that the majority of injured children receive care in general rather than children’s hospitals.

The research on this subject indicates two failings. First, identification of child abuse is poor. Although emergency medicine physicians do receive didactic training in child abuse, a survey of residents found that many believed the training was not sufficient (Wagh and Heon, 1999). Results of one study also indicate that prehospital providers lack the knowledge necessary for recognizing, managing, and reporting cases of child abuse (Markenson et al., 2002). Second, high rates of coding errors for pediatric ED visits contribute to underestimates of child abuse. In many cases, child abuse cases identified in the ED are documented using only E-codes. Those cases would be missed in epidemiological studies that select cases using only ICD 995 abuse codes (Kunen et al., 2003).


Performance measures specific to emergency care are in the initial stages of development, so formal assessments of the quality of the emergency care system are currently lacking. However, there is reason for concern about the quality of the care delivered. The emergency care system faces a number of challenges that threaten its ability to deliver quality care. Overwhelming demands on the system without the resources necessary to meet those demands contribute to a growing national crisis in emergency care. Under the current system, however, accountability for assuring access to or monitoring the quality of the system is dispersed among many providers. The result is that the system falls short of providing the type of care it should be able to provide.

Growing Pressures on the Emergency Care System

One of the greatest challenges faced by the emergency care system is overwhelming patient loads. The public’s dependence on the ED as a source of care is growing; the total number of ED visits rose by 26 percent between 1993 and 2003 (McCaig and Burt, 2005). In some EDs, nonurgent patients must wait 6 to 8 hours before being seen; nationwide, 2 percent of all patients, including pediatric patients, who come to the ED leave before ever being seen (McCaig and Burt, 2005; 2002 NHAMCS data, calculations by IOM staff).

The rising number of patient visits is only part of the problem; EDs are also experiencing great difficulty with moving seriously ill and injured patients from the ED into inpatient beds. In response to cost-cutting measures and lower reimbursement by managed care, Medicaid, and other payers, hospital inpatient bed capacity declined precipitously over the last decade.

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