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Imagine having a loved one die in an ambulance after the closest hospital turned him away because the emergency room was overcrowded.
It happens all the time across the country, according to recent reports by the Institute of Medicine. Called "diverting," it is just one of many major problems quietly plaguing America's emergency care system.
National experts convened at Primary Children's Medical Center on Thursday to send an alert and brainstorm for solutions.
"The bottom line is we have a crisis," said Brent Eastman, chief medical officer of ScrippsHealth, a health care network in San Diego with four acute-care hospitals. "It's under the surface. The public isn't aware of it. Congress isn't really aware of it. We have a big job to do."
Emergency departments are stretched to the breaking point, doctors, administrators and officials agreed. Among the contributing factors: a shortage of specialists willing to be on call; increased liability and medical malpractice insurance rates; sparse research dollars; and uncompensated care for the uninsured.
Also cited: overuse of emergency rooms by the uninsured; undercompensation for providers by Medicare and Medicaid; and poor communication between hospitals, ambulance services and 911 dispatchers.
More than 40 percent of hospitals report overcrowding on a daily basis, according to the reports, and there are roughly 500,000 ambulance diversions a year. Some hospitals have closed down their emergency rooms because of the financial and liability burdens.
With the looming threat of another devastating natural disaster, terrorist attack or disease outbreak, the need for a comprehensive plan is critical, speakers stressed.
"It's true we have a long way to go before we can say we're ready for any and every possible hazard," said Admiral John Agwunobi, assistant secretary for the U.S. Department of Health and Human Services.
David Sundwall, the executive director of the Utah Department of Health, said Utah fares better when it comes to emergency preparedness than other states.
"I think Utah has a leg up because of the spirit of cooperation between the hospitals here" and because of the preparation for the 2002 Winter Olympics, he said.
Even so, in January, Utah received a D grade for its emergency care system in a report by the American College of Emergency Physicians. The chief complaints against Utah were inadequate spending on hospital care and a lack of sufficient registered nurses and hospital beds.
Following Thursday's workshop in Salt Lake City, the Institute of Medicine will hold meetings in Chicago, New Orleans and Washington, D.C. Summaries of the events will be available next spring.
The IOM committee that worked for three years on the reports has made recommendations, some of which are already sparking controversy.
The first is that Congress fund a five-year project to develop coordinated and accountable emergency care systems and to determine best practices. They also want Congress to appoint a lead agency for trauma and emergency care, commit more money for research and consider how to limit hospitals' and doctors' liability.
To help hospitals deal with the onus of unpaid care, experts want the federal government to disperse $50 million a year. Which hospitals would get that money is unclear.
Thomas Russell, executive director of the American College of Surgeons, one of the supporting organizations for the reports, said giving physicians a financial incentive to be on call is a key step.
"Being on call is very disruptive if you have a busy practice," he said. "You're going to irritate your existing patients and your pattern of work. And there's quite a lot of liability exposure. It's also very fatiguing if you're there all night."
Changing patients' behavior is another challenge, he said.
"A lot of these patients are using [emergency rooms] who shouldn't be," Russell said. "It's going to take education and understanding to get that across. I think there are resolutions but just letting it continue to go along as it has isn't a solution."
The Institute of Medicine was established in 1970 under the National Academy of Sciences and provides unbiased information to policy makers.
Recommendations
* Congress should set aside $50 million to reimburse hospitals for unpaid emergency care.
* Congress should allocate $88 million for grants that promote greater coordination and regionalization of emergency care.
* Congress should provide $37.5 million each year for the next five years to the Emergency Medical Services for Children Program to address deficiencies in pediatric emergency care.