Defining the Future of Emergency Care

Four decades ago, the National Academy of Sciences and National Research Council published Accidental Death and Disability: The Neglected Disease of Modern Society. Release of this landmark report was a watershed event in the development of emergency medical services (EMS) in the United States. Emergency care has dramatically evolved since then. Breakthroughs in biomedical research have given us tools to rapidly diagnose life-threatening conditions and the capacity to intervene to blunt or prevent their effects. This increase in capability produced a commensurate increase in expectations. Once, emergency physicians admitted acutely ill patients to the hospital for a diagnostic evaluation. Now, they must complete the evaluation themselves to justify the need for admission. Thanks to television shows such as ER and stories on the evening news, the public expects miracles to happen when they enter an emergency department (ED). Many are quick to blame the doctor if it doesn’t work out that way. To guarantee that patients have access to emergency care, Congress enacted the Emergency Medical Treatment and Active Labor Act (EMTALA), a federal law that mandates treatment without regard for the patient’s ability to pay. But success came at a price. No funding was appropriated to defray the costs of EMTALA-mandated care. As the number of uninsured Americans increased and even fully insured patients encountered problems securing timely appointments outside the ED, use grew at a rapid rate. It now exceeds 114 million visits per year, more than 10% of all outpatient encounters in the United States. Some visits are for relatively minor problems, but most involve potentially serious illnesses or injuries. Recently, the Agency for Healthcare Research and Quality reported that in 2003, 55% of community hospital admissions for conditions other than maternal and neonatal ones began in the ED. Unfortunately, the rapid growth in ED use collided with equally dramatic reductions in hospital capacity. The result is that in cities across the United States, patients on stretchers line the hallways of EDs, waiting for the next available inpatient bed. There was a time when the notion of diverting an inbound ambulance was unthinkable. Today, it happens more than a half million times per year.