The Institute of Medicine has just released
3
comprehensive reports on Emergency Medicine.
Institute of Medicine Report: The Future of Emergency Care
Robert I. Broida, MD, FACEP
The
Institute of Medicine
(IOM) is a major player in U.S. healthcare. They are an agency of the
National
Academy of Sciences, providing advice to policy-makers on healthcare
matters. Their landmark 1999 report,
To Err is Human: Building A Safer Health System,
helped launch many of the patient safety initiatives that hospitals are
implementing throughout the country.
The
IOM’s
Committee on the Future of Emergency Care just released a
trio of reports
addressing the “crisis” in emergency care. Studying the issues since 2003,
their mission was to “examine the state of emergency care in the U.S., to create
a vision for the future of emergency care, including trauma care, and to make
recommendations to help the nation achieve that vision.”
The
314-page IOM report confirms much of what we already know, concluding
that “the nation's emergency medical system as a whole is overburdened, underfunded, and highly fragmented.” The report specifically addresses key
issues such as ED overcrowding, ambulance diversion, boarding and surge
capacity, noting “ambulances are turned away from emergency departments once
every minute on average and patients in many areas may wait hours or even days
for a hospital bed. Moreover, the system is ill-prepared to handle surges from
disasters such as hurricanes, terrorist attacks, or disease outbreaks.“
Two
other reports (Pediatric EDs and
Emergency Medical Services) address those
specific areas.
Highlights of the IOM ED report,
Hospital-Based Emergency Care: At the Breaking
Point:
1.
Overcrowding: Most EDs are operating near or at capacity. The US had a
net loss of 703 hospitals between 1993 and 2003. Inpatient beds dropped by
198,000 (17%). During the same time, the population grew by 12%, hospital
admissions increased by 13% and ED visits rose by 26% to 113.9 million in 2003.
91% of EDs report overcrowding as a problem. 40% report it daily, which stresses
both providers and patients, potentially impacting quality of care and
increasing medical errors. They specifically noted a JCAHO July 2002 sentinel
event alert that
tied 50 hospital deaths to treatment delays.
2.
Boarding: They cited ACEP’s 2003 survey reporting that 73% of EDs
experienced boarding of admitted patients on a typical Monday evening. It is not
unusual for busy EDs to board patients more than 48 hours. This has effects
similar to overcrowding, but also taints the patient’s view of the hospital
admission experience (i.e. negative patient satisfaction).
3.
EMS Diversion: Almost 50% of all hospitals (70% of urban) reported using
diversion status in 2004. In 2003, 501,000 ambulances were diverted, averaging 1
per minute.
4.
Left Without Being Seen: The report also cited a study showing that in
2003, 1.9 million patients left without being seen (1.7% of all ED patients vs.
1.1% in 1993). An additional 1% left AMA (before treatment was completed).
5. Healthcare Safety Net: “Hospital emergency departments are the provider of last
resort for millions of patients who are uninsured or lack adequate access to
care from community providers.”
6.
Medical Necessity: 50.4% of visits were classified as emergent or
urgent. 32.8% were classified as non-urgent (or semi-urgent). The IOM report
discusses the issue of medical necessity for emergency care and correctly
questions whether this should be “determined by the patient’s signs and symptoms
at the time of arrival” (page 34)
7.
Financial Class: Medicaid ED utilization was 81 visits per 100 persons
in 2003, up from 65.4 in 2002. Medicare ED utilization was 52.4 visits per 100
enrollees in 2003. Self-pay was 41.4 visits per 100 persons. Private insurance
was lowest, at 21.5%.
8.
Reimbursement: The average combined physician/hospital ED charge was
$943 in 2001. The average payment received was $492 (52%). The average charge
increased by 49% since 1996, while the average payment only increased by 29%.
9.
Maldistribution: 21% of Americans live in rural areas while only 12% of
emergency physicians practice in rural settings (down from 15% in 1997). 67% of
these physicians are neither EM residency trained nor board certified.
10.
Research: Emergency medicine is not well represented in the
National
Institutes of Health
(NIH), and the funding reflects this political reality. NIH
training grants to emergency medicine departments averaged $51.66 per graduating
resident vs. over $5,000 per Internal Medicine resident in 2003 (and $12,500 per
Pathology resident).
Recommendations:
1.
Improve Operational Efficiency: The IOM report specifically charges
hospital CEOs with addressing patient flow problems. In order to facilitate
this, they recommend that training in operations management be promoted by
professional and accrediting organizations. They also specifically recommend
that the JCAHO “reinstate strong standards that directly address ED crowding,
boarding and diversion” (rather than the watered-down standards that were
promulgated due to industry pressure).
2.
Increase use of Clinical Decision Units: The IOM recommends that the
Centers for Medicare and Medicaid Services (CMS) “remove the current
restrictions on the medical conditions that are eligible for separate CDU
payment.”
3.
Prohibit Boarding and Diversion: The IOM views boarding and diversion as
“antithetical to quality medical care,” recommending that hospitals end both
practices, except in the setting of a mass casualty event. They also call upon
CMS to convene a working group to develop standards and guidelines for
“enforcement of these standards.”
4.
Information Technology: Recognizing that “emergency physicians are all
too often deprived of critical patient information” and that EDs frequently
operate with little operational data, the IOM recommends that hospitals adopt IT
solutions to enhance efficiency and improve safety and quality. They recommend
dashboard systems that track and coordinate patient flow, communications systems
that will link to records or providers clinical decision-support tools and
documentation systems.
5.
Funding: IOM recommends dedicated funding to hospitals that provide
“significant” amounts of uncompensated care, with an initial outlay of $50
million to be doled out by CMS based upon need.
6.
Disaster Preparedness: They also urge Congress to authorize large
increases in disaster preparedness funding for FY 2007 to address such issues
such as improving the trauma care system, enhancing surge capacity and EMS
response, designing evidence-based training programs, increasing the number of
decontamination showers, negative pressure rooms, personal protective equipment,
ICU beds and further research. Training and certification organizations are
encouraged to incorporate disaster preparedness into the training and
certification process.
7.
On-Call Specialists: The IOM notes that “providing emergency call has
become unattractive to many specialists in critical fields such as neurosurgery
and orthopedics” due to availability, reimbursement and liability concerns.
They recommend regionalizing critical on-call specialty services between
hospitals as one solution to this problem.
8.
Malpractice Reform: Due to the “extraordinary exposure to medical
malpractice claims,” the IOM urges Congress to appoint a commission to examine
the impact of medical malpractice lawsuits and recommends state and federal
action to mitigate the adverse impact of these lawsuits.”
9.
Rural EDs: With chronic workforce shortages, the IOM recommends that
rural EDs link up with academic centers for professional consultation,
telemedicine, referral and transport and CME.
10.
Research: The IOM recommends increased funding and coordination between
federal agencies for emergency medicine research, including training of new
investigators, development of multi-center research networks and a dedicated
center or institute.
11.
Regionalization: The IOM recommends that all EDs and trauma centers be
categorized to best direct critically ill and injured patients to appropriate
facilities on a regional basis. They also urge the development of evidence-based
model prehospital care protocols. In addition, they recommend that Congress
fund an $88 million “demonstration program, administered by the Health Resources
and Services Administration, to promote regionalized, coordinated, and
accountable emergency care systems throughout the country.”
12.
Accountability: The IOM urged the Department of Health and Human
Services (HHS) to create an expert panel to “develop evidence-based indicators
of emergency care system performance,” including structure and process measures,
including the performance of individual providers and outcome measures (over
time). In order to address the patchwork of state and local emergency care
systems, they recommend establishment of a national Lead Agency (within HHS) for
emergency and trauma care by 2008.
Why it's important:
1.
The IOM is solely interested in the public good, not the needs of various
constituents.
2.
The IOM report is pushing JCAHO and CMS to adopt changes that will be
beneficial to emergency medicine.
3.
The report links deficiencies in emergency care to decreased patient
safety, which still has a lot of traction in healthcare.
4.
There is a lot of money involved: for research, for equipment and
training, for uncompensated care, for technology, for regional systems, etc.
5.
They get a lot of things right:
a.
“When a hospital is full or its ancillary services are slow, ED crowding,
inpatient boarding, and ambulance diversion are almost inevitable.” (page 20)
b.
“boarder is a misnomer, because it implies that these patients require
little care. In fact, ED boarders are often the sickest, most complex patients
in the emergency department – which is why they require hospitalization.” (page
30)
c.
“Increasingly, admitting physicians are insisting that EDs complete very
detailed workups before they will admit a patient to the hospital.” (page 37)
d.
“There is substantial evidence that reimbursement to safety net hospitals
is inadequate to cover the costs of emergency and trauma care.” (page 41)
e.
“While many of the factors contributing to ED overcrowding are outside
the immediate control of the hospital, many more are the result of operational
inefficiencies in the management of hospital patient flow.” (page 103)
The IOM report is an
excellent resource document and may well lay the ground work for significant
changes in the emergency care landscape for years to come. As an independent
body, their work lends key support to many of the issues that have plagued
emergency medicine for years.
Link to the full report (314 page pdf)
IOM Report 
