Emergency care is a fundamental part of our nation's health care system. But with reduced ED capacity, along with rising demand—the result of an aging population, the influx of new patients brought about by health care reform, and demands on providers to decrease the numbers of preventable illnesses and injuries—the system is strained to the point of near failure. A new “report card” issued by the American College of Emergency Physicians (ACEP) gives the overall ED environment nationwide a grade of D+.
The report assigns grades to several aspects of emergency care: access, D-; quality and patient safety environment (the use of “systems and protocols to improve lifesaving care and facilitate effective and efficient systems of care”), C; medical liability environment, C-; injury prevention and public health, C; and disaster preparedness, C-.
The report is a follow-up to the ACEP's 2009 report card, in which the system earned an overall grade of C-. That report identified a number of problems, chief among them ED crowding, and recommended steps to alleviate the situation; in the years since, however, excessive crowding and other problems have persisted—and in some cases are now worse.
The nation's lack of access to emergency care reflects an inadequate workforce: only 4% of physicians in the United States work in emergency care, yet EDs handle 11% of all outpatient care and 28% of all acute care visits. It also reflects diminished hospital capacity. The grades for disaster preparedness and quality and patient safety environment also declined, although some individual states have seen improvement.
Much of the strain on EDs comes down to resources. On first reading, the report appears to be nothing but bad news, but as Maryfran Hughes, nursing director in the ED at Massachusetts General Hospital in Boston, explains, the results are mostly a reflection of systems and policies, rather than the quality of patient care.
“We still feel a lot of pride in the quality [of the care we provide], even when we're working in circumstances that are less than optimal,” Hughes says.
A low grade in disaster response, for instance, might be, as it is in Massachusetts, a reflection of a dearth of “surge beds” (beds available for use in response to a sudden increase in need). “It's not that we haven't had enough drills or that the hospitals aren't talking to each other.”
In the report, the ACEP makes 11 recommendations to improve the nation's emergency care, including protecting access to ED care as health reforms are implemented, pursuing state laws and programs to reduce preventable deaths and injuries, and funding education programs to address staff shortages, among others.
In the meantime, the challenge for emergency care nurses is working around system and policy problems to provide the best patient care experience possible. “We've had overcrowding for more than 10 years, and we've done a lot with our inpatient colleagues [to manage it],” Hughes says, emphasizing the need for good communication. Improving communication can lead, for instance, to more quickly filling empty inpatient beds when they become available or to texting among nurses to determine how to move patients most efficiently. The full report is available at www.emreportcard.org.—Laura Wallis