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In a series of new reports, the Institute of Medicine (IOM) reports that the nation's emergency care safety net is stretched to the limit and is unable to cope with any major man-made or natural disaster that may loom. Emergency care specialists have responded by using the reports as a call to arms, harshly criticizing the shortage of post 9/11 emergency funds for EDs and warning of a breakdown of the nation's emergency care system.

In the two years after 9/11, says the trio of IOM reports titled "At the Breaking Point," federal officials doled out only 4 percent of a multibillion-dollar emergency preparedness budget to EDs. And EDs garnered only 5 percent of the funding from the National Bioterrorism Hospital Preparedness Program. That kind of math, the group says, has to be corrected.

"We need a comprehensive effort to shore up America's emergency medical care resources," sums up Gail L. Warden, president emeritus of the Henry Ford Health System and one of the authors of the report.

At the root of the problem, notes the IOM, is a chilling, downward, long-term trend in the United States toward fewer and fewer hospital beds while ER visits are surging upward, from 90.3 million in 1993 to 114 million in 2003.

Remaining EDs are often inadequately staffed and supplied, adds the IOM. Only 6 percent of pediatric emergency departments have all the necessary supplies for treating cases, while only half stock 85 percent of the recommended supplies.

In many ways, says the IOM report, the ED is a "victim of its own success." Emergency departments have become a primary source of care for the uninsured, while patients who are covered often turn to emergency departments when their own doctors can't see them. As patients flow into the ED in ever larger numbers, the departments are increasingly likely to be gridlocked by the overload, forcing a steadily rising number of ambulance diversions to hospitals which have extra capacity. Diversions now occur a half million times each year, creating delays that can threaten a patient's life. Emergency specialists are increasingly unwilling to treat the uninsured and physicians with their own practices are increasingly unlikely to fill in any gaps. EMS services, meanwhile, have become fragmented among professional and volunteer groups.

Correcting a situation that has been deteriorating for years will take a monumental effort.

"The report calls on hospitals to improve efficiency and patient flow using tools developed from engineering and operations research, such as systems that track and coordinate patient flow, says Dr. Rick Blum, president of the American College of Emergency Physicians. It also calls for greater accountability and public reporting of performance, as well as panels to develop evidence-based protocols for EMS, emergency and trauma care of adult and pediatric patients.

The EMS report also calls for increased funding, especially for EMS-related disaster preparedness; enhanced training for EMS workers; and improved coordination among EMS agencies. According to the IOM, the emergency care system of the future should be highly coordinated, regionalized, and accountable, with one lead federal agency consolidating many of the government programs that deal with emergency and trauma care.

The IOM reports are just the latest in a string of studies that have raised searing criticism of the country's deteriorating emergency care system. In May ACEP reported that three-fourth of emergency department medical directors reported a shortage of on-call specialists, up from two-thirds the year before.

Says Blum: "The availability of specialists has spiraled downward in just one year."

ACEP is lobbying for a pair of bills before Congress the group hopes can begin to address the situation. ACEP wants to stop the "boarding" of patients in EDs until inpatient beds open up as a way to help avoid the gridlock that often afflicts urban hospitals. And the physicians want liability relief for treating patients in the ER and a boost in reimbursements to provide proper compensation. ACEP is also calling for the creation of a coordinated communication system to link all EDs, trauma centers, dispatchers and EMS workers. And the IOM is calling on Congress to set up five-year demonstration projects that can work toward creating the kind of integrated, regional emergency care systems that can develop the kind of best practices that can be followed by everyone in the field.

Congress must convene a hearing on the state of emergency medicine in this country and dedicate funding to the emergency care system to support disaster preparedness, says Blum. Hospitals must be reimbursed for the significant amounts of uncompensated emergency and trauma care they provide."

Anything less, he says, will likely destroy the country's emergency care infrastructure.

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