It’s the 20th anniversary of the formation of the Committee on the Future of Emergency Care in the United States Health System. Intended to examine the state of emergency care and make recommendations for improvement, the committee has had an impact in some areas of Emergency Medicine, but not in others.

Is it time for a reassessment? 

“Absolutely,” says Arthur L. Kellerman, MD, MPH. “The magnitude of the challenges facing emergency care are greater than ever and our patients and nation need it,” he says. 

Dr. Kellermann was a member of the original committee and played a behind-the-scenes role in encouraging its formation.  Years before, he’d started his EM career as medical director of the ER at Memphis’ public hospital and Memphis Fire EMS. He then moved to Atlanta, to establish the Emory Center for Injury Control and later served as founding chair of Emory’s Department of Emergency Medicine. In 2000, as he was completing his second term on ACEP’s Board, he was elected to the IOM – now National Academy of Medicine – in 2000. Shortly afterwards, he was asked to Co-chair a major IOM Committee.

Four years later, as that committee completed its work, Dr. Kellermann attended a dinner where he sat beside the then-president of the IOM, Harvey Fineberg, MD. Sensing an opportunity, he mentioned how influential the 1966 National Academy of Sciences report “Accidental Death and Disability: The Neglected Disease of Modern Society” was to establishing modern EMS in the United States. ¹

  “I remarked that EM was not even a specialty then, and suggested it might be an opportune time for an updated IOM report that examined the achievements and challenges of emergency care in the U.S.,” says Dr. Kellermann.  “Dr. Fineberg was intrigued, and he and his staff subsequently put a proposal together. ACEP staff secured the support of the several federal agencies, and the project rolled forward from there.”

Although the reports generated national attention, prompted executive branch action and a congressional hearing, Kellermann regrets that they fell short of the Committee’s intended goals. 

Originally envisioned as a single report, several federal agencies stepped up to offer funding, Kellermann says, thanks to efforts by ACEP Government Affairs staff. This funding expanded the committee’s work to include three reports: Hospital Based Emergency Care – at the Breaking Point; Emergency Medical Services – at the Crossroads; and Emergency Care for Children – Growing Pains,” all released in 2007.

“Emergency Medicine research was and still is tremendously underfunded,” says John E. Prescott, MD, another member of the committee. “We wanted to reach emergency physicians, nurses and others working in trauma as well as those at Health and Human Services and the Centers for Disease Control. There was no center at the NIH that looks at emergency care as a specialty.” 

Dr. Prescott, currently retired, was Chief Academic Officer of the Association of American Medical Colleges from 2008-2021 where he says he worked with “every single school of medicine in the U.S.,” as well as working closely on behalf of the association on projects with the White House and the Departments of Veterans Affairs, Defense, and Health and Human Services. Additionally, he has served as dean of the West Virginia University (WVU) School of Medicine, president and CEO of its faculty plan, founding chair of its Department of Emergency Medicine and state EMS Medical Director in West Virginia. 

“Working closely with the CDC, I came to know a lot about rural medicine and how to improve it,” he says, guessing he may have been tapped for the committee through his work as principal investigator on more than $6.1 million in federal grants. “I was asked to participate and was thrilled to do it,” he adds. Prior to WVU, Dr. Prescott served as a military emergency physician at Brooke Army Medical Center, TX and Fort Bragg/Fort Liberty, NC.

“More emergency physicians started to rise in the ranks in the federal government at that time and were getting a reputation for making things happen,” Dr. Prescott says. “There was skepticism, because it was largely a new specialty, but these physicians were advocating on behalf of patients whether that care happened in the ED or in the prehospital world.” He added that it was prescient for the Institute of Medicine to say, Let’s look at this system and see what’s going on. Is it working? What needs to change in the future? 

Results 

According to a 2006 report brief ², the committee identified the following issues for Emergency Care: 

• Serious overcrowding in the ED
• A fragmented emergency care system 
• A shortage of on-call specialists
• A lack of disaster preparedness
• Shortcomings in pediatric emergency care 

Their recommendations included: 

• Improving hospital efficiency and patient flow using tools developed in engineering and operations research  
• A coordinated, regionalized, accountable system that should be seamless from the patient’s point of view  
• Increased resources to help organize the delivery of emergency care services, especially prehospital, and in terms of disaster preparedness
• Paying attention to children’s needs when it comes to standards and protocols for triage, transport and disaster planning, among other things. 

Dr. Kellermann was optimistic that this work would put Emergency Medicine on the map for good, given the caliber of the committee, its multi-agency funding, the IOM’s reputation and subsequent congressional interest. He’d hoped to establish a lead federal agency and funded emergency care research center at NIH, as well as concerted national attention to solve ER crowding, boarding inpatients in hallways and EMS diversion. 

“Despite establishment of an Emergency Care Coordination Center at the HHS Office of the Assistant Secretary for Preparedness and Response, the creation of an NIH Office of Emergency Care Research, the appointment of highly capable Emergency Medicine leaders to head both programs, and the congressional hearing, the American healthcare system did not seize the opportunity to do better.” Dr. Kellermann says. “To my dismay, boarding and diversion [of ambulances] not only persist; they are worse than ever. I had high hopes at the time, but they haven’t been realized. It’s time for another push.”

Dr. Prescott says while significant changes have been made since the time of the report, including improved communications in the pre-hospital world, stroke care and trauma care, it’s time to take another good look at Emergency Medicine. 

“Emergency Care in the United States is good, but it can certainly improve and be better,” Dr. Prescott says. “It’s going to take time, money and commitment within hospitals, the specialty and in the federal government.” 

Dr. Kellermann says he has profound respect for everyone involved in the delivery of emergency care but is astonished that the rest of the U.S. healthcare has turned its back on these challenges year after year. “Emergency care is the safety net of the safety net, and saves lives 24/7/365,” he says. “All who step up to provide around-the-clock care deserve the public’s and America’s support. As a community of health professionals, we must keep pushing for better. If we don’t speak up for our patients and ourselves, nobody will.”

Renée Bacher is a freelance medical writer located Baton Rouge, Louisiana.

References

1. National Academy of Sciences (US) and National Research Council (US) Committee on Trauma; National Academy of Sciences (US) and National Research Council (US) Committee on Shock. Accidental Death and Disability: The Neglected Disease of Modern Society. Washington (DC): National Academies Press (US); 1966.
2. National Academics. The future of emergency care in the United States health system.https://nap.nationalacademies.org/resource/11621/EmergencyCare.pdf. Accessed August 21, 2023.