Crisis Seen in Nation's ER Care

ERs are notorious money losers. About 14 percent of ER patients are uninsured. About 16 percent are covered by Medicaid, the federal-state insurance program for the poor, and 21 percent by Medicare, the program for the elderly. More than half of hospitals report losing money on emergency care of both groups of government-insured patients.

All of this has led to extreme bottlenecks in ERs, manifested by delays in every step of treatment, according to the reports.

In 2003, 501,000 ambulances were diverted from the hospital where they normally would have delivered a patient because the ER was full. In 2004, 70 percent of urban hospitals reported that their emergency departments had been "on diversion" at least once.

Nationwide, about 14 percent of ER patients end up admitted to the hospital. A study by the Government Accountability Office in 2003 found that 20 percent of emergency departments had to "board" patients in hallways or other temporary space, for an average of eight hours, before a bed opened. The American College of Emergency Physicians several years ago surveyed 90 emergency departments on a single Monday evening. Seventy-three percent reported that they had two or more patients boarding.

A 2004 study found that ERs at university-based hospitals were classified as crowded 35 percent of the time, meaning all emergency beds were occupied, patients were in the hallways, the waiting room was full, and the waiting time for treatment was more than one hour.

Another hazard largely unrecognized by Americans is that hospitals, especially in rural areas, often cannot find specialists such as orthopedic surgeons and neurosurgeons willing to cover the ER.

In some cases, this is because doctors are unwilling to treat high-risk patients with complicated ailments, many of them uninsured, at inconvenient times. Sometimes it is simply a function of shortages. In 2002, there were fewer practicing neurosurgeons in the United States (about 3,000) than a decade earlier.

Largely unknown is the human cost of these problems.

Many studies have shown that high-stress, chaotic environments contribute to errors. One from 1991 showed that though relatively few "adverse outcomes" occur in the ER, it was the site of 70 percent of those attributable to negligence.

The number of deaths caused by a delay in treatment or lack of expertise is especially uncertain, though it may not be small. San Diego established a trauma system in 1984 after autopsies of accident victims who died after reaching the ER suggested that 22 percent of the deaths were preventable, said Eastman, one of the Institute of Medicine committee members.

Trauma care in many ways is the model on which the committee hopes the emergency care system will be rebuilt.

Some states and urban areas have systems in which the level of trauma care every hospital is capable of providing is known and a centralized dispatching agency directs patients based on real-time information about each hospital's capacity and staffing.