Emergency care system gets low grades

National report card says situation is dire in many states and changes are needed.

By Brian Hedger — Posted Jan. 19, 2009

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The emergency care system nationwide earned an overall grade of C-, with access to emergency health care getting a D-, according to a report by the American College of Emergency Physicians.

Overcrowding continues to plague emergency departments as the population ages and grows, and the number of emergency departments dwindles, says the ACEP "National Report Card on the State of Emergency Medicine," released in December 2008.

Boarding of patients in EDs is widespread and contributes heavily to overcrowding and ambulance diversions, the report noted. Combined with increasing numbers of specialists opting not to take emergency call, access to emergency care is nearly in crisis mode.

"The fact that the overall grade is a C-, that's probably better than we deserve," said ACEP President Nick Jouriles, MD, professor of emergency medicine at Northeastern Ohio Universities College of Medicine and an emergency physician at Akron General Medical Center. "The emergency departments are overwhelmed and not getting support, and people are dying because of this."

The report cited the 2007 "ACEP Poll on the Critical Issues Facing Emergency Patients" that surveyed about 1,500 emergency physicians. Results showed that 90% of respondents classified their ED as overcrowded, while 80% said overcrowding had gotten worse than the previous year. Also, nearly 70% said boarding was frequent in their EDs.

Addressing the boarding problem is the most immediate step that can be taken to improve emergency access, Dr. Jouriles said.

Long term, the report recommends the health care system be reformed, beginning with Congress passing the Access to Emergency Medical Services Act this year.

The legislation would increase financial reimbursements for emergency physicians and on-call specialists, create a commission to study factors that affect access to EDs and call on the Centers for Medicare & Medicaid Services to collect data on ED boarding in order to craft standards.

The report also recommends federal and state medical liability reforms, more federal funding for disaster preparedness, better emergency medical services coordination, and improving quality and patient safety by using health information technology.

"Access [to emergency care] is as close as you can get to a complete failure, and that's where we're at," Dr. Jouriles said.

The American Medical Association recognizes the crisis in emergency medicine. At its 2008 Interim Meeting, the AMA's House of Delegates reaffirmed its policy to ensure that physicians in EDs and on-call emergency service be appropriately compensated for providing mandated services.

Overcrowded EDs

The ACEP report graded each state and Washington, D.C., in five categories: access to emergency care; quality and patient safety environment; medical liability environment; public health and injury prevention; and disaster preparedness.

Massachusetts ranked first overall with a B, while Arkansas ranked last with a D-. In access to emergency care, Washington, D.C., was best with an A, while California was last with an F.

Marshall Morgan, MD, wasn't surprised by the grades. He is chief of emergency medicine at the University of California at Los Angeles Medical Center and professor of emergency medicine at the UCLA David Geffen School of Medicine.

He said his emergency department was overcrowded daily and that boarding is a problem. He said finding on-call specialists also is troublesome, because most EDs at smaller community hospitals struggle to get a surgical specialist. They often try to transfer patients to larger places such as UCLA, but to no avail.

"We are almost always closed to transfers because we are stuffed to the gills and there is no place in our hospital for them," he said. "And that's true for a lot of big medical centers."

Loyola University Medical Center, located just outside Chicago, is packed most days, said Mark Cichon, DO, Loyola's director of emergency medical services and associate professor in the Loyola University Stritch School of Medicine.

The same issues at Loyola are plaguing other hospitals nationwide, Dr. Cichon said.

"In terms of access across the country, it is a crisis in emergency medicine," he said.

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