Jun 20, 2006 (CIDRAP News) – The US emergency medical care system is woefully inadequate and unprepared for a pandemic, bioterrorist attack, natural disaster, or other national crisis, three recent reports from the Institute of Medicine (IOM) conclude.
The nation's emergency care system, the reports say, is overburdened, underfunded, and too fragmented to communicate and cooperate effectively across levels and geographic areas. It has little surge capacity to deal with a disaster. In addition, emergency care staff members are often not adequately trained to respond to large-scale disasters or to work with pediatric patients.
The IOM report preceded by 2 days a Department of Homeland Security report that describes major shortcomings in the nation's general preparedness for catastrophic events such as category 5 hurricanes.
Emergency system needs comprehensive help
"Unfortunately, the [emergency care] system's capacity is not keeping pace with the increasing demands being placed on it," said Gail L. Warden, MHA, in a Jun 14 news release from the National Academies, the IOM's parent organization.
"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," added Warden, chair of the committee that wrote the reports and president emeritus of Henry Ford Health System in Detroit.
To remedy this situation, the committee that wrote the reports recommends that:
- Congress appropriate at least $325.5 million toward shoring up the emergency care system—plus funding for readying the system for potential disasters.
- The emergency care system be "regionalized" so that neighboring hospitals, emergency medical services, and other agencies work together to provide care for all the people in their region.
- The Veterans Health Administration (VHA) be integrated into civilian disaster planning and management.
- Guidelines on overcrowding and redirecting ambulances away from packed emergency departments (EDs) be enforced, and coordination and communication between facilities improved.
- Streamlining tools, such as queuing theory, dashboard systems, and 23-hour observation units, be used to optimize patient treatment and flow.
The IOM's 26-member Committee on the Future of Emergency Care in the US Health System convened in September 2003. Its conclusions on problem areas and recommended solutions have just been published as a series of three reports: Hospital-Based Emergency Care: At the Breaking Point, Emergency Medical Services at the Crossroads, and Emergency Care for Children: Growing Pains.
Concerning funding, an IOM overall summary of the three documents states, "Perhaps the area in which greater funding is most important is disaster preparedness. To date, despite their importance in any response to disaster, the various parts of the emergency care system have received very little of the funds that Congress has dispensed for disaster preparedness.
"In part this is because the money tends to be funneled through public safety agencies that consider medical care to be a low priority. Congress should therefore make significantly more disaster-preparation funds available to the emergency system through dedicated funding," the summary says.
Hospital-Based Emergency Care: At the Breaking Point specifies the following preparedness funding priorities:
- Strengthening and sustaining trauma care systems
- Enhancing ED, trauma center, and inpatient surge capacity
- Improving EMS response to explosives
- Designing evidence-based training programs
- Increasing the availability of decontamination showers, standby intensive care unit capacity, negative-pressure rooms, and appropriate personal protective equipment
- Conducting international collaborative research on the civilian consequences of conventional-weapons terrorism
In addition to asking for more preparedness funding, the IOM committee says Congress should establish a pool of $50 million to reimburse hospitals for uncompensated emergency and trauma care.
Also, in the next 5 years Congress should provide $88 million to foster coordination and "regionalization" of emergency care and $187.5 million to address shortcomings in emergency pediatric care, the reports conclude.
Regional coordination urged
Regionalization would involve directing patients not to just the nearest medical center, but to the nearest facility in the region equipped to handle patients' specific needs. It "can improve health outcomes, mitigate overcrowding, and reduce costs," according to the IOM news release.
Regionalization would also eliminate the need for every hospital to maintain on-call services for every specialty, which would help address staff shortages caused by decreasing numbers of specialists willing to take emergency calls, the news release said.
Hospital-Based Emergency Care says the VHA is "well positioned to enhance regional response, particularly since its hospitals are required by law to maintain excess capacity." Therefore, the report says, federal organizations should work with states to integrate the VHA into regional disaster planning.
To remedy overcrowding and ambulance diversions, the committee asked that the Joint Commission on Accreditation of Healthcare Organization (JCAHO) reinstate strong guidelines to reduce crowding, "boarding" patients in halls or exam rooms until beds become available, and diverting ambulances when EDs are overcrowded. It also called on the Centers for Medicare and Medicaid Services to convene a working group to develop standards to address the situation.
Further, the reports note, overcrowding and ambulance diversions are caused by lack of coordination and communication between facilities. Patient admission and transport should be better coordinated across municipalities, the reports conclude.
In recommending using queuing theory to help improve efficiency, the committee highlighted its ability to smooth the peaks and valleys of patient admissions, which can eliminate bottlenecks, improve care, and lower costs.
The 23-hour observation unit, or clinical decision unit, the reports say, can help ED staff with patient triage, which can help reduce ED crowding. And dashboard systems can help coordinate patient flow.
DHS reports on preparedness for catastrophes
In another lengthy report, the Department of Homeland Security (DHS) on Jun 16 assessed the nation's preparedness for catastrophes such as a major terrorist attack or a category 5 hurricane. The assessment included all 56 states and territories, as well as 75 urban areas.
The assessment was ordered by President Bush and Congress in the wake of Hurricane Katrina, according to a DHS news release. Last February the agency released a report based on preparedness self-assessments by states and major cities; the new report represents the findings of expert "peer review teams" that visited the states and cities and checked their plans against national standards.
Among the key findings in the Nationwide Plan Review for states and urban areas are:
- Most planning processes are not adequate as defined in the National Response Plan (NRP).
- A common deficiency in state and urban areas is the absence of a clearly defined command structure.
- The ability to give the public accurate, timely information should be strengthened.
- Significant weaknesses in evacuation planning are of profound concern.
- Resource management is the "Achilles heel" of emergency planning.
Among the key findings for the federal government are:
- Clear guidance needs to be developed on how state and local governments can coordinate operations with federal partners according to the NRP.
- Collaboration between government and non-governmental organizations should be strengthened at all levels.
- Federal, state, and local governments should work with the private sector to optimize transportation of people with disabilities before, during, and after an emergency.
- The federal government should provide leadership, guidance, and resources necessary to build a shared national homeland security planning system.
IOM's "Future of Emergency Care" series
National Academies Jun 14 press release