Emergency care is on life support, advisory group says.

Overcrowding, underfunding, outdated equipment, and no readiness to handle a major medical disaster like an epidemic or a hurricane--that sounds like a description of the medical system of an underdeveloped country. But those are just some of the frightening conditions afflicting emergency care in the United States, according to the Institute of Medicine (IOM).

The IOM, a branch of the National Academy of Sciences that serves as an independent government advisory group, convened a committee in 2003 to study the nation's emergency medical services. In June, the committee published its research in three reports-Emergency Medical Services at the Crossroads; Emergency Care for Children: Growing Pains; and Hospital-Based Emergency Care: At the Breaking Point--that present a sobering picture of the country's emergency departments.

Among their findings:

* Across the country, ambulances were turned away from emergency rooms over 500,000 times in just one year (2003) because of overcrowding.

* Patients in many areas wait hours or even days for a hospital bed.

* Emergency medical services received only 4 percent of the $3.38 billion in federal funding for emergency preparedness from the Department of Homeland Security in 2002 and 2003.

* Many emergency medical response teams have outdated or poorly functioning communications equipment, and there is poor coordination among the emergency response teams and hospitals.

* Emergency rooms took in 114 million patients in 2003, a 26 percent increase over the past decade--yet during the same 10-year period, the United States lost 703 hospitals and 425 emergency departments.

* Hospitals would need federal aid of at least $50 million to recover costs of caring for uninsured patients.

"There are a number of factors influencing the emergency care system," said Darrell Gaskin, an associate professor at Johns Hopkins University's Bloomberg School of Public Health, in Baltimore, and an IOM committee member.

One factor is increased demand. Contrary to conventional wisdom, "a lot of this comes from privately insured people, who use emergency rooms because they cannot reach their primary care physician in the evening or on weekends," said Gaskin. "A second factor is Medicaid, which pays physicians so poorly that folks who use it can't find primary care physicians at all."

The third big issue, he said, is that most emergency rooms have an inefficient system for moving patients through the emergency department and into the main hospital, creating bottlenecks in surgical and intensive-care units. Also, Gaskin said, hospitals tend to give top priority to elective surgery, which is normally paid for privately and not by insurance companies. "These [patients] get the prime surgical spots," he said.

Once patients do see a physician, another problem may strike: the lack of specialists.

"Keeping people like neurosurgeons, hand specialists, and pediatricians on call is very difficult," he said. "First, there are simply not enough of them; and second, because of liability costs, rightly or wrongly, doctors feel they are taking a financial risk by working in emergency care."

Gaskin pointed out another little-known fact about emergency care: In some states, first responders and emergency medical technicians (EMTs) don't get paid unless they transport patients to a hospital. So they have no incentive to treat the patient themselves--even if he or she needs only a simple treatment that can be accomplished on the site.

Emergency rooms have long been a medical safety net for the poor and uninsured. Because of the Emergency Medical Treatment and Active Labor Act (EMTALA), hospitals must treat all patients.

"The result," said Gaskin, "is that emergency care services are truly at the breaking point." The committee recommended some solutions to the crisis, among them:

* regional authorities, similar to multistate transportation authorities, that would coordinate the work of first responders, hospitals, and emergency rooms

* community health centers that would provide primary care physicians to underserved populations and better pay for health care workers who serve them

* credentialing across states so that a state in crisis can accept help from out-of-state health care workers (during Hurricane Katrina, for instance, doctors who wanted to volunteer in Mississippi and Louisiana had to wait days for credentialing and liability issues to be cleared)

* recruitment of more on-call specialists and better training in pediatric care.

The IOM reports sound a dire alarm, but they also say that taking such measures could quickly bring relief to emergency departments. Gaskin cited the work being done by other organizations to address this issue, such as Urgent Matters--a program at George Washington University--that consults with emergency rooms on implementing triage techniques and best practices to improve the flow of patients.

"Of course, these ideas will require resources, meaning money, as well as coordination at the state and federal levels," Gaskin said. "But we are getting the message out. And two of our members are testifying on Capitol Hill [at press time], so there will at least be some discussion there."

The three reports are available online at www.iom.edu/CMS/3809/16107/35010.aspx.