When emergencies have to wait

Arthur Kellermann, Emory's chair of emergency medicine, has long lobbied for greater support for emergency room care.

Photo by Jack Kearse

Emory’s Chair of Emergency Medicine Arthur Kellermann has watched our nation’s emergency departments (EDs) stretched thin year after year. On any given night, emergency services at Grady and Emory University hospitals reflect the typical problems of emergency rooms across the country—overcrowded with long wait times, frequent diversion of ambulances, and resources stretched to the max. In the United States, ambulances are redirected from one emergency department to another facility once every minute on average, and patients in many areas of the country may wait from hours or even days for a hospital bed.

For more than a decade, Kellermann has been an outspoken proponent for improving emergency medical care, and over the past three years, he served on a committee of the Institute of Medicine (IOM) investigating the future of emergency care in the United States. The committee’s final reports delivered a devastating verdict and an urgent call to action. In short, the emergency medical system is “at the breaking point”—barely able to handle daily caseloads, much less a surge of casualties from a disaster.

“If we are struggling to deal with tonight’s 911 calls in city after city across the United States, how in the world are we supposed to handle pandemic flu or a major terrorist attack or the next natural disaster?” Kellermann asked a National Public Radio reporter upon release of the reports in June.

The critical condition of today’s emergency medical system (EMS) stems from insufficient funding and steady growth in uncompensated emergency care, according to the IOM. In the early 1980s, federal funds for enhancing emergency response services declined abruptly, leading to haphazard development of EMS services. In 1986, Congress passed a law that made emergency care a right for everyone in the United States, but provided no mechanism to pay for this care. Over the next 20 years, patient volumes increased while hundreds of emergency departments closed from lack of funding.

In 2003, EDs received nearly 114 million patients—a 26 percent increase over the previous decade—but the country lost 703 hospitals and 425 emergency departments during the same period. This poses a serious challenge.

When hospitals are full, admitted patients often back up in the ED. When EDs become dangerously overcrowded, the staff may ask inbound ambulances to divert to other facilities. In 2003, U.S. hospitals diverted more than 500,000 ambulances because of overcrowding in the ED. Diverting ambulance patients from one hospital to another puts additional stress on patients, family members, and the community, Kellermann said.

Conditions in the Grady ED, which handles more than 100,000 visits each year, reached a record low in 2002 and 2003 when, because of crowding, average throughput times exceeded seven hours and the ED was on diversionary status more than 20 percent of the time. To counter those trends, Leon Haley, associate professor, vice chair and chief of emergency medicine at Grady, implemented a model to identify major bottlenecks in patient flow, instituted new diagnostic test ordering processes, and improved staff coordination in the ED’s fast track for people with minor illnesses or injuries. Those efforts produced results: the ED reduced average time from arrival to bed placement by 57 percent.

With the support of the Robert Wood Johnson Foundation and later the Healthcare Georgia Foundation, Haley also created an ED-based “care management unit” with seven beds staffed by four nurses and four case managers. This unit is used to evaluate and treat patients with chest pain, heart failure, asthma, and hyperglycemia—conditions that would usually mandate hospital admission. While these patients undergo rapid treatment in the unit, case managers teach them how to better manage their health and arrange follow-up with a primary care provider. The goal of the program is to decrease the number of short-stay admissions and repeat visits to the ED.

Kellermann, who currently is on sabbatical as a Robert Wood Johnson Health Policy Fellow in Washington, is doing his part to promote awareness of the challenges faced by EDs across the country. Covered in more than 172 news sources across the United States, including NPR, CNN, the Associated Press, and USA Today, the chair of emergency medicine may finally have a soapbox tall enough from which to be heard.—Rhonda Mullen

The original version of this story appeared in fall 2006 issue of Momentum and is reprinted with permission.