Most schools expect that they will dial 911 for emergency room care if a student is ill or injured, and for schools without full-time nurses this is the major source of help in health crises. But a spate of recent reports, and a new analysis of emergency room care released by the Centers for Disease Control and Prevention (CDC) in September, say that throughout the United States, the hospital emergency room itself is in crisis.

In particular, the reports show that children may not be well served in emergency departments, which often lack child-size diagnostic and treatment equipment and may have no pediatric physicians or nurses on staff.

Here are some of the findings from recent reports:

• In 2003, more than a third of hospital emergency departments diverted inbound ambulances to other facilities because the emergency room was full, prolonging ambulance time and disrupting established patterns of care;
• Half of emergency departments had more than 5 percent of their nursing positions vacant, and many lacked specialist physicians;
• Growth in the use of hospital emergency services in recent years has coincided with a decline in the number of emergency departments, overburdening the capacity of those that continue to operate;
• As hospitals cut back on their number of beds, many emergency rooms have large numbers of "boarders"—patients who have been stabilized and diagnosed for hospital admission but are being kept in the emergency room because there are no available hospital beds.

Hospital emergency departments are required by federal law, the Emergency Medical Treatment and Active Labor Act, to provide an appropriate medical screening examination to anyone who comes to the ED and requests examination or treatment for a medical condition, or for whom care is requested, and to provide appropriate stabilization treatment and hospitalization if necessary. Hospitals are held liable for the cost of care for patients who are unable to pay their bills, so uncompensated use of the emergency room by uninsured patients is estimated to have cost community hospitals almost $27 billion in 2004.

Writing in the Journal of the American Medical Association in September, a physician who assisted in emergency room care of persons severely injured in the 1996 bombing of the Atlanta Olympics says the exemplary response of Grady Memorial Hospital’s emergency department to that crisis could not happen today, and he questions whether emergency services in general can manage another bombing or other terrorist or natural disaster.

Dr. Arthur Kellerman points to three overlapping reports released in June 2006 by the Institute of Medicine, a component of the National Academies of Science, that "describe an overburdened system that is rapidly approaching its limits." Those reports indicate that during the past decade, emergency department visits have increased by 26 percent, while the number of emergency departments has decreased by 9 percent and hospitals have closed 198,000 beds.

Kellerman notes that his observations are hardly new and have been documented for years, but he says the federal government has largely ignored the problem, with responsibility for emergency and trauma response scattered across three agencies (Health and Human Services, Transportation, and Homeland Security), where "highly capable people work but are unable to set priorities."

Noting that reform of the emergency system is urgent, Kellerman says, "When your life is on the line, you want your doctor—not your ambulance—to go the extra mile."

A statistical analysis of emergency departments published in September 2006 by the Centers for Disease Control and Prevention is available online at www.cdc.gov/nchs. Three reports--"Hospital Based Emergency Care: At the Breaking Point," "Emergency Medical Services: At the Crossroads," and "Pediatric Emergency Care: Growng Pains," published by the National Academies Press in June 2006 can be read in part or ordered at http://www.nap.edu.