Primary Care Gaps Leave EDs in Crisis

The nation’s emergency departments are being overwhelmed, in part because of patients' lack of access to primary care services, according to a report released June 14 by the Institute of Medicine of the National Academies. The report is one of three covering various aspects of the status of emergency care in the United States.

Emergency departments across the country have been flooded with an increasing number of patients who have Medicaid coverage or no coverage at all, leading to overcrowding, "boarding" (i.e., holding patients in the ED until an inpatient bed is available) and ambulance diversions, according to the IOM’s Committee on the Future of Emergency Care in the U.S. Health System.

“There are 46 million uninsured (patients) who have come to view the emergency room as their most important site of care and, in many cases, their primary care physician,” said committee chair Gail Warden, M.H.A., president emeritus of the Henry Ford Health System, during a June 14 IOM press conference here.

According to the report "Hospital-Based Emergency Care: At the Breaking Point," however, “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.”

Unfortunately for these patients, the ED is a poor provider of primary care, said IOM committee member David Sundwall, M.D., of Salt Lake City, a family physician who directs the Utah Department of Health, in an interview.

There are multiple reasons why patients are not accessing primary care services in their communities, said Sundwall. Many face language or cost barriers. Some simply are not aware of the benefits of primary care, he said.

The report cites those primary care benefits as

The absence of primary care leads to diminished quality of care and, in turn, sicker patients who eventually end up in the ED, according to the report.

Regional variations exist in the ready availability of primary care, with rural areas tending to have too few primary care physicians to serve their patient populations. And for low-income patients, who often cannot afford to take time off work, primary care may be difficult to access because the offices usually are only open from 9 a.m. to 5 p.m.

“It is really a system-wide problem,” said Sundwall. “It’s an argument for having a medical home.”

The committee also reported that EDs typically lack appropriate equipment and personnel trained to handle pediatric care despite the fact that children make up more than a quarter of health care visits. In addition, it found that communication between EDs, ambulances and community physicians often is poor.

The IOM plans to conduct a series of dissemination workshops in the coming months to gather input from the public and stakeholder groups on the findings and recommendations of the emergency care committee's reports.