up for long untreated conditions; this is a highly ineffective way to apply ever shrinking resources. Obviously, access to complex urgent care is a necessity but if a provider’s time is being taken up by patients that could have been better served accessing preventative or general care, then the whole point of the ED is being wasted.

This was all too clear on a recent visit to an ED with my mom. The waiting room was full of people, many of whom did not - at least to the untrained eye - require "emergency" care. (I can only base this observation on overheard cell phone conversations and the fact that some people had stopped to bring fast food and beverages in with them – not, it seems, a decision that could be entered into in a true emergency). The staff was harried and overwhelmed and triaging required sorting through an additional layer of folks who could have been better served by accessing a primary care clinic.

If the numbers quoted by the poster above are accurate and EDs are in general freefall across the nation, a more interesting data point would be how many of the increased visits were actually for “emergency” care. Because without that distinction, the data simply supports the notion that EDs are becoming a first and last resort for an increasing number of individuals who have no other gateway to healthcare.

Jul 3, 2006 7:27:35 PM
Robert A. Lowe, MD, MPH says

While I agree that it would be marvelous to unburden emergency departments by eliminating unnecessary or non-emergency ED visits, the problem is that no one has found a way to tell which visits are not emergencies without conducting a full evaluation. Every seasoned emergency physician has stories of "near misses," patients who appeared to have minor problems until we looked more closely - and found the life-threatening condition. Research has shown that, to date, we have no reliable way of identifying "inappropriate" ED visits without risking the health of people who would be sent away from EDs for true emergencies.

I am delighted to see so much interest in this topic but the above discussion also saddens me. Why should we be asked to choose between enhancing primary care and salvaging the emergency medical care system? I know that I want prompt and convenient access to a skilled primary care provider for chronic problems and for health maintenance - and that I also want access to a well-prepared, well-staffed emergency department if I, or someone I love, has an emergency medical condition (or a potentially emergent medical condition). Shouldn't we be advocating for BOTH of these resources for ourselves, our families, and our communities? What does it say about our societal priorities that we are asking which of these needs should be sacrificed for the benefit of the other need?

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