Emergency Medical Services: At the Crossroads
Emergency Care for Children: Growing Pains
Hospital-Based Emergency Care: At the Breaking Point

Date:  June 14, 2006
Contacts:  Christine Stencel, Media Relations Officer
Michelle Strikowsky, Media Relations Assistant
Office of News and Public Information
202-334-2138; e-mail <news@nas.edu>


Action Needed to Bolster Nation’s Emergency Care System;
Lack of Funds, Coordination Lead to Overcrowding and Ambulance Diversions

WASHINGTON -- Despite the lifesaving feats performed every day by emergency departments and ambulance services, the nation's emergency medical system as a whole is overburdened, underfunded, and highly fragmented, says a new series of three reports from the Institute of Medicine of the National Academies.  As a result, 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, bombings, or disease outbreaks, said the committee that wrote the reports.

Congress should allocate significant funds to ensure that America's emergency departments (EDs), trauma centers, and medical first responders are fully equipped and ready to provide prompt and appropriate care, the reports say.  The committee also called for actions to reduce crowding of emergency rooms, boost the number of specialists involved in emergency care, and get all emergency medical services in an area to work collaboratively to steer patients to the most appropriate facilities.

"Most of us need emergency services only rarely, but we assume that the system will be able to provide us rapid, skilled care when we do," said committee chair Gail L. Warden, president emeritus, Henry Ford Health System, Detroit.  "Unfortunately, the system's capacity is not keeping pace with the increasing demands being placed on it.  We need a comprehensive effort to shore up America's emergency medical care resources and fix problems that can threaten the health and lives of people in the midst of a crisis."

Inadequate Funding Plagues System

Insufficient funding and uncompensated care have sapped the capacity of the U.S. emergency medical system, the committee found.  Since federal funds for emergency medical response services declined abruptly in the early 1980s, first responder services have been left to develop haphazardly across the country.  Many ambulance services use antiquated communications equipment and do not have adequate means to coordinate with hospitals and other first responders in their areas.  In 2003, EDs received nearly 114 million patients -- a 26 percent increase in volume over the previous decade -- but the country experienced a net loss of 703 hospitals and 425 EDs during the same 10-year period.  Hospital EDs provide a growing amount of safety net care for uninsured patients, a significant proportion of which goes uncompensated.  They also must play key roles in disaster response, although they have received scant funding for these efforts, the committee found.  For example, emergency medical services received only 4 percent of the $3.38 billion distributed by the U.S. Department of Homeland Security for emergency preparedness in 2002 and 2003.

To address these deficiencies, Congress should establish a pool of at least $50 million to reimburse hospitals for uncompensated emergency and trauma care, the reports conclude.  Lawmakers also should significantly increase funding to provide hospitals with resources needed to handle disaster situations.  In addition, Congress should allocate $88 million to be disbursed as grants over five years for projects designed to test ways to promote greater coordination and regionalization of emergency care.  And it should appropriate $37.5 million each year for the next five years to the Emergency Medical Services for Children Program, to address deficiencies in pediatric emergency care.  Even though children make up more than a quarter of all ED and trauma patients, according to one survey, only 6 percent of hospital EDs have all of the supplies deemed essential for managing pediatric emergencies.

Ending Overcrowding and Ambulance Diversions

Hospitals need to tackle problems with the flow of patients and end the practices of diverting ambulances and "boarding" patients in halls or exam rooms until beds become available, the committee said.  According to a recent study, ambulances were diverted 501,000 times in 2003 because of overcrowding in EDs.  Federal programs should revise their reimbursement policies to reward hospitals that appropriately manage patient flow and penalize those that fail to do so, the reports say.  The committee recommended that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) reinstate strong guidelines to reduce crowding, boarding, and diversion, and called on the Centers for Medicare and Medicaid Services to convene a working group to develop standards to address these problems.

Crowding and ambulance diversions also occur because of lack of coordination among emergency medical response teams and hospitals, which is the result of incompatible communications systems and other practical impediments, as well as entrenched professional interests, the reports say.  Some of the nation's emergency medical services are municipally managed, while others are privately owned; some are organized as part of fire departments, while others are operated by area hospitals or other medical organizations.  Few emergency medical services around the nation coordinate patient transport to medical facilities effectively, the committee found.  

Regionalization as a Remedy

Regionalization of emergency care services -- in which patients are directed not just to the nearest hospital, but to the nearest facility with the best resources to handle his or her particular needs --
can improve health outcomes, mitigate overcrowding, and reduce costs, the reports say.  The committee urged federal agencies to develop criteria to classify all emergency medical services and EDs in each community on the basis of their capabilities.  Regional collaboration would also mean that not every hospital has to maintain on-call services for every specialty, which would help address shortages caused by the dwindling number of specialists willing to take emergency calls.  

The report series was sponsored by the Josiah Macy Jr. Foundation; the U.S. Department of Health and Human Services' Health Resources and Services Administration, Agency for Healthcare Research and Quality, and Centers for Disease Control and Prevention; and the U.S. Department of Transportation's National Highway Traffic Safety Administration.  Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public.  A committee roster follows. 
Pre-publication copies of The Future of Emergency Care series, which includes Emergency Care Services at the Crossroads, Emergency Care for Children: Growing Pains, and Hospital-Based Emergency Care: At the Breaking Point, are available from the National Academies Press; tel. 202-334-3313 or 1-800-624-6242 or on the Internet at http://www.nap.edu.  Reporters may obtain copies from the Office of News and Public Information (contacts listed above).

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[ This news release and report are available at http://national-academies.org ]  

Board on Health Care Services

Committee on the Future of Emergency Care in the U.S. Health System

Gail Warden, M.H.A. (chair)
President Emeritus
Henry Ford Health System

Stuart H. Altman, Ph.D.
Sol C. Chaikin Professor of National Health Policy
Heller School of Social Policy
Brandeis University
Waltham, Mass.

Brent R. Asplin, M.D., M.P.H.
Department Head
Regions Hospital Emergency Department, and
Associate Professor of Emergency Medicine
University of Minnesota
St. Paul

Thomas F. Babor, Ph.D., M.P.H.
Department of Community Medicine and Health Care
University of Connecticut Health Center

Robert R. Bass, M.D.
Executive Director
Maryland Institute for Emergency Medical Services Systems, and
National Association of State EMS Officials

Benjamin K. Chu, M.D., M.P.H.
Regional President
Kaiser Foundation Health Plan and Hospital
Southern California Region

A. Brent Eastman, M.D.
Chief Medical Officer and N. Paul Wittier Chair of Trauma
Scripps Health
San Diego

George L. Foltin, M.D.
Center for Pediatric Emergency Medicine, and
Associate Professor of Pediatrics and Emergency Medicine
New York University School of Medicine
Bellevue Hospital Center
New York City

Shirley Gamble, M.B.A.
Chief Operating Officer
United Way Capital Area
Austin, Texas

Darrell J. Gaskin, Ph.D.
Associate Professor
Department of Health Policy and Management
Johns Hopkins Bloomberg School of Public Health

Robert C. Gates, M.P.A.
Project Director
Medical Services for Indigents
Orange County Health Care Agency
Santa Ana, Calif.

Marianne Gausche-Hill, M.D.
Clinical Professor of Medicine and Director of Pre-hospital Care
Harbor-UCLA Medical Center
Torrance, Calif.

John D. Halamka, M.D.
Chief Information Officer
Beth Israel Deaconess Medical Center

Mary M. Jagim, R.N.

Internal Consultant for Emergency Preparedness Planning

MeritCare Hospital Emergency Center

Fargo, N.D.


Arthur L. Kellermann, M.D., M.P.H.

Professor and Chair

Department of Emergency Medicine

School of Medicine, and


Center for Injury Control

School of Medicine and Rollins School of Public Health

Emory University



William N. Kelley, M.D.

Professor of Medicine, Biochemistry, and Biophysics

University of Pennsylvania School of Medicine



Peter M. Layde, M.D., M.Sc.

Professor and Interim Director

Health Policy Institute, and


Injury Research Center

Medical College of Wisconsin



Eugene Litvak, Ph.D.

Professor of Health Care and Operations Management Director

Program for Management of Variability in Health Care Delivery

Boston University Health Policy Institute



Richard A. Orr, M.D.

Associate Director

Cardiac Intensive Care Unit;

Medical Director

Children's Hospital Transport Team; and


University of Pittsburgh School of Medicine

Children's Hospital of Pittsburgh



Jerry L. Overton, M.A.

Executive Director

Richmond Ambulance Authority

Richmond, Va.


John E. Prescott, M.D.


West Virginia University School of Medicine



Nels D. Sanddal, M.S., REMT-B


Critical Illness and Trauma Foundation

Bozeman, Mont.


C. William Schwab, M.D.

Professor of Surgery and Chief

Division of Trauma and Surgical Critical Care

University of Pennsylvania Health System



Mark D. Smith, M.D., M.B.A.

President and CEO

California HealthCare Foundation



David N. Sundwall, M.D.

Executive Director

Utah Department of Health

Salt Lake City




Robert B. Giffin, Ph.D.

Study Director