Emergency departments (EDs) play a critical role within the American health care system, delivering life and limb saving care daily to thousands of patients. On January 16th 2014, the American College of Emergency Physicians (ACEP) released America’s Emergency Care Environment: A State-by-State Report Card to assess support for emergency care. This Report Card, the third edition of this report, assesses the current state of the acute care system on both a national and on a state-by-state level. This most recent edition provides an alarming evaluation of the support for the emergency care system in the United States, which is particularly concerning given the current state of change and uncertainty that is pervasive throughout the US with regard to health care.

The ACEP 2014 Report Card uses objective data to track various aspects of the acute care system in order to provide a better understanding of the trajectory the overall emergency care system.  It is not a report on individual hospitals or health systems, but rather a grade of the policies, regulations and governmental activities that are important supports for emergency care.

The Report Card’s greatest value lies in its ability to validate on a detailed level the recent claims that have been reverberating throughout the U.S. and the international community related to the important role and need for inclusion of acute care within health systems. In a recent WHO Bulletin article, an Academic Emergency Medicine consensus conference proceedings, and most recently in the entire December issue of Health Affairs, experts argue that an emergency care system is a vital aspect of a mature, functioning health system; yet, is it frequently neglected and is not receiving enough attention. While these publications have used the best data available to validate their claims, this national report provides the most current and comprehensive data that support for the system is not only fraught with deficiencies but is headed in a downward trajectory.

The Report Card is based on 136 objective measures drawn from data collected by quality surveillance organizations such as the Centers for Disease Control and Prevention, the National Highway Traffic Safety Administration and the Centers for Medicare & Medicaid Services as well as two surveys of state officials. The objectives were chosen and compiled by a blue-ribbon task force as the best measures of the five categories essential to a functioning emergency care system: Access to Emergency Care (30 percent), Quality & Patient Safety Environment (20 percent), Medical Liability Environment (20 percent), Public Health & Injury Prevention (15 percent), and Disaster Preparedness (15 percent). Each of these categories was weighted differently with regard to its effect on the system’s ability to deliver emergency care to patients.

A report was created for each state and weighted averages of each state’s grades were used to calculate the national grades. As the governance of EMS, support for Medicaid, medical liability pressures, and many other critical aspects of an emergency system are regulated and funded at the state level, state-based grading is necessary to adequately assess the effects of the differences among state emergency systems and population demographics. While the grade is meant to represent the overall ability of states to provide emergency care to their population, the grades are not meant to reflect the level of care at any one facility or group of facilities.

The Challenge

Unrelated to the ability of any one facility or physician to provide emergency care, the nearly universal poor grades are representative of the enormous weight that has been put on fragmented emergency care systems despite the significant improvement in clinical knowledge, technology and practice in recent decades. For more than two decades the annual increase in ED visits has been twice the rate of increase of the US population; ED visits rose to 130 million in 2010. In contrast, the Centers for Disease Control and Prevention (CDC) reports, the supply of EDs decreased about 11 percent from 1995-2010. The simple paradigm of swiftly increasing demand with dwindling supply has led to vast ED  crowding that has a deleterious effect on the timeliness of care, regardless of level of acuity.

Delays in care are detrimental not only to morbidity and mortality preceding ED treatment but also have been shown to be detrimental to patients who experience longer ED boarding times. These delays can be attributed not only to the increasing number of ED visits but also to the decreasing number of hospital beds for those admitted from the ED. Between 1994 and 2004, a study found that America’s hospitals had a net loss of 198,000 beds. The impact of this can be seen in the results of a 2011 study that found the mortality rate for patients boarded less than 2 hours in the ED was 2.5 percent, compared to 4.5 percent for those boarded 12 or more hours.

The increasing demand for emergency services can be attributed to a multiplicity of factors. These include stipulations that are explicitly set forth in The Emergency Medical Treatment and Active Labor Act (EMTALA), an unfunded federal mandate; these stipulations are also more implicitly woven into American morality, which dictates that the emergency care is provided to all people in need regardless of their ability to pay. As a result of this tenant of emergency care, two-thirds of all uninsured acute care visits take place in the ED, and one-half of all acute care visits to the ED are by those receiving Medicaid or CHIP assistance.

In addition to being the final safety net for the poor and uninsured, emergency visits have increased secondary to changing practices in primary care. The 2013 RAND Health research report found that 4 of 5 patients were told to go to the ED when they called their primary care provider regarding a sudden medical issue. Additionally, two-thirds of all ED visits were outside of normal primary care office hours.

These are the factors that are causing the emergency care system to falter and led the Institute of Medicine to declare in a 2006 report that emergency care in the United States is “at the breaking point.”  The 2014 Report Card again highlights the critical need for the public and their policy leaders to take seriously the vital role of EDs in the health care system.  Because of the detailed nature of the Report Card, it can be used as a road map for ways to improve support for emergency care on a state-by-state as well as a national basis.

What Can Be Done

The emergency care system is not only at the breaking point but starting to fracture. This report highlights the areas of the system that need significant improvement, and illuminates possible paths to this end. The study highlights the importance of regionalized, organized, and adaptive emergency care systems in improving access to emergency care. This is not a new concept and received a thorough and eloquent review recently by Ricardo Martinez and Brendan Carr in the December 2013 issue of Health Affairs. The ACEP report adds to the evidence in favor of greater organization in emergency systems by drawing a direct line from disorganized emergency care systems to objective measures indicating poor care delivery.

Improving the quality of care and the patient safety environment was a key marker of system function in the report card assessment, as it is representative of better quality systems and technologies that improve care and prevent injury and illness. For example, a better integrated and funded EMS system that is not required to transport every patient to the ED could be useful in lessening ED overcrowding and has been estimated to provide a potential savings of $560 million per year to Medicare. This in turn would improve the quality of care able to be provided and increase efficiency.

The medical liability environment greatly affects not only the ability of physicians to make the right decisions for their patients, but affects the ability of the system as a whole to function efficiently and cost-effectively. In order to improve this metric, the report card task force suggests advocating for stronger state legislation that increases timely access to quality care while increasing liability protection. Similarly, public health measures and injury prevention have huge impact on the ability of the emergency system to provide quality care. The task force suggests improving this metric through efforts like prescription drug monitoring programs and state legislation to control traffic fatalities.

Lastly, disaster preparedness is of increasing importance as man-made and natural disasters have become more common and budgeting for disaster planning has fallen. The level of preparedness is drastically different in different regions of the country and even within states. The decreasing number of hospital beds and EDs makes the system even less malleable and less able to accommodate a possible surge in need for emergency care that occurs in disasters. The task force recommends that funding for disaster planning and training be amplified and efforts be made to coordinate disaster planning throughout the government and economic sectors.

The ACEP Report Card is a powerful and honest assessment of where emergency care in the United States is, and the direction that it is headed if significant changes are not made. Many of the stakeholders in the emergency care field have emphasized and focused upon these issues, as evident by the dedication of the December issue of Health Affairs to this topic. The findings presented in this report will serve to further validate the concerns expressed by others and will serve as a vector to broadcast these ideas to those outside of the emergency care field. By reaching a broader audience, this effort will hopefully gain the traction needed to change the direction of emergency care in America.