Victims of Our Own Success? By Neal E. Flomenbaum, MD, Editor-in-Chief

Last month, the Institute of Medicine (IOM) of the National Academies released three major reports on the future of emergency medical care in the United States: “Hospital-Based Emergency Care—At the Breaking Point,” “Emergency Medical Services—At the Crossroads,” and “Emergency Care for Children— Growing Pains.” Together, the three reports paint a grim picture of current conditions in emergency departments, while acknowledging the tremendous advances that have been made in emergency care during the past four decades.

This month, I would like to comment on the report on hospital-based emergency care. Next month, I’ll discuss the other two reports.
The IOM describes a demand for emergency care that has been growing rapidly for more than a decade

while emergency departments, hospital beds, and critical specialty consultants available to patients have all declined in number. Federal legislation (principally the Emergency Medical Treatment and Active Labor Act) is now in place and being enforced to ensure that no one with a possibly emergent condition is turned away before being assessed and, when necessary, stabilized. Two unanticipated results, unfortunately, are overcrowded emergency departments and ambulance diversions.

Along with the report’s many findings are recommendations that range from enhancing operational efficiency, making better use of information technology, creating clinical decision (or observation) units, and increasing federal resources for uncompensated care, disaster preparedness, and emergency care research. Beyond that, two important things about the report stand out in my mind. The first is an emphasis on national solutions rather than local fixes, and the second is the IOM itself.

In a sense, the federal government created this situation by solving another extremely serious problem when it successfully mandated emergency treatment for all. But ridding the environment of a destructive force by introducing a new element to an ecosystem invariably has unintended consequences. Finding local solutions to the problems addressed by the IOM report amid competing needs and an overall lack of funding is difficult if not impossible. By calling for national solutions, the IOM may help restore some balance to the system, but adequate funding for such mandates will be necessary to achieve any meaningful results.

The second key thing is the IOM itself. While many individuals, organizations, editorial writers, and commentators have identified some or all of the problems described in the report and called for most of the proposed solutions, none has carried the weight and influence of the IOM. Significant progress has resulted from previous IOM reports, most notably from its 2000 report “To Err is Human,” describing the staggering number and serious nature of medical errors committed in hospitals. Soon after the release of that report, its findings and recommendations were embraced by the Clinton administration and the Joint Commission on Accreditation of Health-care Organizations and major improvements in reducing medical errors ensued.

Will the IOM’s past successes be repeated? Will the three reports be judged, in time, to be the long-needed, ambitious, comprehensive blueprint for fixing the problems in our nation’s system of emergency care delivery? Or will they be considered merely an overwhelming indictment of the failures of that system?

The IOM report sums up the situation well when it says, “The emergency care system in the United States is in many ways a victim of its own success.”

But as I write this, in the middle of the baseball season, I can’t help but think of that famous line attributed to Yogi Berra, who could have been describing today’s emergency departments when he said of a popular restaurant: “Nobody goes there anymore—it’s too crowded.”

Emerg Med 38(7):9, 2006