TheInstitute of Medicine (IOM; Washington) in a series of reports on emergency care in the U.S. has concluded that the nation's emergency system “as a whole is overburdened, underfunded and highly fragmented,” and the IOM is calling for federal funds to correct the inadequacies it found in the system.

The studies, overseen by a committee of board members of the IOM, found that while demand for emergency services has been growing rapidly – by their estimate emergency department (ED) visits grew by 26% between 1993 and 2003 – over the same period, the actual number of EDs declined by 425.

The number of hospital beds declined by 198,000, which has led to a situation whereby patients are simply “boarded,” or held in the ED until the hospital can find a bed for the patient.

“Most of us need emergency services only rarely, but we assume that the system will be able to provide us rapid, skilled care when we do,” said committee chair Gail Warden, president emeritus, Henry Ford Health System (Detroit). “Unfortunately, the system's capacity is not keeping pace with the increasing demands being placed on it. We need a comprehensive effort to shore up America's emergency medical care resources and fix problems that can threaten the health and lives of people in the midst of a crisis.”

The series of studies found, for example, that the ED system, which is in most cases operating above capacity, is “ill-prepared to handle surges from disasters such as hurricanes, bombings, or disease outbreaks.”

The committee is calling on Congress to create a “coordinated, regionalized, accountable system,” which would involved allocating $88 million over five years for a demonstration project “to encourage states to identify and test alternative strategies for achieving” that vision.

The group is also calling for the federal government to create a single body to be in charge of emergency services, a responsibility which is now “scattered among multiple agencies.”

In addition, the committee said that the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO; Oak Brook, Illinois) should “reinstate strong standards for ED boarding and diversion.”

One of the major problems it cited for ERs is the fact that they are in large part responsible for treatment of most of the uninsured patients, which causes hospitals to lose money overall. To remedy this, Congress should allocate $50 million for “hospitals that provide large amounts of uncompensated emergency and trauma care.”

That leads to a problem with many specialists who are critical to emergency care, such as neurosurgeons, who often work uncompensated for the care they provide.

That funding would also be used to cover personal protective equipment, training and planning for both emergency medical services (EMS) and hospital-based staff.

The report said that EMS agencies often do not coordinate such services with EDs and trauma centers.

In its key findings, the IOM said: “As a result, the regional flow of patients is poorly managed, leaving some EDs empty while others are overcrowded.” The report also noted that EMS often operate on different radio frequencies and lack common procedures for emergencies. Futhermore, the studies found that there are no nationwide standards for the training and certification of EMS personnel.

Another suggestion by the committee of the IOM is that the Department of Health and Human Services should conduct a study of the research needs and gaps in emergency care, and once those gaps are determined, perhaps establish in center or institute specifically devoted to the study and improvement of emergency care.

Another finding was that children make up 27% of all ED visits, but only 6% of EDs in the U.S. have all of the supplies necessary for treating children. Therefore, most children get emergency care in ERs established for the general population.

In its key findings, the committee found that “many drugs and medical devices have not been adequately tested on, or dosed properly for, children.” It also said that while children are the most vulnerable to disasters due to their tendency to become dehydrated more quickly, that “disaster planning has largely overlooked their needs.”

As a result, the committee is calling again on Congress to increase funding for the Emergency Medical Services for Children Program to $37.5 million per year for five years, which would include the study of appropriate medical technologies and devices to meet the specific needs of children.