Confront emergency room crisis with health care reform, better funding
The nation's emergency rooms turn away an ambulance a minute because they're overburdened.
They're also financially strapped and ill-prepared to handle mass influxes of patients after disasters -- anything from hurricanes to terror attacks to a flu pandemic.
That's the ominous prognosis from reports released last week by the Institute of Medicine, part of the National Academy of Sciences.
The same problems affect Florida -- where emergency care wait times average four hours, the fifth-longest in the nation -- and Brevard County.
Florida ranks near the bottom nationally in emergency departments per 1 million residents and needs more, according to a January report from the American College of Emergency Physicians.
The Florida Hospital Association says the situation is at crisis level, citing overcrowding that delays care and a shortage of physicians, including of specialists willing to work in an emergency department.
In Brevard, emergency departments have to send ambulances to other centers from 15 to 20 times a month during the winter when snowbirds swell the population.
That's according to Dr. John McPherson, a medical director at Holmes Regional Medical Center in Melbourne and president of the Florida Association of EMS Medical Directors.
As a result, it can take ambulances some 20 minutes longer to find a place to leave patients, worrisome delays when health is at risk.
The causes of the emergency care crisis are complex -- including population increases and, in Florida, a growing elderly population -- and solving it requires action on several fronts.
Locally, Health First is expanding its emergency care capacity at Palm Bay and Holmes hospitals and plans to build a full service emergency department at its proposed new hospital in Viera.
Other solutions include opening more alternatives to emergency rooms, such as urgent care sites and making sure emergency departments use existing resources efficiently.
But those are only a superficial salve for a problem rooted in a greater health care crisis:
The uninsured.
More than 46 million Americans, including more than 3 million Floridians, lack health coverage.
They, along with Medicaid recipients who can't find doctors, are using emergency rooms as a medical safety net, jamming the system and increasing waiting times for all.
And while ERs are required by law to treat the uninsured, they often aren't compensated for doing so.
One out of every four emergency department visitors at Wuesthoff Medial Center in Rockledge and Melbourne has no insurance coverage or money, and 99 percent of the organization's charity care and bad debt come from emergency care, according to spokeswoman Lisa Crites.
The costs of such unreimbursed care have contributed to the closing of more than 400 emergency departments nationwide since the early 1990s, says the Institute of Medicine study.
The study calls for Congress to establish a pool of at least $50 million to help hospitals recoup those costs.
It also says Congress should significantly boost the scant dollars it has provided so far to help emergency departments prepare for large disasters.
In the wake of devastating hurricanes in recent years -- and in light of the threat of flu pandemic and potential for more terror attacks on American soil -- Congress should follow those recommendations.
But that's still just a start on solving the emergency care crisis.
Nothing short of comprehensive health care reform to ensure more U.S. citizens have access to primary medical services will stem the flow of needy patients into the nation's ERs.
With no action to do that coming from Congress, it's up to states to tackle the challenge. Florida's plans to put Medicaid clients into private HMOs, however, may do more harm than good.
That's because the state will allow private plans to limit the scope of services patients receive, meaning the impoverished may still resort to emergency care.
A more comprehensive approach, such as a law recently passed in Massachusetts to make health care free or affordable to all, is needed and should be pursued by Florida's next governor.
Readers can discuss this editorial in Community Forums. http://community.flatoday.com
July 9, 2006
http://www.floridatoday.com/apps/pbcs.dll/article?AID=/20060709/OPINION/607090332/1004
Dr. David Seaberg, Professor of Medicine at the University of Florida testified to Congress in February 2006 on behalf of the American College of Emergency Physicians. He presented a 10 point plan in a press release copied at the end of this post.
The bill he referenced, HR 3875 has been in committee since October 2005. A related bill was introduced in the Senate in May 2006 and can be accessed at
http://www.govtrack.us/congress/bill.xpd?bill=s109-2750
I can vouch from experience in Texas and now Florida that access to emergency medical services is in crisis on a daily basis. I work at a tertiary psychiatric facility and we refer for emergency or urgent care at least once a week. The urgent care centers offer little more than access to a physician, x-rays and labs on an as needed basis. Any serious condition must go to an emergency room. If the patient is unconscious or has unstable vital signs the patient can get quick access to services but then may have to wait half a day or more for a hospital bed.
All the emergency center facilities and most people with experience know we do not want a number of folks with ‘bird flu like” symptoms waiting for hours in the ER lobby.
The alternative care sites are not yet defined. The alternate care site issue is a local problem that is stymied by a lack of funding sources. HRSA funds for disaster preparedness in my observations were geared more for terrorist events like explosives or one event attacks with anthrax or chemicals. The set up required for ongoing pandemic is quite different. Maybe some foundations have funds to pilot the set up for alternate treatment sites in the event of a pandemic, but I have not seen them.
The Medical Reserve Corps (www.medicalreservecorps.gov) was established to deal with the manpower issues but has no material resources. I describe to potential volunteers that we are tasked to set up a hospital quality environment with volunteer personnel, donated materials and any available space. This is not a task I care to undertake. My hope is that we will have time to develop and acquire resources (3 to 4 years). If the pandemic occurs earlier, we should at least hope to have a plan in place to channel the emergency resources. This process is replicated in some form in 456 MRC units across the USA.
I encourage US Flutracker readers to examine their county pandemic plans and what role if any is expected from the local Medical Reserve Corps Unit. There is probably a role for the interested flutracker to volunteer with the MRC. I also offer a word of caution, the majority of disaster volunteers are not as in tune with pandemic risks and processes as the average flutracker. Please be gentle in suggestions for improvement.
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The press release with Dr. Seaberg’s testimony is listed here.
http://www.acep.org/webportal/Newsroom/NR/general/2006/020806.htm
Washington, DC - David C. Seaberg, MD, a member of the Board of Directors of the American College of Emergency Physicians (ACEP), today testified before a joint hearing of subcommittees of the U.S. House Committee on Homeland Security. Dr. Seaberg, professor and associate chairman of the Department of Emergency Medicine at the University of Florida in Gainesville, gave testimony at the hearing on "Protecting the Homeland: Fighting Pandemic Flu From the Front Lines." Here are excerpts from his statement:
"As the front line of emergency care in this country, emergency physicians will be at the heart of responding to the devastating impact of an avian flu pandemic on the public and our communities. We must take steps now to avoid a catastrophic failure of our medical infrastructure by alleviating overcrowding and improving surge capacity in our nation's emergency departments.
"If the avian flu pandemic, which has been the focus of world attention over the past several months, should begin spreading from human to human and then reach our shores, the consequences to the United States would be catastrophic.
"According to the Centers for Disease Control and Prevention, in the absence of any control measures - vaccination or drugs - it has been estimated that a 'medium-level' pandemic could cause 89,000 to 207,000 deaths, 314,000 to 734,000 hospitalizations, 18 to 24 million outpatient visits, and another 20 million to 47 million people could be infected. Overall, between 15 percent and 35 percent of the U.S. population could be affected by an influenza pandemic and the economic impact could range between $71.3 and $166.5 billion.
"Without sufficient warning, emergency physicians and nurses would be unprepared to place arriving avian flu patients in isolation until it was too late. Since most hospitals only have one isolation unit, there would be no way to isolate the next avian flu patient seeking emergency care. By this time, the emergency physicians and nurses will have been in contact with avian flu, and unless previously inoculated, will be at high-risk of contracting the disease themselves, potentially diminishing their ability to provide care for patients.
"With the majority of the nation's emergency departments already operating either at or over critical capacity, the strain of arriving avian flu patients will cripple America's 4,000 hospital emergency departments.
"The latest figures from the CDC found emergency department visits have risen 26 percent over the past decade - from 89.8 million in 1992 to 114 million in 2003. At the same time, the number of emergency departments decreased by 14 percent. In addition, between 1990 and 1999, hospitals lost 103,000 staffed, inpatient medical/surgical beds and 7,800 Intensive Care Unit (ICU) beds. As a result, fewer beds are available for admissions from the emergency department. Once the emergency departments have filled all of their beds, there is no reasonable way to expect that these stressed systems will be able to suddenly create the surge capacity necessary to effectively manage a pandemic, natural disaster, terrorist attack or other mass-casualty event.
"Since 9/11 we have appropriately spent billions on preparedness. But emergency departments have received virtually none of that support. Policymakers and the public have assumed the nation's emergency departments will be able to meet their vital safety net function. However, lack of overall capacity may lead to a breakdown of the health care safety net when we need it most. If we are unable to effectively respond to a disaster or pandemic, people will suffer needlessly and some will die."
Dr. Seaberg proposed the following 10-Point Plan to increase capacity, alleviate overcrowding and improve surge capacity in the nation's emergency departments:
1. We must increase the surge capacity of our nation's emergency departments by ending the practice of "boarding" admitted patients in emergency departments because no inpatient beds are available. This will require changing the way hospitals are funded to allow for inpatient and intensive-care unit surge capacity to manage this burden.
2. We must implement protocols to collect and monitor real-time data for syndromic surveillance, hospital inpatient and emergency department capacities and ambulance diversion status. Collection of this data is vital to developing appropriate protocols.
3. Homeland Security agencies on the federal, state, and local levels need to understand that hospitals and emergency departments are part of the community's critical infrastructure. We cannot have response and recovery in a disaster without fully functioning, protected, and connected health resources.
4. We must require hospitals and communities that are severely affected by a natural or man-made disaster, or even a severe influenza outbreak, to postpone elective admissions until the crisis has abated. We must develop a way to compensate those facilities for their loss of revenue.
5. Command and control of disaster medical response must be more coordinated across federal, state and local agencies and departments.
6. We must establish a committee of stakeholders and disaster medicine experts from the public- and private-sectors and academic institutions to develop and/or refine national medical preparedness priorities and standards. We must change the national preparedness culture to one which is consensus-driven and evidence-based.
7. We must provide federal and state funding to compensate hospitals and emergency departments for the unreimbursed cost of meeting their critical public health and safety-net roles to ensure these emergency departments remain open and available to provide care in their communities.
8. We must establish a sustainable funding mechanism for disaster preparedness for hospitals, emergency departments and emergency management that is tied to national benchmarks and deliverables.
9. To ensure emergency physicians and nurses play a primary role in disaster planning and are considered in any national allocation of resources and protective measures, Congress should continue to include them in any definitions regarding first responders to disasters, acts of terrorism and epidemics.
10. Congress should pass H.R. 3875, the "Access to Emergency Medical Services Act," which provides incentives to hospitals to reduce overcrowding and provides reimbursement and liability protection for EMTALA-related care.
ACEP is a national emergency medicine specialty society with more than 23,000 members. ACEP is committed to advancing the quality of emergency care through continuing education, research, and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters in each state, as well as Puerto Rico and the District of Columbia, and a Government Services Chapter representing emergency physicians employed by military branches and other government agencies.
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Joe E. Thornton, M.D.
Aka Christian Rivers
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