The nation's emergency rooms have been stretched thin for at least a decade or more, but a new analysis suggests that they have reached a breaking point. Their plight underscores how dreadfully unprepared we are to cope with a major disaster like pandemic influenza or mass casualties from a terrorism attack.
The crisis in emergency medical care was laid bare in three reports issued last week by the Institute of Medicine, a unit of the National Academy of Sciences. Half a million times a year ambulances are diverted from emergency rooms that are full and sent to others farther away. Emergency room patients who need admission to the hospital often spend eight hours or more — sometimes even two days or more — on gurneys in the hallways, waiting for a hospital bed to open up.
Some emergency rooms lack the services of key specialists, such as neurosurgeons, who shy away from emergency room duty because many uninsured patients can't pay and their malpractice premiums would skyrocket because of the risky nature of emergency cases. What is not known is how many people die as a result of delays in treatment or inadequate care under chaotic conditions. No measurement system tracks such data.
The emergency room crisis has many causes, none of them easily or cheaply resolved. The number of people seeking treatment in emergency rooms has jumped sharply over the past decade or so, from 90 million in 1993 to 114 million in 2003. Over the same period, cost pressures forced the closing of some 700 hospitals, almost 200,000 hospital beds and 425 emergency departments. The result is severe crowding, exacerbated by a huge influx of poor people seeking routine care who are either uninsured or on Medicaid but unable to find doctors willing to treat them. By law, emergency rooms must accept all patients, whether they have insurance or not.
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The institute's experts have many proposals for easing the situation, ranging from new regional systems to improve the flow of patients to the most appropriate and least crowded emergency rooms to an infusion of money to cover unpaid emergency care and to bolster preparedness for large-scale disasters. The most important change would be to stop diverting seriously ill ambulance patients and divert instead the poor patients who clog emergency rooms seeking routine care. That would require extending health coverage to the uninsured and providing more primary care clinics and doctors in poor neighborhoods.
