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Institute of Medicine Report on Emergency Medicine

ED News: IOM Report on Emergency Medicine 

6/14/06: 

The Institute of Medicine has just released 3 comprehensive reports on Emergency Medicine. 

Institute of Medicine Report:  The Future of Emergency Care 

Robert I. Broida, MD, FACEP

The Institute of Medicine (IOM) is a major player in U.S. healthcare. They are an agency of the National Academy of Sciences, providing advice to policy-makers on healthcare matters. Their landmark 1999 report, To Err is Human: Building A Safer Health System, helped launch many of the patient safety initiatives that hospitals are implementing throughout the country. 

The IOM’s Committee on the Future of Emergency Care just released a trio of reports addressing the “crisis” in emergency care.  Studying the issues since 2003, their mission was to “examine the state of emergency care in the U.S., to create a vision for the future of emergency care, including trauma care, and to make recommendations to help the nation achieve that vision.”

The 314-page IOM report confirms much of what we already know, concluding that “the nation's emergency medical system as a whole is overburdened, underfunded, and highly fragmented.”  The report specifically addresses key issues such as ED overcrowding, ambulance diversion, boarding and surge capacity, noting “ambulances are turned away from emergency departments once every minute on average and patients in many areas may wait hours or even days for a hospital bed.  Moreover, the system is ill-prepared to handle surges from disasters such as hurricanes, terrorist attacks, or disease outbreaks.“

Two other reports (Pediatric EDs and Emergency Medical Services) address those specific areas.

Highlights of the IOM ED report,
Hospital-Based Emergency Care: At the Breaking Point:
 

1.       Overcrowding: Most EDs are operating near or at capacity. The US had a net loss of 703 hospitals between 1993 and 2003.  Inpatient beds dropped by 198,000 (17%).  During the same time, the population grew by 12%, hospital admissions increased by 13% and ED visits rose by 26% to 113.9 million in 2003.  91% of EDs report overcrowding as a problem. 40% report it daily, which stresses both providers and patients, potentially impacting quality of care and increasing medical errors. They specifically noted a JCAHO July 2002 sentinel event alert that tied 50 hospital deaths to treatment delays.  

2.       Boarding: They cited ACEP’s 2003 survey reporting that 73% of EDs experienced boarding of admitted patients on a typical Monday evening. It is not unusual for busy EDs to board patients more than 48 hours. This has effects similar to overcrowding, but also taints the patient’s view of the hospital admission experience (i.e. negative patient satisfaction).

3.       EMS Diversion:  Almost 50% of all hospitals (70% of urban) reported using diversion status in 2004. In 2003, 501,000 ambulances were diverted, averaging 1 per minute.

4.       Left Without Being Seen:  The report also cited a study showing that in 2003, 1.9 million patients left without being seen (1.7% of all ED patients vs. 1.1% in 1993).  An additional 1% left AMA (before treatment was completed).

5.      Healthcare Safety Net:  “Hospital emergency departments are the provider of last resort for millions of patients who are uninsured or lack adequate access to care from community providers.”

6.       Medical Necessity: 50.4% of visits were classified as emergent or urgent.  32.8% were classified as non-urgent (or semi-urgent). The IOM report discusses the issue of medical necessity for emergency care and correctly questions whether this should be “determined by the patient’s signs and symptoms at the time of arrival”  (page 34)

7.       Financial Class:  Medicaid ED utilization was 81 visits per 100 persons in 2003, up from 65.4 in 2002.  Medicare ED utilization was 52.4 visits per 100 enrollees in 2003. Self-pay was 41.4 visits per 100 persons.  Private insurance was lowest, at 21.5%.

8.       Reimbursement:  The average combined physician/hospital ED charge was $943 in 2001.  The average payment received was $492 (52%).  The average charge increased by 49% since 1996, while the average payment only increased by 29%.

9.       Maldistribution:  21% of Americans live in rural areas while only 12% of emergency physicians practice in rural settings (down from 15% in 1997). 67% of these physicians are neither EM residency trained nor board certified. 

10.   Research:  Emergency medicine is not well represented in the National Institutes of Health (NIH), and the funding reflects this political reality. NIH training grants to emergency medicine departments averaged $51.66 per graduating resident vs. over $5,000 per Internal Medicine resident in 2003 (and $12,500 per Pathology resident).

 

Recommendations:

 

1.       Improve Operational Efficiency:  The IOM report specifically charges hospital CEOs with addressing patient flow problems.  In order to facilitate this, they recommend that training in operations management be promoted by professional and accrediting organizations.  They also specifically recommend that the JCAHO “reinstate strong standards that directly address ED crowding, boarding and diversion” (rather than the watered-down standards that were promulgated due to industry pressure).

2.       Increase use of Clinical Decision Units: The IOM recommends that the Centers for Medicare and Medicaid Services (CMS) “remove the current restrictions on the medical conditions that are eligible for separate CDU payment.”

3.       Prohibit Boarding and Diversion: The IOM views boarding and diversion as “antithetical to quality medical care,” recommending that hospitals end both practices, except in the setting of a mass casualty event.  They also call upon CMS to convene a working group to develop standards and guidelines for “enforcement of these standards.”

4.       Information Technology:  Recognizing that “emergency physicians are all too often deprived of critical patient information” and that EDs frequently operate with little operational data, the IOM recommends that hospitals adopt IT solutions to enhance efficiency and improve safety and quality. They recommend dashboard systems that track and coordinate patient flow, communications systems that will link to records or providers clinical decision-support tools and documentation systems.

5.       Funding:  IOM recommends dedicated funding to hospitals that provide “significant” amounts of uncompensated care, with an initial outlay of $50 million to be doled out by CMS based upon need. 

6.       Disaster Preparedness:  They also urge Congress to authorize large increases in disaster preparedness funding for FY 2007 to address such issues such as improving the trauma care system, enhancing surge capacity and EMS response, designing evidence-based training programs, increasing the number of decontamination showers, negative pressure rooms, personal protective equipment, ICU beds and further research.  Training and certification organizations are encouraged to incorporate disaster preparedness into the training and certification process.

7.       On-Call Specialists:  The IOM notes that “providing emergency call has become unattractive to many specialists in critical fields such as neurosurgery and orthopedics” due to availability, reimbursement and liability concerns.  They recommend regionalizing critical on-call specialty services between hospitals as one solution to this problem.

8.       Malpractice Reform:  Due to the “extraordinary exposure to medical malpractice claims,” the IOM urges Congress to appoint a commission to examine the impact of medical malpractice lawsuits and recommends state and federal action to mitigate the adverse impact of these lawsuits.”

9.       Rural EDs: With chronic workforce shortages, the IOM recommends that rural EDs link up with academic centers for professional consultation, telemedicine, referral and transport and CME.  

10.   Research:  The IOM recommends increased funding and coordination between federal agencies for emergency medicine research, including training of new investigators, development of multi-center research networks and a dedicated center or institute.

11.   Regionalization:  The IOM recommends that all EDs and trauma centers be categorized to best direct critically ill and injured patients to appropriate facilities on a regional basis. They also urge the development of evidence-based model prehospital care protocols.  In addition, they recommend that Congress fund an $88 million “demonstration program, administered by the Health Resources and Services Administration, to promote regionalized, coordinated, and accountable emergency care systems throughout the country.” 

12.   Accountability:  The IOM urged the Department of Health and Human Services (HHS) to create an expert panel to “develop evidence-based indicators of emergency care system performance,” including structure and process measures, including the performance of individual providers and outcome measures (over time). In order to address the  patchwork of state and local emergency care systems, they recommend establishment of a national Lead Agency (within HHS) for emergency and trauma care by 2008.    


Why it's important:
 

1.       The IOM is solely interested in the public good, not the needs of various constituents. 

2.       The IOM report is pushing JCAHO and CMS to adopt changes that will be beneficial to emergency medicine.

3.       The report links deficiencies in emergency care to decreased patient safety, which still has a lot of traction in healthcare.

4.       There is a lot of money involved:  for research, for equipment and training, for uncompensated care, for technology, for regional systems, etc.

5.       They get a lot of things right:

a.       “When a hospital is full or its ancillary services are slow, ED crowding, inpatient boarding, and ambulance diversion are almost inevitable.” (page 20)

b.       “boarder is a misnomer, because it implies that these patients require little care. In fact, ED boarders are often the sickest, most complex patients in the emergency department – which is why they require hospitalization.”  (page 30)

c.       “Increasingly, admitting physicians are insisting that EDs complete very detailed workups before they will admit a patient to the hospital.”  (page 37)

d.       “There is substantial evidence that reimbursement to safety net hospitals is inadequate to cover the costs of emergency and trauma care.” (page 41)

e.       “While many of the factors contributing to ED overcrowding are outside the immediate control of the hospital, many more are the result of operational inefficiencies in the management of hospital patient flow.”  (page 103)

 

The IOM report is an excellent resource document and may well lay the ground work for significant changes in the emergency care landscape for years to come.  As an independent body, their work lends key support to many of the issues that have plagued emergency medicine for years.  

 

Link to the full report (314 page pdf)

  

 
 
 

QA/PI Rules HHS Tort Refom Malpractice Crisis ED Overcrowding 2004 Patient Safety New EMTALA Regs Texas Tort Reform SARS Update JCAHO: Patient Flow 2005 Patient Safety ED Outsourcing Medical Liability 2006 Patient Safety 2007 NPSG-Proposed 2007 Patient Safety IOM Report EM Quality Measures

 

 

        

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