Hospital emergency rooms (ERs) nationwide are overcrowded and have trouble coordinating with their inpatient wards to share the emergency patient loads. Emergency managers often overlook EMS, not realizing it's frequently separate from fire departments.
Hospital and EMS officials cite a lack of funding as one of their problems, despite the billions already spent. The paramount struggle, however, appears to be a lack of coordination between the different entities of emergency management operations. Emergency medicine experts are advocating strategies for breaking medical emergency response silos and say reorganization of emergency departments and EMS could better prepare them for mass casualty events.
Increase Hospital Capacity?
As the number of uninsured Americans climbs, emergency departments are treating more patients who can't afford to pay. As a result, emergency departments are closing because they can't afford to treat those patients for free. Should government emergency managers aim to increase hospital capacity in preparation for a mass casualty event?
Dr. Amy Kaji, director of the Los Angeles County Harbor-UCLA Medical Center's Disaster Resource Center, said emergency patients already clog ERs most days because hospitals don't have enough nurse ward beds. Los Angeles County responded to that challenge by spending federal grant money on a military-style tent to accommodate patients during a mass casualty event.
Dr. Rex Archer, director of health for Kansas City, Mo., thinks hospital capacity shortages during mass casualty events is an overblown concern. Archer insists that hospitals could simply route patients to nearby hospitals and cancel elective surgeries to free up space during an emergency. He argues that newly built "excess hospital capacity" wouldn't be excess for long because physicians would use it for more elective surgeries.
"As it is, probably half of our elective surgeries are unnecessary, inappropriate or just plain dangerous," Archer said.
Cosmetic surgeries, cataract surgeries and some hysterectomies are examples of elective treatments. Archer contends that an increase in elective surgeries would make the United States less healthy.
"During the early '80s when there was a malpractice crisis in California, they stopped elective surgery for 16 weeks," Archer said. "They only did emergency surgeries. The death rate dropped by half for the state. When the crisis was solved, it jumped right back up."
He asserts that increased capacity would also drive up health-care costs nationwide.
Kaji disputes the idea that canceling elective surgeries and rerouting patients would clear sufficient space. More beds are needed, she said.
Dr. Arthur Kellerman, chairman of the Department of Emergency Medicine at Emory University, partially accepts both Archer's and Kaji's arguments.
"When we're diverting at least a half million ambulances a year from private and public hospitals because the ERs are filled with admitted patients who are not being moved upstairs, you can't just say, ‘Oh well, cancel elective admissions and reroute patients to other hospitals,'" Kellerman said. "Other hospitals are on diversion, too. Elective admissions won't get you beds for days, and you need beds in minutes or hours during a mass casualty event.
"On the other hand, we already spend $2.2 trillion on health care per year. We can't afford to build large wings of hospitals and leave them vacant," Kellerman added.
Alternatives to Increased Capacity
Rather than building more hospital capacity, Kellerman advocates changing how hospitals run. He insists ERs in Israel are more prepared to handle mass casualty events than American ERs because Israelis force nurse wards to share the burden.
"Israel never lets their ERs go on diversion or gridlock the way we do," Kellerman said. "If there is a patient in the hallway who's admitted, they're not in the hallway of the ER more than an hour or two. They'll put them in the hallway of an inpatient unit if there is not an immediately available bed. I'll guarantee you they'll find a bed a lot faster than we do in the U.S., where we stack everybody up in the ER."
The American College of Emergency Physicians (ACEP) recently published Emergency Department Crowding: High-Impact Solutions, a report listing recommendations for reducing ER crowding without building extra capacity. Like Kellerman, the report recommends moving some ER patients to inpatient nurse wards. ACEP argues that forcing each hospital unit to care for a small number of additional patients would spread the burden evenly. The ER could function effectively without unduly stressing the inpatient units, claims ACEP.
The report also recommends discharging all hospital patients due to leave each day by noon. Research shows that timely patient discharges could free a significant number of beds for ER patients, according to ACEP. The report warns current hospital discharge processes are complicated. A noon deadline would require leadership and culture changes involving physicians, nurses and staff from ambulances, nursing homes, social work, care management, pharmacy, radiology, lab and housekeeping. ACEP also recommends hospitals schedule elective surgeries evenly during the week. Most elective surgeries usually happen early in the week. The report says this uneven influx of elective patients is a prime contributor to hospital overcapacity.
Archer insists emergency managers should focus on formalizing hospital processes when transferring medical personnel from neighboring medical institutions.
There needs to be a mechanism by which guest doctors' and nurses' licenses are prequalified, so that hospitals can accept them under mutual aid and the liability issues are waived during the emergency, Archer said. "During a declared emergency, certain types of liability issues should be downplayed if you are accepting [doctors and nurses] you normally don't have under your supervision. Should you be held accountable for their actions in the same way as people you've seen and hired yourself? In an emergency, I think the liability threshold should go up quite a ways."
Kaji pointed out that the federal HHS is slowly rolling out a program called the Emergency System for Advance Registration of Volunteer Health Professionals. That system would enable hospitals to rapidly check a visiting doctor's credential and license status during an emergency.
But Kellerman said the federal government is taking too long to execute that program, which was initiated years ago in response to 9/11.
Archer insists that even if hospitals doubled capacity, which they couldn't afford to do, it still wouldn't provide enough beds to handle such an event. Many types of pandemics would leave modern medicine with little to offer infected people anyway.
"If I'm ill and I know there is no room in the hospital - I'm not going to have a bed, I'm going to be on the floor in the hallway, maybe with or without even a pillow, and the hospital doesn't really have anything to treat me with anyway - why would I go to the hospital? I'm going to be a lot more comfortable at home," Archer said.
He thinks emergency managers need to shift their pandemic preparedness efforts toward care outside of hospitals.
"The challenge is going to be that if people are staying home, and they're too weak to feed themselves, how are they getting fed?" Archer said. "If they're communicable, you don't really want them going into grocery stores."
Kellerman asserted that most emergency managers understand the need to battle pandemics away from hospitals, but few follow up by pursuing specifics.
"What questions are you going to ask [citizens]?" Kellerman said. "What kind of instruments are these people going to use to evaluate patients? What are you going to give people in a kit for self-care and where are those kits coming from? [Many emergency managers] are going to answer, ‘I don't really know. We haven't quite worked that out yet. Maybe we'll do that in another six or 12 months.'"
EMS Ignored
Many consider EMS the redheaded stepchild of emergency management. Government leaders tend to think only of police and fire departments when considering emergency first responders, said Bruce Walz, president of Advocates for EMS (AEMS), a Washington, D.C.-based nonprofit organization. As a result, ambulance services are chronically underfunded in the United States.
The problem seems to be a blurry definition of EMS. Most communities receive EMS through their fire departments, but for many, EMS comes from commercial ambulance companies. Other communities have voluntary EMS. Consequently EMS didn't have a unified voice when lawmakers drafted much of the modern legislation that funds emergency management efforts.
"A lot of the legislation was written hastily after 9/11 and through the creation of the DHS [Department of Homeland Security]," Walz said.
Federal regulations often prevent commercial and volunteer EMS from receiving grants offered to EMS contingents attached to fire departments. Also, the Robert T. Stafford Disaster Relief and Emergency Assistance Act provides federal reimbursements for "extraordinary costs" incurred by local EMS during federally declared disasters. Due to conflicting federal regulations, commercial and voluntary EMS often battle to get those reimbursements.
All EMS, including teams connected to fire departments, struggle for federal funding, according to AEMS. From 2003 to 2005, DHS reports showed that no more than 4 percent of the federal grant funding open to EMS was awarded to EMS. In 2007, AEMS advocated a 10 percent minimum requirement. Congress has yet to pass the proposed benchmark.
Even EMS teams in fire departments struggle for funding because grants awarded to fire departments often don't trickle down to their EMS operations, said Walz. The money stays in fire operations.
Interoperability is arguably the most revered buzzword in the emergency management field. Many local governments have received federal grants to fund interoperable communications systems for first responders. However, commercial and volunteer EMS frequently are excluded from those projects, according to Walz.
In addition to funding difficulties, EMS has no efficient way to target the nearest hospital that isn't diverting ambulances during an emergency.
"Most communities have nobody to help those ambulances find open ERs that are properly staffed to meet their patients' needs," Kellerman said. "Ambulance crews end up radioing hospital after hospital, hunting and searching, hoping they can find a place."
He recommends states follow Maryland's lead in establishing regional offices charged with tracking hospital capacity and routing ambulances to the appropriate ERs. That tracking infrastructure would motivate hospitals to reject ambulances less often, insists Kellerman. It would give federal lawmakers a systematic tool for measuring which hospitals are excessively unavailable. The federal government could make its subsidies to hospitals for trauma care contingent on how available those hospitals are to ambulances.
Sign of Hope
So why are ERs and EMS underfunded, given the billions of dollars handed down by the federal government in recent years? What aspect of hospital preparedness did that money improve? The HHS has trouble answering those questions because it didn't connect specific, measurable goals to the funding. For example, some communities bought interoperable communications systems, while their neighbors purchased medical equipment. Others used the money for training and drills. The funding purchased numerous things related to mass casualty events.
"I think anyone would tell you if you asked around, this program has made a huge difference," said Dr. Gregg Pane, director of national health-care preparedness programs for the HHS.
However, the HHS can't point to any aspect of preparedness and say it's improved across the United States since distributing the funding. No baseline has existed to measure it, but that's about to change. The HHS recently published a set of metrics hospitals must satisfy to receive federal grant money. Those metrics require the money be spent on specific types of training and drills, interoperable communications systems, accurate listings of available volunteer medical staff, and numerous other preparedness tools. The document prescribes reporting processes for the hospitals, enabling the HHS to measure success.
"We're upping the ante in terms of accountability," Pane said.
