US emergency departments (EDs) are dangerously overburdened, underfunded and unprepared to cope with mass casualties from hurricanes, pandemics or terrorist attacks, according to 3 landmark reports issued in June.
![Figure](https://www.cmaj.ca/content/cmaj/175/5/464.1/F1.medium.gif)
Figure. The US Institute of Medicine concludes American EDs are dangerously overburdened. Photo by: Corbis/Magma
A nearly 3-year investigation by the Institute of Medicine, an independent scientific group, found a crisis in US EDs, which provide the only treatment guarantee for 47 million Americans without health insurance.
The reports, collectively entitled The Future of Emergency Care, are the first extensive studies of US emergency care in the past 40 years. They present a bleak picture: a half million times a year — about once a minute — ambulances carrying critically ill patients are diverted from full EDs to more distant sites. Once stabilized, patients can wait several hours, even days, on gurneys in ED hallways for inpatient beds. On-call specialists are in short supply because of the cost of malpractice insurance and the difficulty of collecting payment from uninsured patients.
Demand is surging in EDs as capacity is dropping. The number of patients treated at EDs rose 26% between 1993 and 2003. During the same period, US hospitals closed 425 EDs, partly to control spiraling costs.
A 1986 law requires US EDs to stabilize anyone who shows up, regardless of their ability to pay. Only half of ED patients require life-saving intervention, according to the reports.
Inadequate resources put children, who account for 27% of all visits to EDs, at risk. Only 6% of US EDs have all the equipment needed to treat pediatric emergencies, the reports found. Half had 85% of essential supplies.
Many of the reports' key recommendations were aimed at the US Congress including:
• Allocate $50 million to reimburse hospitals for unpaid emergency care to uninsured patients, $88 million over 5 years for projects to test ways to promote greater coordination among emergency care providers and $37.5 million to improve pediatric emergency services.
• Increase funding for disaster preparedness in hospitals.
• Create a lead agency in the Department of Health and Human Services to consolidate government programs dealing with emergency care.
The reports also called on hospitals to stop diverting ambulances and “boarding” patients on gurneys. It also urged EDs and responders to adopt modern information and communication technologies to improve patient flow and improve coordination between 911 dispatchers, ambulance workers and EDs.
Senate Majority Leader Bill Frist (R-Tenn.), a surgeon, wrote in the Philadelphia Inquirer that the problems in EDs are symptoms of larger problems and deficiencies in the US health care system. “Fixing them stands as one of the great public policy challenges of this decade,” Frist wrote.