An 8-month-old baby girl was sent to an emergency department by her pediatrician. She was vomiting and dehydrated, and on the way, went into cardiac arrest. Upon arrival, the emergency physician found her not breathing and without a pulse, so he opened her airway, inserted an endotracheal breathing tube and started chest compressions and breathing for her. Lab tests were obtained within minutes after placing an intraosseous needle in her leg. Placing a line into the bone marrow provided fluids directly into the circulatory system, thus reversing life-threatening dehydration. The specialized procedures required the training of a highly skilled emergency physician. Her heart restarted, and once stabilized, she was taken to the pediatric intensive care unit where peritoneal dialysis was started and she was monitored closely. While severe dehydration can harm any child, she was ultimately diagnosed with Denys-Drash syndrome — a very rare genetic disorder which can lead to renal failure in the first 3 years of life. She almost died, but left the hospital without any problems and continues to do well with supportive medical care.
On a spring day in 2013, a Boston emergency department was almost full when word came of an explosion near the finish line of the Boston Marathon. Emergency department personnel sprang into action to prepare to handle a sudden influx of badly injured patients. When possible, existing patients were moved out of the emergency department or onto inpatient units in order to free up space to treat the bombing victims. The victims started arriving quickly by ambulance to various hospitals throughout the city, thanks to the coordinated response of Boston’s EMS system. At this hospital, emergency physicians, nurses and surgeons were deployed into more than 10 trauma teams ready to receive patients. Existing disaster response systems were put in place to quickly triage the new arrivals and then rapidly move them to available teams at the next appropriate stage of care. Providers at that hospital were prepared to handle the crisis, largely because the hospital had participated in more than 70 disaster drills over the previous seven years, including citywide drills with Boston EMS. The response at all levels was universally lauded for its extraordinary effectiveness in getting injured patients the immediate care they needed.
These experiences illustrate some of the critical characteristics required to save lives and to have successful patient outcomes in emergency medicine: the round-the-clock availability of emergency departments and emergency medical services (EMS) to provide lifesaving care to the victims of sudden serious illness or trauma or mass casualty events; the ability to initially evaluate and treat patients en route to the hospital and provide advance notice of their arrival; the breadth and depth of diagnostic and treatment abilities among emergency physicians; and their ability to coordinate care with and among other clinicians, including on-call specialists.
In the wake of the terrorist attacks of September 11, 2001, emergency physicians have worked with an array of public health and safety organizations to develop comprehensive, coordinated disaster planning. The importance of such planning has sadly played out repeatedly in recent years, from Aurora to Newtown, from Oklahoma to the Jersey Shore, from Boston, Massachusetts to West, Texas. In addition, the ever-present threat of epidemics, such as pandemic flu, emphasizes the need to plan for infectious disease prevention, control, and treatment. But the emergency care system is seriously strained. A lack of resources and the growing, multifaceted demands on emergency departments pose serious challenges for the ability of highly qualified emergency physicians to deliver life and limb saving care. Fewer emergency departments and shortages of inpatient beds have contributed to long wait times in emergency departments.
According to the Centers for Disease Control and Prevention (CDC), the supply of emergency departments has declined by about 11% from 1995 to 2010. Meanwhile, over that same time period emergency visit rates have increased at twice the rate of growth of the U.S. population. The number of emergency department visits was 130 million in 2010, and this number is likely to continue to grow(1). As the Baby Boom generation ages into retirement, a growing number of elderly patients with complicated health problems will likely seek medical care in emergency departments, possibly leading to “catastrophic” crowding(2). In addition, emergency visits are likely to increase when millions of people, added to the Medicaid rolls through the implementation of the Affordable Care Act, seek emergency care because they are unable to find physicians who accept their insurance. Uninsured and underinsured patients routinely lack access to primary care and frequently postpone needed medical care until ultimately requiring attention in the emergency department.
But primary care providers are also heavily dependent on emergency departments to ensure their patients receive proper medical attention. A 2013 RAND study reported that four in five people who called their family doctors about a sudden medical issue got the same advice: Go to the emergency department. Additionally, two-thirds of emergency visits occur after business hours, when doctors’ offices are closed(3).
Emergency physicians today mobilize resources to diagnose and treat every kind of medical emergency and set the course of care for their patients by coordinating with on-call specialists and other health care providers. Care that used to be provided on inpatient floors now is being done in emergency departments, often saving significant hospitalization costs. According to the 2013 RAND study, the 4% of America’s doctors who staff hospital emergency departments manage:
- 11% of all outpatient care in the United States
- 28% of all acute care visits
- Half of the acute care visits by Medicaid and CHIP beneficiaries
- Two-thirds of all acute care for the uninsured
As the demand for emergency care grows, many emergency providers already work in a stressed system that operates in a near-continuous state of crisis. There are many contributors to this public health predicament, from inadequate access to primary care and specialty on-call care to insufficient availability of inpatient beds, which leads to emergency department crowding.
Other causes include increased demand for services to treat preventable illnesses and injuries and the impact of excessive liability costs that fail to account for the inherent risks associated with providing immediate lifesaving emergency care. Little has improved since the release of the American College of Emergency Physicians (ACEP) 2009 National Report Card on the State of Emergency Medicine, which found significant obstacles to and shortcomings in care in every aspect measured. This reinforced the 2006 findings of an Institute of Medicine report, which determined that the U.S. emergency care system was at the breaking point(4). In addition, the lack of followup care for an emergency visit has been cited as a top concern influencing a physician’s decision to admit patients to the hospital(3), which also contributes to higher costs.
2014 Report Card
The American College of Emergency Physicians is dedicated to advancing emergency care, and in 2006 developed its first Report Card on the State of Emergency Medicine as a means to help accomplish this mission.
While this Report Card has a different title, its goal has not changed. This 2014 Report Card continues to assess the emergency care environments of each state and whether government policies are supportive of emergency care in five categories (discussed here in more detail):
- Access to emergency care
- Quality and patient safety environment
- Medical liability environment
- Public health and injury prevention
- Disaster preparedness
The policy environments of each of these categories have changed since the last Report Card in 2009. For too many people, access to emergency care remains obstructed; a problem that is compounded by an increase in the number of people who seek care in emergency departments, and a coinciding decrease in the number of emergency departments, hospital beds, and treatment centers. The nation has shifted its focus to measure quality of care within the quality and patient safety environment. This is reflected within trends in state systems and institutions, but is facing ongoing challenges in the design of the systems as well as in how quality of delivered care is measured.
In the medical liability environment, physicians continue to cite the failure to enact meaningful tort reform as a major contributor to the unnecessary costs of “defensive medicine” and a significant impediment to providing access to on-call specialists needed to provide critically important emergent specialty care.
Difficulties in enacting laws and employing effective strategies to prevent injuries and illnesses continue to plague the public health and injury prevention arena. Finally, in the area of disaster preparedness, the states have seen a decline in federal funding, leading to wide variation in states’ hospital capacity and personnel preparedness. In each of these categories, many states in 2014 continue to receive grades that are merely average or on the verge of failure.
Problems identified in the 2009 ACEP Report Card persist, especially in terms of emergency department crowding and its subsequent effect on the boarding of admitted emergency patients, emergency department wait times, and ambulance diversion.
At the same time, demographic trends are creating—or will soon create—significant challenges to providing quality emergency care, particularly in terms of addressing and eliminating health disparities and in meeting the needs of a rapidly aging society.
As an example of increasing demand, the widespread consequences of opioid addiction among the nation’s young people will continue to increase emergency visits, which will struggle to respond to associated illnesses and overdoses. Any number of studies point to the consequences of increased demand for emergency medicine. For example:
- A 2011 study found that mortality generally increased with increased emergency department boarding time, from 2.5% in patients boarded less than 2 hours, to 4.5% in those boarding 12 hours or more; for admitted patients, their hospital length-of-stay also increased with increased boarding time(5).
- Emergency department crowding has a “deleterious effect on the timeliness of emergency care, even for highacuity patients(6).”
- Emergency department length of stay was significantly longer for African-American patients admitted to ICU beds than Whites (367 minutes vs. 290 minutes)(7).
- Between 2009 and 2011, the rate of emergency visits involving illicit stimulants increased 68%, and the rate of visits involving marijuana rose 19%(8).
The misuse and abuse of prescription painkillers was responsible for more than 475,000 emergency department visits in 2009, a number that has nearly doubled in just five years(9). All of this occurs within the context of the evolving role that emergency medicine is playing in America’s health care system.
In the 2013 RAND research report, policy analysts noted several important changes in that role in terms of delivering not only urgent and emergent care, but also in coordinating patient care.Among the study’s key findings is that the emergency physician plays a key role in triaging access to appropriate levels of health care for patients. For instance, the growth in hospital admissions that occurred between 2003 and 2009 can be attributed almost entirely to an increase in unscheduled inpatient admissions from emergency departments. This trend stems from a new reality: primary care physicians increasingly rely on emergency physicians to help manage care for patients whose illnesses are severe or complex, as emergency departments can efficiently perform complex diagnostic workups and handle after-hours demand for care.
The roles of emergency departments and the emergency care system are likely to evolve further as provisions of the 2010 Affordable Care Act (ACA) become reality and begin to influence and shape the design, delivery, and financing of health care.
These provisions have yet to fully impact emergency medicine, and there is a debate over how these changes will play out—for better or for worse. Advocates point to likely improvements, particularly in terms of making health care accessible to millions more people by fully implementing state and federal Health Insurance Marketplaces (exchanges) and, in many states, expanding Medicaid; improving care coordination and disease management; deploying Accountable Care Organizations (ACOs) as a means of reducing total health care costs while improving care; and widespread provider and consumer use of electronic medical records. In any event, emergency care has never been more important than it is right now, especially as the nation implements health care reform. Emergency physicians have a unique view of the entire medical care system. They treat everyone, from babies to seniors, and see the full spectrum of medical problems. They know where the gaps in the medical care system are and have ideas about how to plug them.
Increases in the number of insured patients through health insurance exchanges, combined with the uneven state adoption of expanded Medicaid coverage, suggest that there will be great demand for emergency services in the coming years. To help ensure access to timely, quality emergency care, federal and state policymakers need to implement the Recommendations of this Report Card.