Washington - American emergency rooms are stretched to the breaking point and are not prepared to handle widespread illness or an event with mass casualties, according to a study released in June by the Institute of Medicine.

"You've got to ask yourself, if our 911 services are struggling to handle our daily and nightly 911 calls, how in the world
are they going to handle a mass-casualty event, a terrorist strike, an outbreak of infectious disease or a natural disaster?" Dr. Arthur Kellermann, a report co-author and chairman of emergency medicine at Emory University School of Medicine, said at a news conference.

The system's failures, the report said, have left patients at many overcrowded emergency departments waiting hours for treatment or being turned away altogether. Authorities say that correcting the problems will require millions of dollars - preferably redirected bioterror money - as well as attention to patient diversions, hospital bed space and nursing shortages.In Georgia, the state's coordination of emergency care lacks both funding and resources, Kellermann said.

There's no regionwide coordination of hospital emergency rooms "to make sure the right person gets to the right hospital
at the right time," he said. "In many cities like Atlanta, there is no control tower."

The American College of Emergency Physicians this year gave overall emergency care in Georgia a C+, when graded
against other states. The grades included an A in medical quality and patient safety but a D+ in access to emergency care.

Georgia may be about average, "but remember, it's average for a system that's at the breaking point," Kellermann said. He added that Atlanta has an especially vulnerable emergency system, because of population increase and the continuing
burden on Grady Memorial Hospital, which has the state's busiest emergency department.

Grady’s solution promoted
The problems, the Institute of Medicine said in its three-volume report, grow from the need for emergency rooms to provide routine care for millions of uninsured patients, a shortage of nurses and medical specialists, and failure to use modern methods of managing the flow of patients.

The institute, an independent scientific advisory panel, also offered hope that the problems can be overcome. It cited a case study involving Grady Health System, which includes Grady Memorial, where satisfaction with ER services fell to a historic low in 2002 amid severe overcrowding.With staff training, changes in diagnostic procedures and creation of a special unit to assess patients who didn't need immediate care, Grady was able to cut in half the average time it takes to place patients in hospital beds. The solutions found at Grady are echoed in the 19 recommendations offered in June by a
committee of more than two dozen leading medical officials appointed in 2003.

Many of the recommendations were aimed at Congress, which the panel said should:

• Quickly approve extra funding for hospitals that provide uncompensated care to uninsured patients.
• "Significantly" increase hospitals' disaster preparedness funding.
• Establish a lead agency in the Department of Health and Human Services for emergency and trauma care, and create a demonstration program to promote a coordinated regional approach to emergency care.

It also said:

• Hospitals should stop "boarding" patients in emergency departments until beds become available and diverting ambulances to alternative hospitals - practices that the panel called "antithetical to quality medical care."
• ERs should adopt a range of information and communication technologies that would allow quicker and safer handling
  of patients.
• Deficiencies in the emergency system itself are compounded by the 46 million uninsured Americans whose primary source of care is often the ER.

Dr. Stuart Segerman, an emergency physician at St. Joseph's Hospital in Atlanta and the immediate past president of the Georgia College of Emergency Physicians, said he did not know how many more hospital beds or nurses were needed in Georgia. But he said the problem must be addressed.

"The governor and the Legislature are going to have to take this up in serious fashion," he said. "It's a space, personnel and population issue . . . with the numbers of patients going up and the numbers of nurses and hospital rooms going down. It's the devil and the deep blue sea; it's so complicated."

Half of visits aren’t urgent
There were almost 114 million ER visits in 2003 - up from 93 million a decade earlier - with only about half of them true medical emergencies. When the poor and uninsured can't get medical services elsewhere, they come to ERs,
which must treat them regardless of their ability to pay.

"We value emergency care in this country so much that it is the only medical care to which Americans have a legal right," Kellermann said. "But we value it so little that we're not willing to pay for it. It is, in the congressional parlance, an unfunded mandate."

Lack of federal funding and government oversight were cited as the root of the problem. In 2002 and 2003, out of the $3.38 billion issued by the Department of Homeland Security for preparedness efforts, only 4 percent was allocated to bolster emergency medical care.

"What this study shows is that the system in its current state cannot handle some of the routine demand, so when a crisis occurs, we're starting way behind the curve in our capacity to respond," said Jeff Levi, executive director of Trust for America's Health, a Washington-based public health advocacy group.

The current shortage of nurses compounds the ER problem. As the baby boomer generation ages, intensive care from nurses will be in even greater demand, making now a crucial time to address the work force shortage in emergency
nursing, said Nancy Bonalumi, president of the Emergency Nurses Association. More than 147,000 potential nurses
were turned away from nursing schools last year because of diminished capacity in U.S. nursing schools, according to the National League for Nursing.

Kellermann said that with fewer resources available, overcrowding in the ER is inevitable. Patients who need immediate
attention are held in exam rooms or even hallways.

"Some wait for hours; others wait for days," he said. "Meanwhile, other patients are arriving every hour."

In 2003, 501,000 ambulances were turned away from full ERs and sent to other hospitals because of overcrowding.

"When I started in my career, this was considered a rare and disturbing event. It now happens over one-half million times
a year in the United States," Kellermann said.

He said hospitals must end diversion of ambulances, in part by improving patient flow through the hospital and by identifying open beds more quickly.

Another problem: The number of emergency rooms is shrinking. While ER visits rose from 1993 to 2003, the number of emergency departments has decreased by about 14 percent, according to a report last year by the Centers for Disease Control and Prevention.

The problem of ambulance diversion is getting worse in Atlanta, Kellermann said. A Band-Aid fix won't work, he added.

"It's an incredible effort by paramedics, nurses, emergency physicians and surgeons to get the city through a tough night," Kellermann said.

St. Joseph's Segerman said the problem is acute around the state.

"It's not just us," he said. "There's no flex in the system. You add another extra 10 people to our [ER] census every day and we are overwhelmed."

The report also cites inadequate preparation for pediatric emergency care. Many ERs lack smaller-sized medical equipment and provide limited training in pediatric emergency care.

- This article is a reprint from The Atlanta Journal-Constitution. The Associated Press contributed to the article.