Document Sample
Overcrowding and Hospital EMS Diversion
(Reference Committee A)
(June 2002)

                                    EXECUTIVE SUMMARY

Council on Medical Service Report 1 responds to Resolution 108 (A-01), which calls on the AMA
to study the issue of overcrowding of emergency departments (EDs), Emergency Medical Services
(EMS) diversions, and lack of hospital beds for admissions, propose ways to reduce or eliminate
the problem, and disseminate information to the public in a manner that will gain public
understanding and support of this serious national problem.

The following report provides background information on ED overcrowding and ambulance
diversions; outlines and details the numerous factors contributing to the problems associated with
overcrowding and diversion; examines some of the various proposals on how to deal with
overcrowding and diversions, including proposed legislation; and summarizes AMA policy that
addresses emergency services and patient transfers.

The report concludes that the problems occurring in the ED are systemic, and are due to a lack of
surge capability and lack of elasticity in the marketplace. Further, an influx of federal funding
could help address a number of the problems hospital EDs are currently experiencing by allowing
for hospital and ED expansion, increased staffing, more available beds, and increased overall
capacity of the system. In addition, the report recommends better integration of ambulatory care
and urgent care centers into the emergency health care system, and that greater efforts be made to
educate both patients and physicians on the appropriate use of the ED. Finally, the report
concludes that there is no “magic bullet” solution to the ED overcrowding and ambulance diversion
problems and, accordingly, local, multi-organizational task forces would be best suited to devise
local solutions to the problems of ED overcrowding and diversion.

                                                                                   CMS Report 1 - A-02
                                                                                          (June 2002)

     Subject:        Overcrowding and Hospital EMS Diversion

     Presented by:   F. Maxton “Mac” Mauney, MD, Chair

     Referred to:    Reference Committee A
                     (Dorothy M. Kahkonen, MD, Chair)

 1   At the 2001 Annual Meeting, the House of Delegates adopted Resolution 108, which calls on the
 2   AMA to study the issue of overcrowding of emergency departments (EDs), Emergency Medical
 3   Services (EMS) diversions, and lack of hospital beds for admissions, propose ways to reduce or
 4   eliminate the problem, and disseminate information to the public in a manner that will gain public
 5   understanding and support of this serious national problem. The Board of Trustees assigned the
 6   requested study to the Council on Medical Service for a report back to the House of Delegates at
 7   the 2002 Annual Meeting.
 9   This report provides background information on ED overcrowding and ambulance diversions;
10   outlines and details the numerous factors contributing to the problems associated with
11   overcrowding and diversion; examines some of the various proposals on how to deal with
12   overcrowding and diversions, including proposed legislation; and summarizes AMA policy that
13   addresses emergency services and patient transfers.
17   Severe overcrowding in America’s EDs is considered a warning sign that the nation’s primary care
18   and hospitals systems are systematically failing. Some hospitals have resorted to advertisements
19   asking patients to avoid their emergency rooms for all but the most urgent care. Most experts say
20   that the problem is not with the EDs themselves, but with the ability of the rest of the health care
21   system to handle patient demand.
23   Data released by the Centers for Disease Control and Prevention (CDC) in June 2001 indicate that
24   there were 103 million ED visits in 1999, up 14% from 90 million visits in 1992. There were
25   significantly fewer hospitals providing emergency care in 1999 as well, resulting in hospitals
26   seeing an additional 35,000 patients per day nationwide. During the same time period, the total
27   number of EDs decreased from 5,210 to 4,740, with ED closures outstripping the rate of facility
28   closures by 28%. It is generally agreed that emergency room visits nationwide continue to rise at a
29   rate of about one million visits per year. This steady rise in the number of patients visiting EDs
30   over the last decade, coupled with the number of EDs progressively declining, have resulted in
31   serious overcrowding problems.
33   In Massachusetts, a survey during a one-week period in 2001 showed that 67 of 76 hospitals
34   statewide had diverted patients away from their EDs because of overcrowding. A few months
35   earlier, a hospital in Miami, FL, published an open letter apologizing for long waits at its
                                       CMS Rep. 1 - A-02 -- page 2
                                              (June 2002)

 1   emergency room. Pressure is mounting because primary care offices are unable to offer the
 2   flexible hours or multi-faceted services many patients require, pushing them toward EDs.
 4   A 1999 study showed that three-quarters of all New York City emergency room visits between
 5   1994 and 1998 were for avoidable or non-emergency care. Half of all patients in the study said that
 6   convenience, rather than financial considerations, caused them to use the emergency room.
 8   The effects of the overcrowded conditions in the ED has resulted in long waits and patient
 9   dissatisfaction. As physicians are seeing more complex acutely ill patients, some are finding they
10   do not have adequate time to thoroughly evaluate each patient, leading to an increased risk for
11   errors, an increased risk for poor outcome, and prolonged pain and suffering for patients. One of
12   the principal effects of the overcrowding situation has been the dramatic increase in the incidence
13   of ambulance diversions.
17   An overcrowded hospital or ED can lead to what is generally referred to as “diversion.” When a
18   hospital goes “on diversion,” it stops accepting patients via ambulance. In urban areas, the portion
19   of time that one or more hospitals are “on diversion” has become an increasing concern. A 2001
20   American Hospital Association (AHA) survey found that 69% of responding hospitals had been on
21   ED diversion at some point during the prior year and suggested that diversions are on the rise.
22   Since January 2000, ambulance diversions have been reported in at least 32 states with substantial
23   problems accessing emergency services occurring in at least 22 of these states.
25   Ambulance diversion programs were originally designed as a stopgap measure to occasionally
26   relieve pressure on overcrowded emergency rooms. It was supposed to help hospitals cope with
27   isolated events such as a particularly bad flu season or a catastrophic freeway pile-up. Diversion
28   programs were set up to let individual EDs re-route ambulances when they already have patients
29   facing long waits. However, by the mid-1990s, even with diversion, some hospitals that had
30   reduced staff and in-patient capacity found themselves with backlogged EDs and not enough beds,
31   nurses or on-call specialists to undo the gridlock.
33   EMS diversion occurred infrequently until a few years ago. Further, the use of diversion is not
34   limited to cash-strapped public hospitals. Increasingly, EMS diversion has been employed by some
35   of the nation’s most prestigious and well-endowed facilities. For example, Cedars-Sinai Medical
36   Center in Los Angeles turned away ambulances more than 40% of the time in June 2001. In the
37   same month, EMS diversions occurred at UCLA Medical Center almost 25% of the time,
38   according to EMS agency records. In Boston, Massachusetts General’s ED was shut to ambulance
39   patients almost 12% of the time in 2001, twice as often as any other hospital in the area. In
40   September 2001, the Boston area’s 27 emergency rooms refused ambulances for a combined 761
41   hours, doubling the September 2000 figure, and October 2001 tripled the occurrences in October
42   2000, with 1,049 hours. Many hospital officials simply accept ambulance diversions as an
43   intractable reality.
45   Hospital and EMS officials are quick to point out that just because an emergency room is “on
46   diversion” does not mean it is not receiving patients. Under federal law, people who get to the
47   hospital without an ambulance must be seen. In addition, if enough facilities go on diversion at the
                                        CMS Rep. 1 - A-02 -- page 3
                                               (June 2002)

 1   same time, rules in most states and localities allow ambulance crews to deliver patients to hospitals
 2   whether the hospitals want them or not.
 4   It is also important to distinguish the way in which the health care system addresses temporary
 5   capacity constraints under normal circumstances from the way in which it addresses capacity
 6   constraints in the event of a disaster or mass casualty. ED diversion is a short-term, temporary
 7   approach used to assure that patients get “the right care at the right time.” If an ED is overcrowded
 8   and another is available, diversion assures timely treatment of a patient and is a warning sign of
 9   capacity constraints under normal conditions. According to the AHA, current ED diversions are
10   “not necessarily an indicator of hospital capacity, capabilities and preparedness in the event of a
11   disaster or mass casualty.”
13   Problems Associated with EMS Diversion
15   EMS diversion creates many problems for patients. Ambulance patients are regularly ending up at
16   hospitals where their insurance is not accepted, and where they are being treated by unfamiliar
17   physicians who do not have access to their medical records. This can create a serious continuity of
18   care issue, especially when a patient needs to be transferred elsewhere, but no paperwork or
19   medical records are available to the treating physician. Diversion has become so routine that more
20   and more patients who call 9-1-1 are openly refusing ambulance transport when they find out the
21   vehicle is not headed to their hospital of choice. The consequences of these increased diversions
22   include significantly escalating transport times, risk of traffic accidents en route, and potential for
23   poor clinical outcome.
25   The American College of Emergency Physicians (ACEP) has prepared guidelines for the
26   development of an ambulance diversion policy. Among the issues included are using diversion as
27   a last resort; having diversion criteria based on the defined capacities or services of the hospital;
28   defining diversion criteria prospectively; not basing hospital diversion on financial decisions, such
29   as to save beds for either elective admissions or potential deterioration of hospitalized patients; and
30   having a plan for the case that all hospitals are on diversion.
34   The Rise in the Number of ED Visits
36   Among the multitude of factors contributing to the problems of overcrowding and diversion is the
37   steady and constant rise in the number of ED visits. This overall increase in patient volume is due
38   to both an aging population and the continually rising number of Medicaid and uninsured patients
39   turning to emergency rooms for care. The percentage of ED patients who are indigent or uninsured
40   rose between 1992 and 1999 from 13.8% to 16.2%. In some areas, limited access to primary care
41   is leading to more ED visits. When a patient cannot get an appointment with his or her primary
42   care physician for three weeks, he or she may wind up visiting the local ED. Nationally, there is a
43   decrease in the number of primary care physicians, and with more physicians working part-time,
44   the hours available for patient care have also decreased. Also, new technologies and upgraded
45   EDs, which allow physicians and hospitals to save more lives, tend to increase the number of
46   people turning to the ED for care. In addition, regional population growth and decreased access to
47   office and clinic physicians due to managed care restrictions have led many EDs to see an increase
                                        CMS Rep. 1 - A-02 -- page 4
                                               (June 2002)

 1   in patient volume. Finally, hospitals in many areas of the country are actively marketing their new
 2   technologies and expanded facilities, which may be bringing more patients into their EDs.
 4   The Nursing Shortage
 6   Experienced nursing staff often provide the indispensable care in EDs. Currently, a profound
 7   shortage of qualified nurses exist to provide for increasing numbers of patients. This issue has
 8   been cited by nearly every hospital administrator and was examined in detail by Council on
 9   Medical Service Report 7 (A-01). Despite hiring bonuses, scholarships, and other efforts,
10   nurse vacancy rates grew to 15% in 2001 from 12% in 2000. A 2001 AHA survey found 126,000
11   vacant nursing slots at U.S. hospitals for lack of qualified candidates. The Bureau of Labor
12   Statistics predicts that nursing positions will increase 23% by 2008, faster than the average for all
13   other occupations. Government projections indicate that by 2015, 114,000 full-time equivalent
14   nursing positions will be unfilled nationally. Further, the number of requests for temporary or
15   traveling critical care nurses is increasing in every area of the country. The Healthcare Association
16   of New York’s April 2000 Staffing Survey showed that 82% of hospitals had a shortage of nurses
17   and that it takes an average of three months for a hospital to fill a vacancy in a nursing position.
19   In Council on Medical Service Report 7 (A-01), the Council recognized the important role nurses
20   play in providing quality care to patients, and encouraged participation in activities with local
21   health care associations and agencies to enhance the recruitment and retention of qualified
22   individuals to the nursing profession. In addition, physicians were encouraged to be aware of and
23   work to improve workplace conditions that impair the professional relationship between physicians
24   and nurses in the collaborative care of patients.
26   A National Shortage of Hospital Beds
28   In many areas of the country, a lack of beds is a primary cause of ED congestion and crowding.
29   When no beds are available, patients wait in the ED to be admitted, creating major back-ups. Bed
30   shortages most commonly involve an inadequate number of intensive care unit (ICU) or telemetry
31   beds. An industry survey of 715 hospitals found that nearly half were running at 90% occupancy
32   during peak periods, drastically higher than a decade ago. In a recent one-week period,
33   metropolitan Boston’s 17 major hospitals reported operating at an almost unheard-of 96.2%
34   occupancy rate. These high occupancy rates simply leave no room for emergency arrivals, forcing
35   patients to be parked in hallway beds, sometimes for days at a time. AHA figures show a loss of
36   more than 103,000 staffed beds in 2000, with 7,800 in medical-surgical ICUs.
38   Hospital, ED and Trauma Center Downsizing, Closing, Merging, and/or Restructuring
40   Access to crucial services is severely affected when closing or downsizing an ED, hospital, or
41   trauma center. Other facilities may not be able to handle potentially large increases in patient
42   volume or provide the same specialized services, as was noted in a recent Council report on the
43   closing of safety-net hospitals (Council on Medical Service Report 3, I-01). When inpatient
44   volume increases beyond expectations, coupled with significant downsizing, serious capacity
45   constraints in hospital inpatient units result. The Los Angeles Times reported that 50 EDs closed in
46   California between 1990 and 1999, while, in Arizona, 6% of hospitals have closed since 1998. In
47   Massachusetts, the imminent closing of Deaconess-Waltham Hospital and the possible shutdown of
48   others in the Boston area led the Massachusetts Medical Society Board of Trustees to create an
                                         CMS Rep. 1 - A-02 -- page 5
                                                (June 2002)

 1   emergency task force to study the impact of hospital closings on patients’ access to care, and to
 2   recommend services and programs to aid physicians affected by such disruptions.
 4   A significant factor affecting the closing of EDs is the variation in state regulation. In Illinois, for
 5   example, operating an ED is a condition of hospital licensure. In Arizona, no legislation explicitly
 6   precludes closures of EDs. In California, acute care hospitals must notify the State Department of
 7   Health Services so an “impact evaluation” can be conducted before downgrading or closing an ED.
 8   At least one public hearing is also required before a hospital can close its ED.
10   Low Reimbursement Rates for Hospitals and Physicians
12   One of the chief factors contributing to the overcrowding of EDs is the low reimbursement rates to
13   hospitals and physicians from both the public and private sector for emergency services. Budget
14   cuts brought on by the 1997 Balanced Budget Act cut federal spending on hospitals, while cuts in
15   financing for other forms of care such as nursing home and home health, have increased the
16   number of chronically ill patients visiting the emergency room. Further, according to a January
17   2001 General Accounting Office (GAO) study, the Emergency Medical Treatment and Active
18   Labor Act (EMTALA) has contributed to a decline in physicians’ willingness to provide services to
19   ED patients because they fear many of these services will be uncompensated. In addition,
20   restrictive managed care contracts that are slow or unlikely to adequately reimburse for emergency
21   services are a factor. Payment policies also can make it difficult for hospitals to find available
22   post-acute care for patients, causing back-ups in the inpatient setting, and then in the ED.
24   According to a January 2002 report in the Annals of Emergency Medicine (G.P. Young et al.), even
25   when patients receive insurance company authorization for ED care, many of the claims are
26   initially denied and reimbursed claims are uniformly downcoded. Of 89% of visits analyzed
27   requiring pre-approval, initial reimbursement was denied for 43% of the ED visits that insurance
28   representatives had pre-approved. Reimbursement was eventually denied for most (65%) of the
29   visits, and 35% of the other visits were downcoded. The study concluded that, even when
30   insurance representatives said they would pay for emergency care, there was no correlation
31   between approval and initial reimbursement. Most of the claims were initially denied whether or
32   not they were pre-approved, and all the claims they were going to pay were downcoded. The
33   Council previously examined this issue in Council on Medical Service Report 5 (I-00), which
34   summarized the reasons for and the rate of managed care retrospective payment denials and down-
35   coding for care provided, and the effect of these practices on patients, physicians, hospitals, and
36   other entities.
38   Limited or Reduced Number of Specialists On-Call
40   Unavailable specialists cause yet another breakdown in the nation’s EDs. This issue was examined
41   in detail by Council on Medical Service Report 3 (I-99) and Board of Trustees Report 29 (A-00).
42   Specialty treatment is sometimes not available because some physicians will not come in when
43   called, will not volunteer to be on-call in the first place, or are simply not available. On-call
44   physicians may not be paid at all, or may not be paid adequately for emergency care, even though
45   fair payment by managed care organizations is a legal requirement. In addition, physicians
46   generally are not paid for “stand-by” services (i.e. staying in the area, wearing a beeper, and being
47   ready to respond in case emergency services are necessary). It appears the problem of on-call
48   physicians is growing, especially since many hospitals no longer require taking call as a condition
                                         CMS Rep. 1 - A-02 -- page 6
                                                (June 2002)

 1   for staff privileges. Also, many of those that are dropping on-call altogether are concentrated
 2   among specialties such as neurosurgery, orthopedics, plastic surgery, and others that are often
 3   involved in providing trauma care. Some hospitals have resorted to paying key specialists as much
 4   as $2,000 a day for ED coverage. One California hospital is reportedly spending $5 million a year
 5   on ED back-up call.
 7   The Continued Erosion of Emergency Response Systems
 9   Emergency response time is at an all-time high and climbing. Like hospitals, EMS providers are
10   under increasing financial stress. Ambulance services that are not supported by a municipality are
11   at increasing risk for insolvency. Like the ED, these are high fixed-cost operations with little
12   control over demand and reimbursement. Also, diminished manpower, reduced hours, and
13   outdated equipment are contributing factors to increased response time.
17   ACEP has appointed a task force to address the complex and multi-faceted ED overcrowding/
18   ambulance diversion “crisis.” Besides publishing guidelines for ambulance diversion, ACEP has
19   developed a comprehensive strategic plan on ED crowding, as well as proposed some temporary
20   solutions such as asking hospitals to cancel elective surgeries; encouraging community physicians
21   to extend office hours; using recovery rooms as ICUs; opening discharged patient holding areas;
22   opening previously closed inpatient units with additional nurses; and working with states to
23   discourage additional hospitals closures, maximize the use of hospitals beds, and develop regional
24   emergency services disaster/diversion plans.
26   There are various other ways the hospital industry is trying to address the overcrowding problems
27   in the ED. Some hospitals have initiated “bedside admissions,” which consists of taking an ED
28   patient straight to an examining room instead of making him or her wait to check in, be examined
29   by a nurse, and eventually being shown to a bed to wait for a physician. Other hospitals have used
30   their hospitalist programs to help relieve pressure on its trauma units and EDs. As previously
31   discussed in Council on Medical Service Report 4 (A-98), hospitalists are inpatient physicians who
32   coordinate admissions, lab tests, exams and discharges – a practice that in some hospitals is
33   improving efficiency so beds become available faster for ED patients who need admission. Some
34   medical centers are relying on home health programs to bring routine care to people with chronic
35   conditions. Other hospitals are offering 24-hour “telephone triage” services that patients can call to
36   decide if they need a physician’s appointment, a visit to an urgent care center, or a trip to the ED.
37   Council on Medical Service Report 3 (I-97) established Policy H-285.944 (AMA Policy Database),
38   which includes principles for demand management through telephone triage programs.
40   For patients with ailments such as chest pain, which may not appear to be an emergency but could
41   easily become one, one California hospital is setting aside monitoring beds in its ED. These beds
42   let physicians wait for test results and watch patients for several hours to see if a critical situation
43   emerges that warrants a hospital admission. Several other hospitals are setting up “fast-track units”
44   in their EDs to speed treatment of patients who come in for minor ailments, the idea being the
45   quicker non-urgent patients get in and out, the more beds become available when ambulances
46   arrive.
                                       CMS Rep. 1 - A-02 -- page 7
                                              (June 2002)

 1   Relevant Proposed Legislation
 3   Several of the proposed bills before Congress related to these issues are consistent with long-
 4   standing AMA policy on access to emergency services (Policy H-130.970). Reps. Benjamin
 5   Cardin (D-MD) and Marge Roukema (R-NJ), and Sens. Bob Graham (D-FL) and Lincoln Chafee
 6   (R-RI) have introduced the Access to Emergency Medical Services Act (S 823/HR 1674). This bill
 7   would establish the “prudent layperson” standard for emergency services under group health plans
 8   and health insurers. The legislation requires plans to pay for emergency treatment and stabilization
 9   based on the patient’s symptoms rather than the final diagnosis. In addition, it prevents plans from
10   forcing patients to obtain prior authorization before seeking emergency care, and it prohibits them
11   from imposing excessive co-payments for treatment in out-of-network EDs. Health plans would be
12   required to educate their members on emergency care coverage and the appropriate use of
13   emergency medical services, including the 9-1-1 system.
15   Rep. Mark Kennedy (R-MN) and Sen. Kent Conrad (D-ND) introduced the Sustaining Access to
16   Vital Emergency Medical Services Act of 2001 (S 587/HR1353) to sustain access to vital
17   emergency medical services in rural areas by awarding grants to eligible entities to provide for
18   improved EMS in rural areas. The Act also establishes a prudent layperson standard for emergency
19   ambulance services under Medicare and Medicaid.
21   In addition, several bills have been introduced regarding the nursing shortage. Rep. Lois Capps
22   (D-CA) and Sen. John Kerry (D-MA) introduced the Nurse Reinvestment Act (HR1436/S 1597)
23   which would (1) develop and issue public service announcements that advertise and promote the
24   nursing profession, highlight the advantages and rewards of nursing, and encourage individuals
25   from diverse communities and backgrounds to enter the nursing profession; and (2) award grants to
26   designated eligible educational entities in order to increase the number of nurses. The Act would
27   also establish a National Nurse Service Corps Scholarship program that provides scholarships to
28   individuals seeking nursing education in exchange for service by such individuals in areas with
29   nursing shortages.
31   The Safe Nursing and Patient Care Act (HR 3238/S 1686), introduced by Reps. Pete Stark (D-OH)
32   and Stephen LaTourette (R-OH), and by Sens. Edward Kennedy (D-MA) and John Kerry (D-MA),
33   would restrict the ability of certain employers to require nurses to work mandatory overtime. The
34   bill is aimed at stemming a growing abuse by employers that compromises patient care and forces
35   many nurses to consider leaving the profession. The bill allows a nurse to refuse mandatory
36   overtime in excess of the regular work shift or beyond 12 hours in a day or 80 hours in a two-week
37   period, prohibits discrimination or retaliation against a nurse for refusing overtime, would impose
38   civil monetary penalties of up to $10,000 against an employer who violates the Act, and establishes
39   an emergency exemption if an appropriate official declares a state of emergency.
43   The AMA has established numerous policies that address emergency services and patient transfers.
44   (Policies H-130.950, H-130.954, H-130.957, H-130.961, H-130.965, H-130.968, H-130.970,
45   H-130.978, H-130.982, H-130.989, H-130.975, H-130.960, H-130.964, H-240.969, and
46   H-285.954). Policy H-130.970(2), which was developed by the Council, supports the principle that
47   all physicians and health care facilities have an ethical obligation and moral responsibility to
48   provide needed emergency services to all patients, regardless of their ability to pay.
                                        CMS Rep. 1 - A-02 -- page 8
                                               (June 2002)

 1   Further, Policy H-130.970(5) states that all health plans should be required to cover emergency
 2   services provided by physicians and hospitals to plan enrollees. As for patient transfers, Policy H-
 3   130.961 urges county medical societies to develop, with their local hospitals, protocols and inter-
 4   hospital transfer agreements. Finally, Policy H-130.965 states that the AMA opposes the refusal by
 5   an institution to accept patient transfers solely on the basis of economics; and supports working
 6   with the AHA to develop model agreements for appropriate patient transfer.
10   During the past year, the issues of overcrowding and diversion have gained growing attention. The
11   Council believes that the problems occurring in the ED are systemic, and are due to a lack of surge
12   capability and lack of elasticity in the marketplace. It is evident that an influx of federal funding
13   could help address a number of the problems hospital EDs are currently experiencing. Simply put,
14   hospitals are under tremendous financial constraints, and additional capital would allow for
15   hospital and ED expansion, increased staffing, more available beds, and would increase the overall
16   capacity of the system.
18   The Council applauds ACEP for its comprehensive efforts to tackle these issues and encourages
19   other appropriate organizations to undertake similar initiatives. Notably, ACEP’s following three-
20   part long-term prescription for these problems includes strategies that already have been discussed
21   by previous Council reports and subsequent AMA policy: (1) decrease the number of uninsured
22   through incremental steps such as tax credits and enrollment outreach to Medicaid/State Children’s
23   Health Insurance Programs (S-CHIP) populations; (2) provide new federal incentives for recruiting
24   and training nurses and to persuade them to stay in the hospital environment; and (3) increase
25   reimbursements to hospitals and physicians for emergency care from both federal and private
26   payers.
28   The Council believes that many of the patients who present to EDs could be treated safely and
29   adequately at their own physician’s office, or at clinic-type facilities such as ambulatory or urgent
30   care centers. Patients with acute conditions can be seen there more quickly than at an ED, and the
31   cost of treatment may even be less because of lower overhead and professional fees and lack of
32   facility charges. Given the complexity of these problems, a realistic interim response to ED
33   overcrowding better integration of ambulatory care and urgent care centers into the emergency
34   health care system.
36   Further, the Council believes that some physicians themselves may contribute to the problem.
37   Physicians occasionally refer patients to the ED if they cannot fit them into their daily appointment
38   schedule or if they learn they cannot admit them as regular patients because no beds are available.
39   The Council believes it is important that more of an effort be made to educate both patients and
40   physicians on the appropriate use of the ED and, therefore encourages the development of
41   educational brochures and pamphlets as to when it is appropriate and necessary to go to the ED.
43   Finally, the Council recognizes there is no “magic bullet” solution to the ED overcrowding and
44   ambulance diversion problems and, accordingly, there is little merit in supporting only one solution
45   that would universally apply to every situation in every market. The Council believes that local,
46   multi-organizational task forces would be best suited to devise local solutions to the problems of
47   ED overcrowding and diversion. Two local solutions that appear to have been particularly
48   effective in some locations are the creation of telephone triage programs to assist patients in
                                       CMS Rep. 1 - A-02 -- page 9
                                              (June 2002)

 1   deciding whether they need to come to the ED, and establishing “fast-track units” to speed
 2   treatment of patients who come in for minor ailments. Council on Medical Service Report 3 (I-97)
 3   discussed in detail the issue of demand management through telephone triage.
 7   The Council on Medical Service recommends that the following be adopted and the remainder of
 8   the report be filed:
10   1.     That the AMA reaffirm Policy H-165.920, which advocates for the use of tax credits to
11          expand health insurance coverage to the uninsured. (Reaffirm HOD Policy)
13   2.     That it is the policy of the AMA that the overall capacity of the emergency health care
14          system needs to be increased through facility and emergency services expansions that will
15          reduce emergency department overcrowding and ambulance diversions; incentives for
16          recruiting, hiring, and retaining more nurses; and making available additional hospital
17          beds. (New HOD Policy)
19   3.     That it is the policy of the AMA to advocate for increased public awareness as to the
20          severity of the emergency department crisis, as well as the development and distribution of
21          patient-friendly educational materials and a physician outreach campaign to educate
22          patients as to when it is appropriate to go to the emergency department.
23          (New HOD Policy)
25   4.     That it is the policy of the AMA to support the establishment of local, multi-organizational
26          task forces, with representation from hospital medical staffs, to devise local solutions to the
27          problem of emergency department overcrowding and ambulance diversion and encourage
28          the exchange of information among these groups. (New HOD Policy).
30   5.     That it is the policy of the AMA that hospitals be encouraged to establish and use
31          appropriate criteria to triage patients arriving at emergency departments so those with
32          simpler medical needs can be redirected to other appropriate ambulatory facilities. (New
33          HOD Policy)
35   6.     That it is the policy of the AMA that hospitals be encouraged to create nurse-staffed and
36          physician-supervised telephone triage programs to assist patients by guiding them to the
37          appropriate facility. (New HOD Policy)
39   7.     That the AMA support federal legislation that all health payors should be required to cover
40          emergency services provided by physicians and hospitals, consistent with AMA policy on
41          access to emergency services (H-130.970). (Directive to Take Action)
43   8.     That it is the policy of the AMA to work with the American Hospital Association and other
44          appropriate organizations to encourage hospitals and their medical staffs to develop
45          diversion policy that includes the criteria for diversion; monitor the frequency of diversion;
46          identify the reasons for diversion; and develop plans to resolve and/or reduce emergency
47          department overcrowding and the number of diversions. (New HOD Policy)