A good deal of media attention heralded the June 14 release of three reports that conclude the Institute of Medicine’s two-year examination of the U.S. emergency medical system. The attendant headlines in newspapers across the country—“Crisis Seen in Nation’s ER Care” (Washington Post), “Emergency Medical Care Listed in Critical Condition” (USA Today)—may sound hyperbolic, but the problems identified by the IOM are real and quite sobering.
The reports introduce the public to what neurosurgeons and others working within the healthcare system day in and day out know firsthand: Emergency departments are overcrowded, patients presenting in the nation’s ERs often wait long periods of time before being seen, ambulance diversions are increasing, and the system as a whole is highly fragmented and variable.
These problems are at least partially rooted in the increasing number of ER visits (113.9 million in 2003, compared with 90.3 million a decade earlier) at a time when the number of facilities with emergency departments has been declining, said the IOM. Concurrently the uninsured population has been increasing, while there has been a decline in federal funding for emergency medical services since the early 1980s that has resulted in haphazard development of emergency medical systems across the United States.
Further, close to 70 percent of urban hospitals diverted patients at some point during 2004, resulting in transfer or rerouting from an ER that was full or lacked services to one farther away. Major reasons for diversion included shortages of available intensive care unit beds and on-call specialists.
At my own institution, an academic medical center, countless patients with emergent neurosurgical problems have taken a circuitous route to reach our hospital, in part because the emergency system functions under the premise that optimal neurosurgical care will be provided by other institutions, when in actuality those facilities do not always have the resources—equipment or personnel—to provide such care. What this means is that my facility functions as a de facto regional care center for neurosurgery; what this means to patients is that they often experience delays in getting appropriate treatment.
Another perspective, that of a neurosurgeon practicing at a hospital in an Idaho community of about 175,000 people, was discussed in the pages of the Winter 2004 issue of the Bulletin. That scenario involved the neurosurgeon and his partner covering emergency call 24/7 with one of them on call every other night. When, citing unsustainable negative impact on personal life and elective practice, they stopped providing their hospital with emergency coverage, emergent neurosurgical cases from that area began to be transported to my facility.
Scenarios such as this one point to proactive regionalization of neurosurgical emergency care as an idea whose time has come. Such a plan should not necessarily mean that regional facilities would be academic medical centers, but certainly that they would be strategically located, well-equipped and appropriately staffed centers supported by adequate federal and state funding as well as by well-coordinated and swift transport of patients in need of neurosurgical emergency care. From a neurosurgical perspective, the development of coordinated, regionalized care is the fundamental change which must occur.
Emergency access to on-call specialists in some regions was noted in the IOM report as a problem which, the authors admitted, stemmed from the disruptive lifestyle, poor compensation, and increased liability that is associated with providing emergency surgical care. As part of a multipronged strategy for improvement, the report recommended regionalization of specialty services.
To achieve regionalization, appropriate triage is necessary. The IOM called for effective communication and coordination among various components of the system, including 911 emergency call and dispatch, ambulances, EMS workers, and hospital emergency departments. In addition to increased state and federal funding for facilities that bear a disproportionate amount of the cost of care for the uninsured, the report called for methods to determine the performance of the different system components and for public reporting. It also included a recommendation that Congress establish a five-year demonstration program to fund individual states in developing a coordinated, regionalized and accountable system which will be used to identify “best practices” on which to base larger scale development.
Based on the AANS 2006 Workforce Survey of ER coverage and related issues, the results of which are reported in this issue’s cover story, neurosurgeons have been providing emergency coverage, though more than three-quarters of them identified neurosurgical emergency call coverage as a problem in their practice areas. Clearly, we need to find ways to render the system manageable; the regionalization of neurosurgical care will be the best solution for both patient care and for neurosurgery as a specialty.
William T. Couldwell, MD, is editor of the AANS Bulletin. He is professor and Joseph J. Yager Chair of the Department of Neurosurgery at the University of Utah School of Medicine.
For Further Information
See the cover section.