and lower reimbursements by managed care, Medicare, and other payers. By 2001, 60 percent of hospitals were operating at or over capacity.

The high demand for hospital-based emergency and trauma care reflects several trends. First, EDs have become one of the nation’s principal sources of care for patients with limited access to other providers, including the 45 million uninsured Americans. Indeed, the Emergency Medical Treatment and Active Labor Act of 1986 prevents hospitals from restricting access for uninsured patients by requiring hospitals to provide a medical screening examination to all patients and to stabilize or transfer patients as needed. With limited access to community-based primary and specialty care, many turn to the emergency system when in medical need, often for conditions that have worsened because of a lack of regular primary care.

Medicaid beneficiaries also turn to the ED. In fact, Medicaid enrollees visit the ED at a higher rate than any other category of patient (81 visits per 100 enrollees)—double the rate of the uninsured population and nearly four times that of privately insured patients. Although Medicaid enrollees are insured, the low rates of provider reimbursement in many states limit the number of office-based practitioners who are willing to accept them as patients.

In addition, the ED often serves as primary care provider, a role for which it is not optimally designed. Rather, the ED is designed for rapid, high-intensity responses to acute injuries and illnesses. Physicians in the ED face constant interruptions and distractions, and typically lack access to the patient’s full medical records. Because nonemergency patients are usually low triage priorities, they often experience extremely long wait times as they are passed over for more urgent cases.

Costs are another concern. When an ED is not busy, the cost of treating an additional nonemergency patient is probably quite low. But while the literature on this issue is mixed, a number of studies suggest that nonemergency care in the ED is more costly than that in alternative settings. Indeed, ED charges for minor problems have been estimated to be two to five times higher than those of a typical office visit. When the ED is at full capacity, treating additional patients who could be cared for in a different environment means fewer resources—physicians, nurses, ancillary personnel, equipment, and time and space—available to respond to emergency cases.

By law, the front door of the ED is always open. When a hospital’s inpatient beds are full, as is frequently the case, ED providers cannot transfer the most severely ill and injured patients to an inpatient unit. As a result, ED patients who require hospitalization begin to back up in the ED. The aggregate result of this imbalance between public demand and hospital capacity is an epidemic of overcrowded EDs, frequent “boarding” of patients waiting for inpatient beds, and ambulance diversion:

Front Matter (R1-R26)

Summary (1-16)

1 Introduction (17-36)

2 The Evolving Role of Hospital-Based Emergency Care (37-80)

3 Building a 21st-Century Emergency Care System (81-128)

4 Improving the Efficiency of Hospital-Based Emergency Care (129-164)

5 Technology and Communications (165-208)

6 The Emergency Care Workforce (209-258)

7 Disaster Preparedness (259-290)

8 Enhancing the Emergency Care Research Base (291-320)

Appendix A Committee and Subcommittee Membership (321-322)

Appendix B Biographical Information for Main Committee and Hospital- Based Emergency Care Subcommittee (323-336)

Appendix C List of Presentations to the Committee (337-342)

Appendix D List of Commissioned Papers (343-344)

Appendix E Statistics on Emergency and Trauma Care Utilization (345-352)

Appendix F Historical Development of Hospital-Based Emergency and Trauma Care (353-364)

Appendix G Recommendations and Responsible Entities from the Future of Emergency Care Series (365-382)

Index (383-398)