Arizona's emergency medical system is in critical condition, threatened by nurse and physician shortages and a lack of emergency and trauma facilities, according to a national study released Dec. 9.

The American College of Emergency Physicians, which grades states on criteria ranging from disaster preparedness to medical liability, handed down a D+ to Arizona's emergency medical system.

The state's low grade ranks it 45^th in the nation.

The report indicates that delayed access to emergency care in Arizona – the most heavily weighted category in the report – was the main contributor to the state's overall failing grade.

More than 1.65 million Arizonans visited an emergency room in 2007. The average wait time – 5 hours and 27 minutes – was 90 minutes longer than the national average.

The primary cause for the delay in receiving care was a shortage of qualified physicians and nurses, according to the study.

"If you don't have enough physicians who are working, then you obviously can't staff the departments to the levels that they need to be staffed based on patient volume," said Craig Norquist, president of the Arizona College of Emergency Physicians. "And if there are not enough physicians in the state to take care of the patients who are here, then obviously, yes, your wait time will go up. But it also could have adverse effects on the quality of patient treatment."

Attempts by hospitals to recruit more physicians have been hindered by the state's medical-liability laws, Norquist said.

In the time-sensitive environment of an emergency room, with patients often incapacitated, emergency physicians often make life-or-death decisions based on limited information.

"In an emergency situation, I don't have the benefit of knowing some of the past medical issues that you have had or the potential medical problems I may be faced with," Norquist said.

And the treatment prescribed might be the wrong one.

"A patient who had years and years of being on a medication like steroid medication, that patient is going to have a much higher surgical risk than a patient who has not been on steroids," Norquist said. "But if that patient comes in and can't answer any questions, you call a surgeon and then find out the person is someone you never would have taken to surgery had you known about the medication."  

Malpractice laws in many states provide liability protection for physicians sued in response to medical errors resulting from emergency-provided treatment.

But in Arizona, such situations are not differentiated from medical errors resulting from a physician's negligence. 

Also, Arizona's malpractice laws do not include a cap on the amount of damages a jury can award a patient in malpractice suits.

"Fortunately, we have not had many major cases where the physician is held responsible for millions and millions of dollars," Norquist said. "But, in theory, they certainly could be."

Norquist and others hope the Legislature will approve a bill in the upcoming session to reform the state's malpractice laws. Sen. Carolyn Allen, R-Scottsdale, has sponsored such a bill during the past three sessions, each time with unsuccessful results. 

But state medical liability reform would do little to increase the number of registered nurses, who on average have less malpractice insurance than physicians, said Joyce Benjamin, executive director for the Arizona Nurses Association.

The shortage of registered nurses – there are 560.8 per 100,000 people in Arizona – is partially the result of a lack of hospitals and trauma centers.

The hospital shortage in Arizona is one of the key contributors to the state's failing grade, according to the report.  States average 20 emergency rooms per 1 million people, while Arizona has only seven emergency rooms per 1 million people.

More than 60 percent of the state's registered nurses come from the various associate-degree programs offered by the state's community college system, according to the Arizona Nursing Association.

Like doctors, nursing students seeking associate degrees obtain required hands-on training through clinical rotation hours in a hospital.

A shortage of hospitals, therefore, forces nursing programs to limit the number of students they accept based how many can be placed in clinical rotations.

"The hospitals are maxed out with so many students," said Benjamin. "They (hospitals) are taking as many students as they can for the clinical rotation, but it is getting hard to place the students."

There are approximately 45 emergency departments in Arizona and more than 1,700 students are on two-year waiting lists to enter associate-nursing programs.  

The Arizona Nursing Association hopes to expand the number of nursing students by offering clinical rotations during night shifts and in long-term care and rehab clinics.

"We are trying to look at creative ways to give nurses good clinical experiences instead of always being in the hospital," Benjamin said.