In view of all that’s been written lately on the hazards of ER delays, this Perspective piece in NEJM is timely. The author, Arthur Kellermann, M.D., M.P.H., reports findings and recommendations from an Institute of Medicine (IOM) committee on emergency care. Due to increased utilization and shrinking resources, according to the article, ER care has reached a point of crisis. It points out that EMTALA, intended to improve ER access has in fact diminished it by giving emergency rooms an unfunded mandate.
As I read the article everything seemed reasonable until I got to the discussion of ambulance diversion and emergency department boarding. Briefly, when no inpatient beds are available for hospital admission the emergency department may commence care of the patients and keep (“board”) them in the department until an inpatient bed becomes available. In extreme situations ambulances are diverted to other area hospitals. These practices have become quite common due to overcrowding. But now the IOM is recommending these practices cease, except in disaster conditions. That’s all well and good, but what’s the hospital to do when there’s no room in the inn? Dr. Kellermann writes that the IOM decrees “Hospitals can achieve this goal by adopting operations-management techniques and related strategies to enhance efficiency and improve patient flow.” Huh? Isn't that what hospitals have been struggling to do for their very survival ever since DRGs were enacted in 1983? This is supposed to solve the problem of ER overcrowding, suddenly? It strikes me as naïve. The full IOM report is here.