Crisis for nation's EDs

Emergency departments are in need of their own triaging and plan for recovery. There were 114 million visits to EDs in 2003, an 18% increase from 1995. The uninsured, Medicaid beneficiaries, patients needing primary care and those with serious mental illness account for the growing number of visits due to those patients' limited access to other physicians, according to published studies, including the 2006 Institute of Medicine report Hospital-Based Emergency Care.

The subtitle of that report?

"At the breaking point."

Chances are the subtitle wasn't a shock to physicians. Specialty societies with stakes in the ED have conducted a number of studies in recent years showing just that. In 2005, 73% of ED medical directors told the American College of Emergency Physicians that there was inadequate specialist on-call coverage. That's up from the 66% of ED medical directors who answered that way just a year earlier.

Surveys that the American College of Surgeons, American Assn. of Neurological Surgeons and American Society of Plastic Surgeons conducted in 2005 and 2006 found that a majority of surgeons take ED call five to 10 days a month, and many surgeons provide on-call services simultaneously at two or more hospitals.

The American Medical Association, at its Interim Meeting in November 2006, recommended several strategies to meet the problem head on. The strategies are a result of a work group that included the AMA and representatives from 10 specialty societies.

First, there need to be more residency training positions and money to pay for them in specialties that provide emergency and trauma care -- areas such as emergency medicine and neurological, orthopedic and general surgery.

While the emergency department patient load has increased, in general terms the number of physicians being trained in specialties crucial in emergency and trauma situations has not increased, according to an AMA Board of Trustees report. For example, there were 828 neurological surgeon residents in 2004, up only slightly from the 794 training in 1994. The number of residents in general surgery decreased to 7,685 in 2004; down from 8,217 in 1994.

On top of that, about one-third of surgeons in general, neurological, orthopedic and plastic surgery are 55 or older. That's a factor when hospital bylaws let older physicians opt out or decrease their on-call responsibility.

Work also needs to be done to ensure that insurers pay physicians providing emergency care. That payment needs to be made whether the patient is in network or out of network. And there needs to be financial support for providing EMTALA-mandated care to patients. On-call specialists treat many ED patients who are uninsured. While hospitals can recover some of the costs for caring for those patients, that is not the case for trauma surgeons. Those facts helped an American College of Surgeons report conclude that the "single most important factor in shaping the surgical workforce issue today is declining reimbursement."

In addition, emergency physicians and specialists who provide EMTALA-mandated care need protection under state and federal laws. These physicians have a higher medical liability exposure than physicians who don't provide that care, with surveys by specialty groups showing that more than one-third of responding physicians had been sued by patients they saw in the ED.

Lastly, physicians who provide emergency services to patients from physician shortage areas, no matter where the medical care is provided, should get bonus payments. Often, patients in shortage areas need to be airlifted to other cities to get the care they need because it is unavailable in their hometown or county.

The stories about the many-hour waits patients face in EDs are notorious in cities nationwide. And ED crowding has led to more ambulances being diverted, which can lead to unacceptable delay in treatment. On top of that, there is little room for a surge in capacity if a major disaster strikes. Action on many fronts is needed to keep EDs equipped to help patients in their time of need.