Executive Summary

The emergency care system in the United States remains in serious condition, with numerous states facing critical problems. That is the disturbing but unmistakable finding of the 2009 edition of The National Report Card on the State of Emergency Medicine, a report designed to provide the American public with an objective assessment of the emergency care environment across the country. 

The American College of Emergency Physicians convened a blue-ribbon task force to produce this second edition of the Report Card. Building upon the 2006 edition, the 2009 Report Card provides a focused, comprehensive look at America’s emergency care system as measured in five categories. The categories consist of 116 objective metrics drawn from the most recent comparable data available from reliable and established sources.

These five categories have been weighted to determine a grade for each state, the District of Columbia, and the nation as a whole:

• Access to Emergency Care (30%)
• Quality and Patient Safety Environment (20%)
• Medical Liability Environment (20%)
• Public Health and Injury Prevention (15%)
• Disaster Preparedness (15%)

The Report Card is designed to evaluate the conditions under which emergency care is delivered in the United States. It does not measure the quality of care provided in individual hospitals or by individual emergency providers – rather, it considers the legislative and regulatory environment, the existing infrastructure, and the available workforce that constitute the emergency care system we all rely upon every day.

The findings of the 2009 Report Card are sobering.

The overall grade for the United States is C-

The C- grade is the same as that reported in the 2006 Report Card. However, while the two editions are significantly different and not directly comparable, the 2009 Report Card provides a more extensive evaluation of the nation’s emergency care system and confirms its tenuous condition. Individual state grades range from the highest, a B in Massachusetts, to the lowest, a D- in Arkansas.

Access to Emergency Care: D-

The nation has too few emergency departments to meet the needs of a growing and aging population. Over the past decade, the number of patients coming to the nation’s emergency departments annually has increased 32 percent, from 90.3 million to 119.2 million. At the same time, the number of hospital emergency departments has dropped nearly 7 percent, from 4109 to 3833. In addition, shortages of health care professionals at multiple levels - nurses, primary care physicians, emergency physicians, and other specialists - also jeopardize access to quality emergency care.

This category receives the poorest overall grade by far and encompasses many of the critical issues that require the most attention. Unfortunately, a lack of data related to several key issues that substantially impact access to emergency care may impede the identification and development of much-needed improvements. While national data for hospital crowding, emergency department patient boarding, ambulance diversions, and shortages of on-call specialists are available, there is a critical lack of detailed and state-specific data related to these and other major emergency care access issues. Collection and analysis of such data should be a priority for states as they work to address these issues and ensure adequate access to care.

Quality and Patient Safety Environment: C+

There was little uniformity among the states in this category, with grades varying widely. States performing well tend to have funded EMS systems with protocols in place to provide rapid response to life-threatening conditions such as heart attacks and strokes. These states also tend to monitor quality measures, track adverse events, and use electronic medical records more broadly than others.

The emergency care system, along with the health care system in general, has benefited from extensive efforts to continually improve the quality of care provided. Despite these nationwide efforts, the Report Card Task Force found only a few objective metrics of quality that are measured state-by-state. National quality improvement metrics required by the Centers for Medicare and Medicaid Services and The Joint Commission provide some of the metrics for this section. Given the relative paucity of existing sources of data pertaining to emergency care, the Task Force surveyed the 50 states and the District of Columbia to obtain additional data.

Medical Liability Environment: C-

While this is an area in which some states excel, the medical liability environment is causing a crisis in many states. Adverse legal environments have caused physicians to retire early, curtail higher-risk services, decrease their availability to emergency patients or move to states with less liability exposure – decreasing the medical care available to patients. Several states, such as Texas, have made strides in improving their medical liability environment. Modeling such successes should be a goal across the nation.

The Report Card measures each state’s overall legal atmosphere, tort reform efforts such as caps on non-economic damages and expert witness rules, and the cost and availability of medical liability insurance. These factors affect access to emergency care and the ability of emergency physicians to find on-call specialists when a patient’s needs demand it.

Public Health and Injury Prevention: C

Preventable illnesses and injuries continue to be significant contributors to unnecessary deaths, disabilities and suffering across the country. In many cases, states have failed to pass legislation proven effective at protecting the public from traumatic injuries or preventable diseases. The lack of such legislation may result in avoidable health care expenditures and additional demands on the medical system. More importantly, unexpected tragedies could be prevented by the required use of seat belts, children’s car seats, and motorcycle helmets, or by tougher restrictions and penalties for drunk drivers.

Numerous indicators are available to measure the state of public health and injury prevention. The Report Card category focuses on five major subcategories – traffic safety, injuries, injury prevention efforts, immunizations, and health risk factors - in order to provide a picture of the state of public health as it pertains to the emergency care system.

Despite existing, proven, and economically efficient public health methods for promoting health and reducing morbidity and mortality, the United States remains far behind the outcomes reached in other industrialized countries.

Disaster Preparedness: C+

This new category was added to the 2009 edition of the Report Card to reflect the disaster planning efforts that are increasingly being tightly integrated into the emergency care system. Both natural disasters such as Hurricane Katrina, and manmade catastrophes such as the terrorist attacks of September 11, 2001, underscore the vital importance of disaster response.

Some of the state-specific data in this category are not yet available at the federal level, and were obtained by the Task Force through an extensive survey of the 50 states and the District of Columbia.

This category focuses on four key areas critical to an effective medical response to disasters: state coordination, hospital capacity, availability of trained personnel, and funding.

Recommendations

The national grade of a C+ reflects a lack of essential funding to frontline medical providers as well as a lack of consistent direction by the federal government, despite the investments made by numerous states.

In response to these findings, the American College of Emergency Physicians makes the following eight recommendations:

1. Create stronger emergency departments through national health care reform.
2. Alleviate boarding in emergency departments and hospital crowding.
3. Pass the Access to Emergency Medical Services Act.
4. Enact federal and state medical liability reforms.
5. Infuse a greater level of federal funding and support into disaster preparedness targeted for emergency medical preparedness and response.
6. Increase support for the nation’s health care safety net.
7. Develop greater coordination of emergency services.
8. Increase the use of systems, standards, and information technologies to track and enhance the quality and patient safety environment.

The national emergency health care system is in serious condition. Citizens, emergency care providers and government officials should carefully review their state’s report card to identify problem areas and actively support efforts to improve our nation’s emergency care system.