IOM, homeland security cite lack of readiness

EDs already beset by overcrowding, pt diversions

Two comprehensive national reports released recently within days of each other reach the same disturbing conclusion: the United States remains woefully unprepared to respond to terrorist attacks and natural disasters.

A major part of the preparedness problem can be found at the routinely crowded emergency department (ED) in any given city in America. The nation's emergency medical system as a whole is overburdened, underfunded, and highly fragmented, reports the Institute of Medicine (IOM). 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. A chronic problem could turn into catastrophe should needed surge capacity not be available in the wake of a terrorist strike or natural catastrophe. The ED situation is akin to a dam at the bursting point awaiting the next flood.

"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 Gail L. Warden, MHA. who chaired the IOM report committee and is president emeritus of the Henry Ford Health System in Detroit. "Unfortunately, the system's capacity is not keeping pace with the increasing demands being placed on it."

On the heels of the IOM report, the U.S. Department of Homeland Security (DHS) completed a nationwide preparedness review that found significant problems in such areas as evacuation, attention to populations with special needs, command structure, and resource management.

The IOM report recommended that Congress allocate funds to ensure that EDs, trauma centers, and medical first responders are fully equipped and ready to provide prompt and appropriate care. The IOM also called for actions to reduce crowding of emergency department, 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. The DHS concluded that planning products, processes, tools, and technologies should be developed to facilitate "a common nationwide approach to catastrophic planning."

IOM: Ambulances on the road to decline

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, the IOM report stated. 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% 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, the IOM reported.

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% of the $3.3 billion distributed by the DHS 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, the IOM urged. 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. Citing deficiencies in pediatric emergency care, the IOM called for a $37.5 million appropriation annually for the next five years to the Emergency Medical Services for Children Program. Even though children make up more than a quarter of all ED and trauma patients, according to one survey, only 6% of hospital EDs have all of the supplies deemed essential for managing pediatric emergencies, the IOM found.

The IOM cited the well publicized patient flow problems that beset EDs, saying diverting ambulances and "boarding" patients in hallways is becoming increasingly common. According to the IOM, 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 report says. The committee also 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.

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 IOM reported. 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 also would 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.

DHS: Response system 'partially sufficient'

Responding to directives from President Bush and the Congress following Hurricane Katrina, the DHS did a nationwide review to determine if existing emergency operations plans for states and urban areas are sufficient for managing a catastrophic event. The review was conducted in all 50 states and six territories, and 75 urban areas over a six-month period. Reviewers examined nearly 2,800 emergency operations plans and related documents with participation from more than 1,000 emergency managers and homeland security officials. To provide an overall picture, plan components were assessed on a scale of "sufficient," "partially sufficient," or "not sufficient" to manage a catastrophic event. The majority of components assessed fell into the "partially sufficient" category.

"The findings of the nationwide plan review unequivocally support the need to modernize planning processes, products, and tools," said George Foresman, DHS undersecretary for preparedness. "It is a natural evolution towards working together as a nation to implement the lessons from seminal events such as the Sept. 11 attacks and Hurricane Katrina."

The findings of the DHS report included:

  • The majority of the nation's current emergency operations plans and planning processes cannot be characterized as fully sufficient to manage catastrophic events as defined in the national response plan (NRP).
  • States and urban areas are not conducting adequate collaborative planning as a part of "steady state" preparedness.
  • Assumptions in basic plans do not adequately address catastrophic events.
  • Basic plans do not adequately address continuity of operations and continuity of government.
  • The most common deficiency among state and urban area direction and control annexes is the absence of a clearly defined command structure.
  • Many states and urban areas need to improve systems and procedures for communications among all operational components.
  • All functional annexes did not adequately address special needs populations.
  • States should designate a specific state agency that is responsible for providing oversight and ensuring accountability for including people with disabilities in the shelter operations process.
  • Timely warnings requiring emergency actions are not adequately disseminated to custodial institutions, appropriate government officials, and the public.
  • The ability to give the public accurate, timely, and useful information and instructions through the emergency period should be strengthened.
  • Significant weaknesses in evacuation planning are an area of profound concern.
  • Capabilities to manage reception and care for large numbers of evacuees are inadequate.
  • Capabilities to track patients under emergency or disaster conditions and license of out-of-state medical personnel are limited.
  • Resource management is the "Achilles heel" of emergency planning. Resource management annexes do not adequately describe in detail the means, organization, and process by which states and urban areas will find, obtain, allocate, track, and distribute resources to meet operational needs.

(Editor's note: More information on the IOM emergency care reports can be found on the web at www.iom.edu/CMS/3809/16107/35007.aspx. The DHS nationwide plan review is on the web at www.dhs.gov/interweb/assetlibrary/Prep_NationwidePlanReview.pdf.)