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ABSTRACT Five decades ago, hospitals staffed their emergency rooms with rotating community physicians or unsupervised hospital staff. Ambulance service was frequently provided by a local funeral home. Beginning in the late 1960s and accelerating thereafter, emergency care swiftly evolved into its current form. Today, modern emergency departments not only are capable of providing around-the-clock lifesaving care in individual emergencies and disasters. They also conduct timely diagnostic workups, provide access to after-hours acute care, and serve as the "safety net of the safety net" for millions of low-income and uninsured patients. But the field's success has led to a new set of challenges. To overcome them, emergency care must become more integrated, regionalized, prevention oriented, and innovative.
Entering Vanderbilt Hall inNewYork City's Grand Central Terminal, the visitor is struck by the buzz of activity. Each day 75,000-100,000 passengers pass through the train station's doors. In addition to serving as a transportation hub, it is a place of commerce, a gathering point, and a cultural landmark.1 Like Grand Central, modern hospital emergency departments (EDs) are constantly in motion. And like Grand Central, EDs have purposeful order beneath their superficial chaos.
In 2010 EDs in the United States managed 130 million encounters.2 Patients come to the ED for a variety of reasons and depart to one of several destinations. Some go directly to an operating room or intensive care unit, while others are admitted to a pediatric ward, specialty service, or general medicine unit.Afew are transferred to another facility. However, the vast majority of ED patients (84 percent nationwide) are discharged home.3
EDs were created to provide communities with access to lifesaving care, twenty-four hours a day. Many also serve as community hubs for disaster response, diagnostic centers to evaluate urgent conditions, and walk-in clinics for weekend and after-hours care of painful or worrisome conditions. For millions of low-income Americans, EDs are the only place they can turn4-thus serving as the "safety net of the safety net."5(p18)
The Origins Of Modern Emergency Care
As recently as the 1950s, the "emergency room" was often just that-a hospital room reserved for emergency cases. The room was staffed by either inexperienced interns or rotating members of the hospital's medical staff-regardless of their training, expertise, or interest.3 Rising demand in the...