Nation's emergency care at 'breaking point'

WASHINGTON -- Half a million times a year -- about once every minute -- ambulances carrying sick patients are turned away from full emergency rooms and sent to others farther away,

It's a sobering symptom of how the nation's emergency-care system is overcrowded and overwhelmed, "at its breaking point," concludes an investigation by the Institute of Medicine.

"The safety net ... has large holes," co-author Dr. A. Brent Eastman, chief medical officer at ScrippsHealth in San Diego, said Wednesday. "You may not be caught and saved when your life depends on it."

How many people die as a result? The two-year review couldn't come up with an answer; there's little tracking of how emergency patients fare after that frantic 911 call or race to the hospital. But there are troubling clues. For example, in some cities emergency workers save half of the victims of cardiac arrest -- but in other places they save merely 5 percent.

This nationwide crisis comes from just day-to-day emergencies. Emergency rooms are far from ready to handle the mass casualties that a bird flu epidemic or terrorist strike would bring, the institute said Wednesday in a three-volume report.

"If you can barely get through the night's 911 calls, how on earth can you handle a disaster?" asked report co-author Dr. Arthur Kellerman, Emory University's emergency medicine chief.

Even a school bus crash would qualify as a disaster for most hospitals: Although children make up more than a quarter of all ER visits, only 6 percent of emergency departments have all the supplies needed -- such as child-sized equipment -- to treat pediatric emergencies, and few have doctors trained in children's care either, the institute's panel found.

That ERs are overburdened isn't new. But the review by the institute, an independent scientific group that advises the government, provides an unprecedented look at the problem's scope -- and recommends urgent steps for health organizations and local and federal officials to start fixing it.

At the root of the crisis: Demand for emergency care is surging, even as the capacity for hospitals, ambulance services and other emergency workers to provide it is dropping.

There were nearly 114 million emergency room visits in 2003, up from 90 million a decade earlier. Only about half were true medical emergencies. When the poor and uninsured can't get health care anywhere else, they come to emergency rooms, which must treat them regardless of ability to pay.

Yet lack of reimbursement for ER care is one reason some emergency departments go out of business. During the past decade, the total number of U.S. hospitals decreased by 703, and the number of ERs by 425. And the total number of hospital beds dropped nationwide by 198,000.

Topping the report's recommendation list is a call for states and hospitals to set up regionally coordinated emergency systems that manage patient flow to avoid overcrowding much like airports direct flight traffic. They would direct ambulances not necessarily to the nearest ER but to the one best equipped to treat each patient's condition.