3
Building a 21st-Century Emergency Care System

Hospitals are part of a continuum of emergency care services that includes 9-1-1 and ambulance dispatch, prehospital emergency medical services (EMS) care and transport, hospital-based emergency and trauma care, and inpatient services. While today’s emergency care system offers significantly more medical capability than was available in years past, it continues to suffer from severe fragmentation, an absence of systemwide coordination, and a lack of accountability. These shortcomings diminish the care provided to emergency patients and often result in worsened medical outcomes. To address these challenges and chart a new direction for emergency care, the committee envisions a system in which all communities will be served by well-planned and highly coordinated emergency care services that are accountable for performance and serve the needs of patients of all ages within the system.

In this new system, 9-1-1 dispatchers, EMS personnel, medical providers, public safety officers, and public health officials will be fully interconnected and united in an effort to ensure that each patient receives the most appropriate care, at the optimal location, with the minimum delay. From the patient’s point of view, delivery of services for every type of emergency will be seamless. All service delivery will also be evidence based, and innovations will be rapidly adopted and adapted to each community’s needs. Hospital emergency department (ED) closures and ambulance diversions will never occur, except in the most extreme situations, such as a hospital fire or a communitywide mass casualty event. Standby capacity appropriate to each community based on its disaster risks will be embedded in the system. The performance of the system will be transparent, and the public will be



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Hospital-Based Emergency Care: At the Breaking Point 3 Building a 21st-Century Emergency Care System Hospitals are part of a continuum of emergency care services that includes 9-1-1 and ambulance dispatch, prehospital emergency medical services (EMS) care and transport, hospital-based emergency and trauma care, and inpatient services. While today’s emergency care system offers significantly more medical capability than was available in years past, it continues to suffer from severe fragmentation, an absence of systemwide coordination, and a lack of accountability. These shortcomings diminish the care provided to emergency patients and often result in worsened medical outcomes. To address these challenges and chart a new direction for emergency care, the committee envisions a system in which all communities will be served by well-planned and highly coordinated emergency care services that are accountable for performance and serve the needs of patients of all ages within the system. In this new system, 9-1-1 dispatchers, EMS personnel, medical providers, public safety officers, and public health officials will be fully interconnected and united in an effort to ensure that each patient receives the most appropriate care, at the optimal location, with the minimum delay. From the patient’s point of view, delivery of services for every type of emergency will be seamless. All service delivery will also be evidence based, and innovations will be rapidly adopted and adapted to each community’s needs. Hospital emergency department (ED) closures and ambulance diversions will never occur, except in the most extreme situations, such as a hospital fire or a communitywide mass casualty event. Standby capacity appropriate to each community based on its disaster risks will be embedded in the system. The performance of the system will be transparent, and the public will be

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Hospital-Based Emergency Care: At the Breaking Point actively engaged in its operation through prevention, bystander training, and monitoring of system performance. While these objectives will require substantial, systemwide change, they are achievable. Early progress toward the goal of more integrated, coordinated, regionalized emergency care systems became derailed over the last two decades. Efforts stalled because of deeply entrenched interests and cultural attitudes, as well as funding cutbacks and practical impediments to change. These obstacles remain today, and represent the primary challenges to achieving the committee’s vision. However, the need for change is clear. The committee calls for concerted, cooperative efforts at multiple levels of government and the private sector to finally achieve the objectives outlined above. This chapter describes the committee’s vision for a 21st-century emergency care system. This vision rests on the broad goals of improved coordination, expanded regionalization, and increased transparency and accountability, each of which is discussed in turn. Next, current approaches of states and local regions that exhibit these features are profiled. The chapter then details the committee’s recommendation for a federal demonstration program to support additional state and local efforts aimed at attaining the vision of a more coordinated and effective emergency care system. The chapter ends with a discussion of the need for system integration and a presentation of the committee’s recommendation regarding a federal lead agency to meet that need. THE GOAL OF COORDINATION The value of integrating and coordinating emergency care has long been recognized. The 1996 National Academy of Sciences/National Research Council (NAS/NRC) report Accidental Death and Disability called for better coordination of emergency care through Community Councils on Emergency Medical Services that would bring together physicians, medical facilities, EMS, public health agencies, and others “to procure equipment, construct facilities and ensure optimal emergency care on a day-to-day basis as well as in a disaster or national emergency” (NAS and NRC, 1966, p. 7). The National Highway Traffic Safety Administration’s (NHTSA) 1996 report Emergency Medical Services Agenda for the Future also emphasized the goal of system integration: EMS of the future will be community-based health management that is fully integrated with the overall health care system. It will have the ability to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to treatment of chronic conditions and community health monitoring…. [P]atients are assured that their care is considered part

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Hospital-Based Emergency Care: At the Breaking Point of a complete health care program, connected to sources for continuous and/or follow-up care, and linked to potentially beneficial health resources…. EMS maintains liaisons, including systems for communication with other community resources, such as other public safety agencies, departments of public health, social service agencies and organizations, health care provider networks, community health educators, and others…. EMS is a community resource, able to initiate important follow-up care for patients, whether or not they are transported to a health care facility. (NHTSA, 1996, Pp. 7, 10) In 1972, the NAS/NRC report Roles and Responsibilities of Federal Agencies in Support of Comprehensive Emergency Medical Services promoted an integrated, systems approach to planning at the state, regional, and local levels and called for the Department of Health, Education and Welfare (DHEW) to take an administrative and leadership role in federal EMS activities. The Emergency Medical Services Systems Act of 1973 (P.L. 93-154) created a new grant program in DHEW’s Division of EMS to foster the development of regional EMS systems. The Robert Wood Johnson Foundation added support by funding the development of 44 regional EMS systems. Although the drive toward system development waned after the demise of the DHEW program and the subsequent absorption of federal EMS funding into federal block grants in 1981, the goals of system planning and coordination remained paramount within the emergency care community. Limited Progress While the concept of a highly integrated emergency care system as articulated in NHTSA’s Emergency Medical Services Agenda for the Future is not new, progress toward its realization has been slow. Prehospital EMS, hospital-based emergency and trauma care, and public health have traditionally worked in silos (NHTSA, 1996), a situation that largely persists today. For example, public safety and EMS agencies often lack common communications frequencies and protocols for communicating with each other during emergencies. Jurisdictional borders contribute to fragmentation under the current system. For example, one county in Michigan has 18 different EMS systems with a range of different service models and protocols. Coordination of services across state lines is particularly challenging. Trauma systems provide a valuable model for how such coordination could and should operate. The inclusive trauma system is meant to ensure that each patient is directed to the most appropriate setting, including a level I trauma center, when necessary. To this end, many elements within the regional system—community hospitals, trauma centers, and particularly prehospital EMS—must coordinate the regional flow of patients effectively. Such coordination not only improves patient care, but also is a critical tool in reducing overcrowding in EDs.

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Hospital-Based Emergency Care: At the Breaking Point Unfortunately, only a handful of systems nationwide coordinate transport effectively throughout the region. Short of formally going on diversion, there is typically little information sharing between hospitals and EMS regarding overloaded emergency and trauma centers and availability of ED beds, operating suites, equipment, trauma surgeons, and critical specialists—information that could be used to balance the load among EDs and trauma centers in the region. Too often hospitals are located such that one is overloaded with emergency and trauma patients, while just several blocks away another works at a comfortable 50 percent of capacity. There is little incentive for ambulances to drive by a hospital to take patients to a facility that is less overloaded. The benefits to patients of better regional coordination have been demonstrated. Furthermore, the technologies needed to facilitate such approaches exist; police and fire departments are ahead of the emergency care system in this regard. The main impediment appears to be entrenched interests and a lack of sufficient vision to change the current system. The problem is intensified in some regions by turf wars between fire-fighters and EMS personnel that were documented in a series of articles for USA Today (Davis, 2003). Moreover, air medical services typically operate outside the control of the EMS system and have a poor record of safety and effectiveness in transporting patients. The situation is exacerbated in cities with both private and public EMS agencies that sometimes compete for patients and transport based on hospital ownership of the agency rather than what is best for the patient. Even within EDs, there may be friction between emergency staff trying to admit patients and personnel on inpatient units who have no incentive to speed up the admissions process. Lack of coordination between EMS and hospitals can result in delays that compromise care, and emergency physicians sometimes clash with on-call specialists and admitting physicians over delays in response. Linkages with Public Health The ED has a special relationship with the community and state and local public health departments because it serves as a community barometer of both illness and injury trends (Malone, 1995). In her analysis of heavy users of ED services, Malone argued that “emergency departments remain today a ‘window’ on wider social issues critical to health care reforms” (Malone, 1995, p. 469). A commonly cited example is the use of seat belts. We now know that increased use of seat belts reduces the number of seriously injured car crash victims in the ED—the ED served as a proving ground for documenting the results of seat belt enforcement initiatives. Although prevention activities have been limited in the emergency care setting, that

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Hospital-Based Emergency Care: At the Breaking Point setting represents an important teaching opportunity. To take advantage of that opportunity, emergency care providers would benefit from the resources and experiences of public health agencies and experts in the implementation of injury prevention measures. Perhaps now more than ever, with the threat of bioterrorism and outbreaks of such diseases as avian influenza and severe acute respiratory syndrome (SARS), it is essential that EMS, EDs, trauma centers, and state and local public health agencies partner to conduct surveillance for disease prevalence and outbreaks and other health risks. Hospital EDs can recognize the diagnostic clues that may indicate an unusual infectious disease outbreak so that public health authorities can respond quickly (GAO, 2003c). However, a solid partnership must first be in place—one that allows for easy communication of information between emergency providers and public health officials. Linkages with Other Medical Care Providers As discussed earlier, EDs fill a variety of gaps within the health care network and serve as key safety net providers in many communities (Lewin and Altman, 2000). Studies have shown that a significant number of patients use the ED for nonurgent purposes because of financial barriers, lack of access to clinics after hours, transportation barriers, convenience, and lack of a usual source of care (Grumbach et al., 1993; Young et al., 1996; Peterson et al., 1998; Koziol-McLain et al., 2000; Cunningham and May, 2003) (see Chapter 2). There is also evidence that clinics and physicians are increasingly using EDs as an adjunct to their practice, referring patients to the ED for a variety of reasons, such as their own convenience after regular hours, reluctance to take on a complicated case, the need for diagnostic tests they cannot perform in the office, and liability concerns (Berenson et al., 2003; Studdert et al., 2005). (See the detailed discussion of these issues in Chapter 2.) Unfortunately, in many communities there is little interaction between emergency care services and community safety net providers—this even though they share a common base of patients, and their actions may affect one another substantially. The absence of coordination represents missed opportunities for enhanced access; improved diagnosis, patient follow-up, and adherence to treatment; and enhanced quality of care and patient satisfaction. Successes Achieved While progress toward a highly integrated emergency care system has been slow, some important successes in the coordination of emergency

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Hospital-Based Emergency Care: At the Breaking Point care services point the way toward solutions to the fragmentation that dominates the system today. For example, the trauma system in Maryland, described in more detail later in this chapter, provides a comprehensive and coordinated approach to the care of injured children. Children’s hospitals have also been successful in accomplishing regional coordination to ensure the transport and appropriate care of children needing specialized services. The pediatric intensive care system is a leading example of regional coordination among hospitals, community physicians, and emergency medical technicians (EMTs) (Gausche-Hill and Wiebe, 2001). These are but a few examples demonstrating the possibilities for enhancing coordination of the system as a whole. One promising public health surveillance effort is Insight, a computer-based clinical information system at the Washington Hospital Center (WHC) in Washington, D.C., designed to record and track patient data, including geographic and demographic information. The software proved useful during the 2001 anthrax attacks, when it enabled WHC to transmit complete, real-time data to the Centers for Disease Control and Prevention (CDC) while other hospitals were sending limited information with a lag time of one or more days. The success of Insight attracted considerable grant funding for the system’s expansion; WHC earmarked $7 million for the system to link it to federal and regional agencies and to integrate it with other hospital systems (Kanter and Heskett, 2002). Many communities have established primary care networks that integrate hospital EDs into their planning and coordination efforts. A rapidly growing number of communities, such as San Francisco and Boston, have developed regional health information organizations that coordinate the development of information systems to facilitate patient referrals and track the sharing of medical information between providers to optimize a patient’s care across settings. The San Francisco Community Clinic Consortium brings together primary and specialty care providers and EDs in a planning and communications network that closely coordinates the care of safety net patients throughout the city. The Importance of Communications Communications are a critical factor in establishing systemwide coordination. An effective communications system is the glue that can hold together effective, integrated emergency care services. It provides the key link between 9-1-1/dispatch and EMS responders and is necessary to ensure that on-line medical direction is available when needed. It enables ambulance dispatchers to tell callers what to do until help arrives and to track a patient’s progress following the arrival of EMS responders. An effective communications system also enables ambulance dispatchers to assist EMS

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Hospital-Based Emergency Care: At the Breaking Point personnel in directing patients to the most appropriate facility based on the nature of their illness or injury and the capacity of receiving facilities. It links the emergency medical system with other public safety providers—such as police and fire departments, emergency management services, and public health agencies—and facilitates coordination between the medical response system and incident command in both routine and disaster situations. It helps hospitals communicate with each other to organize interfacility transfers and arrange for mutual aid. And it facilitates medical and operational oversight and quality control within the system. THE GOAL OF REGIONALIZATION The objective of regionalization is to improve patient outcomes by directing patients to facilities with optimal capabilities for any given type of illness or injury. Substantial evidence demonstrates that doing so improves outcomes and reduces costs across a range of high-risk conditions and procedures, including cardiac arrest and stroke (Grumbach et al., 1995; Imperato et al., 1996; Nallamothu et al., 2001; Chang and Klitzner, 2002; Bardach et al., 2004). The literature also supports the benefits of regionalization for severely injured patients in improving patient outcomes and lowering costs (Jurkovich and Mock, 1999; Mann et al., 1999; Mullins and Mann, 1999; Chiara and Cimbanassi, 2003; Bravata et al., 2004; MacKenzie et al., 2006), although the evidence in this regard is not uniformly positive (Glance et al., 2004). MacKenzie and colleagues (2006) have provided the strongest evidence to date for the benefits of such regionalized trauma systems. In their study, mortality among patients receiving trauma center and comparable non–trauma center care in 14 states was compared after adjustment for differences in case mix. Mortality among patients with serious injuries was significantly lower at trauma centers. Other studies have likewise documented the value of regionalized trauma systems in improving outcomes and reducing mortality from traumatic injury (Jurkovich and Mock, 1999; MacKenzie, 1999; Mullins, 1999; Nathens et al., 2000). Organized trauma systems have also been shown to add value in facilitating performance measurement and promoting research. Formal protocols within a region for prehospital and hospital care contribute to improved patient outcomes as well (Bravata et al., 2004). While regionalization to distribute trauma services to high-volume centers is optimal when feasible in terms of transport, Nathens and Maier (2001) argued for an inclusive trauma system in which smaller facilities have been verified and designated as lower-level trauma centers. They suggested that care may be substantially better in such facilities than in those outside the system, and comparable to national norms (Nathens and Maier, 2001). An inclusive trauma system addresses the needs of all injured patients across

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Hospital-Based Emergency Care: At the Breaking Point the entire continuum of care and utilizes the resources of all committed and qualified personnel and facilities, with the goal of ensuring that every injured patient is triaged expeditiously to a level of care commensurate with his or her injuries. Research has demonstrated a number of additional benefits of regionalization. Regionalizing inventories (pooling supplies at regional warehouses) has been shown to reduce inventories, improve the capacity to serve the target population, and save money. Regionalization may also be a cost-effective strategy for developing and training teams of response personnel. Regionalization benefits outbreak investigations, security management, and emergency management as well. Both the Health Resources and Services Administration (HRSA) and CDC have made regional planning a condition for preparedness funding (GAO, 2003a). Concerns About Regionalization Not all aspects of regionalization are positive. If not properly implemented, regionalizing key clinical services may adversely impact their overall availability in a community. For example, regional allocation of patients with suspected acute myocardial infarction could result in the closure of a cardiac unit or even an entire hospital, particularly in rural areas. The survival of small rural facilities may require identification and treatment of those illnesses and injuries that do not require the capacities and capabilities of larger facilities, as well as repatriation to the local facility for long-term care and follow-up after stabilization at the tertiary center. A systems approach to regionalization considers the full effects of regionalizing services on a community. Determining the appropriate metrics for this type of analysis and defining the process for applying them within each region are significant research and practical issues. Nonetheless, in the absence of rigorous evidence to guide the process, planning authorities should take these factors into account in developing regionalized systems of emergency care. The committee believes communities will best be served by emergency care systems in which services are organized so as to provide the optimal care based on the patient’s location and condition. To the extent that the movement toward specialty hospitals impacts the configuration of services and therefore the ability of the system to optimize emergency services, it is an appropriate subject for the committee to address. While the committee does not advocate for or against the further development of specialty hospitals, it does believe that their development would potentially impact emergency care and that this impact, which in some cases could be adverse, should be considered in the regionalization of emergency care. Specialty hospitals that do not provide emergency care can drain financial resources from those that do (GAO, 2003b; Dummit, 2005). Also, specialty hospitals present an

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Hospital-Based Emergency Care: At the Breaking Point attractive option for some specialists, potentially luring them away from the medical staffs of general hospitals. In such cases, general hospitals may be forced to subsidize specialists, or recruit new ones, to remain compliant with the Emergency Medical Treatment and Active Labor Act (EMTALA) (Asplin and Knopp, 2001; Iglehart, 2005; Johnson et al., 2001). Specialty hospitals may also siphon commercially insured patients away from general hospitals while retaining the option of sending their sickest patients to the nearest general hospital ED. Despite these problems, the movement toward specialty hospitals is gathering strength. The number of ambulatory surgery centers increased by about 6 percent per year between 1997 and 2003, to a total of 3,735 recorded nationally in 2003; the number of specialty hospitals increased by approximately 20 percent per year between 1997 and 2003, to a total of 113 in 2003 (Iglehart, 2005). In December 2003, Congress declared an 18-month moratorium on the development of new specialty hospitals partly owned by physicians who refer their patients to those facilities. Federal agencies were directed to study these facilities and recommend an extension of the moratorium or a new policy. The moratorium expired in 2005, but the Centers for Medicare and Medicaid Services (CMS) is studying how to revise its payment rates and procedures for approving specialty hospitals. Configuration of Services The design of the emergency care system envisioned by the committee bears similarities to the inclusive trauma system concept originally conceived and first proposed and developed by CDC, and adapted and disseminated by the American College of Surgeons. Under this approach, every hospital in the community can play a role in the trauma system by undergoing verification and designation as a level I to level IV/V trauma center, based on its capabilities. Trauma care is optimized in the region through protocols and transfer agreements that are designed to direct trauma patients to the most appropriate level of care available given the type of injury and relative travel times to each center. The committee’s vision expands this concept beyond trauma care to include all serious illnesses and injuries, and extends beyond hospitals to include the entire continuum of emergency care—including 9-1-1 and dispatch and prehospital EMS, as well as clinics and urgent care providers. In this model, every provider organization can potentially play a role in providing emergency care services according to its capabilities. Provider organizations undergo a process by which their capabilities are identified and categorized in a manner not unlike trauma verification and designation, which results in a complete inventory of emergency care provider organizations within a community. Initially, this categorization may simply be based on the ex-

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Hospital-Based Emergency Care: At the Breaking Point istence of a service—for example, capacity to achieve cardiac reperfusion or perform emergency neurosurgery. Over time, the categorization process may evolve to include more detailed information, such as the times specific emergency procedures are available; the arrangements for on-call specialty care; service-specific outcomes; or general emergency service indicators, such as time to treatment, frequency of diversion, and ED boarding. Prehospital EMS services are similarly categorized according to ambulance capacity; availability; credentials of EMS providers; advanced life support (ALS) and pediatric advanced life support (PALS); treat and release and search and rescue capabilities; disaster readiness (e.g., extrication capability and personal protective equipment); and outcomes for sentinel indicators, such as out-of-hospital cardiac arrest. A standard national approach to the categorization of emergency care providers is needed. Categories should reflect meaningful differences in the types of emergency care available, yet be simple enough to be understood easily by emergency care organizations and the public at large. The use of national definitions would ensure that the categories would be understood by providers and by the public across states or regions of the country, and would also promote benchmarking of performance. The committee concludes that a standard national approach to the categorization of emergency care, defined in the broadest possible sense, is essential for the optimal allocation of resources and provision of critical information to an informed public. Therefore the committee recommends that the Department of Health and Human Services and the National Highway Traffic Safety Administration, in partnership with professional organizations, convene a panel of individuals with multidisciplinary expertise to develop evidence-based categorization systems for emergency medical services, emergency departments, and trauma centers based on adult and pediatric service capabilities (3.1). The results of this process would be a complete inventory of emergency care assets for each community, which should be updated regularly to reflect the rapid changes in delivery systems nationwide. The development of the initial categorization system should be completed within 18 months of the release of this report. Treatment, Triage, and Transport Once the basic classification system proposed above is understood, it can be used to determine the optimal destination for patients based on their condition and location. However, more research and discussion are needed to determine the circumstances under which patients should be brought to the closest hospital for stabilization and transfer as opposed to being transported directly to the facility offering the highest level of care, even if that facility is farther away. A debate remains over whether EMS providers

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Hospital-Based Emergency Care: At the Breaking Point should perform ALS procedures in the field, or rapid transport to definitive care is best (Wright and Klein, 2001). It is likely that this answer depends, at least in part, on the type of emergency condition. It is evident, for example, that whether a patient will survive out-of-hospital cardiac arrest depends almost entirely on actions taken at the scene, including rapid defibrillation, provision of cardiopulmonary resuscitation (CPR), and perhaps other ALS interventions. Delaying these actions until the unit reaches a hospital results in dismal rates of survival and poor neurological outcomes. Conversely, there is little that prehospital personnel can do to stop internal bleeding from major trauma. In this instance, rapid transport to definitive care in an operating room offers the victim the best odds of survival. For example, a recent study showed that bypassing a level II trauma center in favor of a more distant level I trauma center may be optimal for head trauma patients (McConnell et al., 2005). EMS responders who provide stabilization before the patient arrives at a critical care unit are sometimes subject to criticism because of a strongly held bias among many physicians that out-of-hospital stabilization only delays definitive treatment without adding value; however, there is little evidence that the prevailing “scoop and run” paradigm of EMS is always optimal (Orr et al., 2006). For example, in cases of out-of-hospital cardiac arrest, properly trained and equipped EMS personnel can provide all needed interventions at the scene. In fact, research has shown that failure to reestablish a pulse on the scene virtually ensures that the patient will not survive, regardless of what is done at the hospital (Kellermann et al., 1993). On the other hand, a scoop and run approach makes sense when a critical intervention needed by the patient can be provided only at the hospital (for example, surgery to control internal bleeding). Decisions regarding the appropriate steps to take should be resolved using the best available evidence. The committee concludes that there should be a national approach to the development of prehospital protocols. It therefore recommends that the National Highway Traffic Safety Administration, in partnership with professional organizations, convene a panel of individuals with multidisciplinary expertise to develop evidence-based model prehospital care protocols for the treatment, triage, and transport of patients (3.2). The transport protocols should also reflect the state of readiness of given facilities within a region at a particular point in time. Real-time, concurrent information on the availability of hospital resources and specialists should be made available to EMS providers to support transport decisions. Development of an initial set of model protocols should be completed within 18 months of the release of this report. Treatments may require modification to reflect local resources, capabilities, and transport times; however, the basic pathophysiology of human illness is the same in all areas of the country. Once in place, the national protocols could be

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Hospital-Based Emergency Care: At the Breaking Point A lead federal agency could better move the emergency and trauma care system toward improved integration; unify funding and other decisions; and represent all emergency and trauma care patients, providers, and settings, including prehospital EMS (both ground and air), hospital-based emergency and trauma care, pediatric emergency and trauma care, rural emergency and trauma care, and medical disaster preparedness. Specifically, a federal lead agency could: Provide consistent federal leadership on policy issues that cut cross agency boundaries. Create unified accountability for the performance of the emergency and trauma care system. Rationalize funding across the various aspects of emergency and trauma care to optimize the allocation of resources in achieving system outcomes. Coordinate programs to eliminate overlaps and gaps in current and future funding. Create a large combined federal presence, increasing the visibility of emergency and trauma care within the government and among the public. Provide a recognizable entity that would serve as a single point of contact for stakeholders and the public, resulting in consolidated and efficient data collection and dissemination and coordinated program information. Enhance the professional identity and stature of emergency and trauma care practitioners. Bring together multiple professional groups and cultures, creating cross-cultural and interdisciplinary interaction and collaboration that would model and reinforce the integration of services envisioned by the committee. Although creating a lead agency could yield many benefits, such a move would also involve significant challenges. Numerous questions would have to be addressed regarding the location of such an agency in the federal government, its structure and functions, and the possible risk of weakening or losing current programs. HRSA’s rural EMS and EMS/Trauma Systems programs have already been defunded, and the EMS-C program is under the constant threat of elimination. There is real concern that proposing an expensive and uncertain agency consolidation could jeopardize programs already at risk, such as EMS-C, as well as cripple new programs that are just getting started, such as NHTSA’s enhanced 9-1-1 program. This is particularly likely if there is resistance to the consolidation from within the current agency homes for these programs. A related concern is that the priority currently given to certain programs

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Hospital-Based Emergency Care: At the Breaking Point could shift, resulting in less support for existing programs. EMS advocates have expressed concern that hospital-based emergency and trauma care issues would dominate the agenda of a new unified agency. The pediatric community is worried about getting lost in a new agency, and has fought hard to establish and maintain strong categorical programs supported by historically steady funding streams. There is concern that under the proposed new structure, the current focus of the EMS-C program could get lost or diminished, or simply lose visibility in the multitude of programs addressed by the new agency. There is also the potential for administrative and funding disruptions. Combining similar agencies, particularly those that reside within the same department, may be straightforward. But combining agencies with different missions across departments with different cultures could prove highly difficult. The problems that were experienced during the consolidation of programs in DHS increase anxiety about this proposal. Another concern is that removing medical-related functions from DHS and DOT could exacerbate rather than reduce fragmentation. Operationally, nearly half of EMS services are fire department–based. Thus, there is concern that separating EMS and fire responsibilities at the federal level could splinter rather than strengthen relationships. The Committee’s Recommendation Despite the concerns outlined above, the committee believes the potential benefits of consolidation outweigh the potential risks. A lead federal agency is required to fully realize the committee’s vision of a coordinated, regionalized, and accountable emergency and trauma care system. The committee recognizes that a number of challenges are associated with the establishment of a new lead agency, though it believes these concerns can be mitigated through appropriate planning. The committee therefore recommends that Congress establish a lead agency for emergency and trauma care within 2 years of this report. The lead agency should be housed in the Department of Health and Human Services, and should have primary programmatic responsibility for the full continuum of emergency medical services and emergency and trauma care for adults and children, including medical 9-1-1 and emergency medical dispatch, prehospital emergency medical services (both ground and air), hospital-based emergency and trauma care, and medical-related disaster preparedness. Congress should establish a working group to make recommendations regarding the structure, funding, and responsibilities of the new agency, and develop and monitor the transition. The working group should have representation from federal and state agencies and professional disciplines involved in emergency and trauma care (3.6).

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Hospital-Based Emergency Care: At the Breaking Point Objectives of the Lead Agency The lead agency’s mission would be to enhance the performance of the emergency and trauma care system as a whole, as well as to improve the performance of the various components of the system, such as prehospital EMS, hospital-based emergency care, trauma systems, pediatric emergency and trauma care, prevention, rural emergency and trauma care, and disaster preparedness. The lead agency would set the overall direction for emergency and trauma care planning and funding; would be the primary collector and repository of data in the field; and would be the key source of information about emergency and trauma care for the public, the federal government, and practitioners themselves. It would be responsible for allocating federal resources across all of emergency and trauma care to achieve systemwide goals, and should be held accountable for the performance of the system and its components. Location of the Lead Agency The lead agency would be housed within DHHS. The committee considered many factors in selecting DHHS over DOT and DHS. The factor that drove this decision above all others was the need to unify emergency and trauma care within a public health/medical care framework. Emergency and trauma care is by its very nature involved in multiple arenas—medical care, public safety, public health, and emergency management. The multiple identities that result from this multifaceted involvement reinforce the fragmentation that is endemic to the emergency and trauma care system. For too long, the gulf between EMS and hospital care has hindered efforts at communication, continuity of care, patient safety and quality of care, data collection and sharing, collaborative research, performance measurement, and accountability. It will be difficult for emergency and trauma care to achieve seamless and high-quality performance across the system until the entire system is organized within a medical/public health framework while also retaining its operational linkages with public safety and emergency management. Only DHHS, as the department responsible for medical care and public health in the United States, can encompass all of these functions effectively. Although DOT has played an important role in both EMS and acute trauma care and has collaborated effectively with other agencies, its EMS and highway safety focus is too narrow to represent all of emergency and trauma care. DHS houses the Fire Service, which is closely allied with EMS, particularly at the field operations level. But the focus of DHS on disaster preparedness and bioterrorism is also too narrow to encompass the broad scope of emergency and trauma care.

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Hospital-Based Emergency Care: At the Breaking Point Because emergency and trauma care functions would be consolidated in a department oriented toward public health and medical care, there is a risk that public safety and emergency management components could receive less attention, stature, or funding. Therefore, the committee considers it imperative that the mission of the new agency be understood and clearly established by statute so that the public safety and emergency management aspects of emergency and trauma care will not be neglected. Programs Included Under the Lead Agency The committee envisions that the lead agency would have primary programmatic responsibility for the full continuum of EMS; emergency and trauma care for adults and children, including medical 9-1-1 and emergency medical dispatch; prehospital EMS (both ground and air); hospital-based emergency and trauma care; and medical-related disaster preparedness. The agency’s focus would be on program development and strategic funding to improve the delivery of emergency and trauma care nationwide. It would not be primarily a research funding agency, with the exception of existing grant programs mentioned above. Funding for basic, clinical, and health services research in emergency and trauma care would remain the primary responsibility of existing research agencies, including the National Institutes of Health (NIH), AHRQ, and CDC. Because of the limited research focus of the lead agency, it would be important for existing research agencies, NIH in particular, to work closely with the new agency and strengthen their commitment to emergency and trauma care research. On the other hand, it may be appropriate to keep certain clinical and health services research initiatives with the programs in which they are housed, and therefore bring them into the new agency. For example, the Pediatric Emergency Care Applied Research Network could be moved into the new agency along with the rest of the EMS-C program. In addition to existing functions, the lead agency would become the home for future programs related to emergency and trauma care, including new programs that would be dedicated to the development of inclusive systems of emergency and trauma care. Working Group While the committee envisions consolidation of most of the emergency care–related functions currently residing in other agencies and departments, it recognizes that many complex issues are involved in determining which programs should be combined and which left in their current agency homes. A deliberate process would be established to determine the exact composition of the new agency and to coordinate an effective transition.

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Hospital-Based Emergency Care: At the Breaking Point For these reasons, the committee is recommending the establishment of an independent working group to make recommendations regarding the structure, funding, and responsibilities of the new agency and to coordinate and monitor the transition process. The working group would include representatives from federal and state agencies and professional disciplines involved in emergency care. The committee considered whether FICEMS would be an appropriate entity to assume this advisory and oversight role and concluded that, as currently constituted, it lacks the scope and independence to carry out this role effectively. Role of FICEMS FICEMS is a highly promising entity that is complementary to the proposed new lead agency. FICEMS would play a vital role during the proposed interim 2-year period by continuing to enhance coordination and collaboration among agencies and providing a forum for public input. In addition, it could play an important advisory role to the independent working group. Once the lead agency had been established, FICEMS would continue to coordinate work between the lead agency and other agencies, such as NIH, CMS, and DoD, that would remain closely involved in various emergency and trauma care issues. Structure of the Lead Agency While the principle of integration across the multiple components of emergency and trauma care should drive the structure, operation, and funding of the new lead agency, the committee envisions distinct program offices to provide focused attention and programmatic funding for key areas, such as the following: Prehospital EMS, including 9-1-1, dispatch, and both ground and air medical services Hospital-based emergency and trauma care Trauma systems Pediatric emergency and trauma care Rural emergency and trauma care Disaster preparedness To ensure that current programs would not lose visibility and stature within the new agency, each program office should have equal status and reporting relationships within the agency’s organizational structure. The committee envisions a national dialogue over the coming year—coordinated by the proposed independent working group, aided by input from FICEMS,

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Hospital-Based Emergency Care: At the Breaking Point and with the involvement of the Office of Management and Budget and congressional committees with jurisdiction—to specify the organizational structure in further detail and implement the committee’s recommendation. Funding for the Lead Agency Existing programs transferring to the new agency would bring with them their full current and projected funding, although this may not be possible for some funds, such as the Highway Trust Funds, which contribute to the operational funding for the Office of EMS. Congress should also establish additional funding to cover the costs of the transition to the lead agency and associated administrative overhead. In addition, Congress should add new funding for the offices of hospital-based emergency and trauma care, rural emergency and trauma care, and trauma systems. In light of the pressing challenges confronting emergency care providers and the American public, this would be money well spent. While the committee is unable to estimate the costs associated with establishing a unified lead agency, it recognizes that those costs would be substantial. At the same time, however, the committee believes that countervailing cost savings would result from reduced duplication and lower overhead. Consequently, new funding that flowed into the agency would result in new programming, rather than an increase in existing overhead. Mitigation of Concerns Regarding the Establishment of a Lead Federal Agency The committee recognizes that transitioning to a single lead agency would be a difficult challenge under any circumstances, but would be especially difficult for an emergency and trauma care system that is already under duress from funding cutbacks, elimination of programs, growing public demand on the system, and pressure to enhance disaster preparedness. During this critical period, it is important that support for emergency and trauma care programs already in place in the various federal agencies be sustained. In particular, the Office of EMS within NHTSA has ongoing programs that are critical to the EMS system. Similarly, existing emergency care–related federal programs, such as those in HRSA’s EMS-C program and Office of Rural Health Policy and at CDC, should be supported during the transition period. If the committee’s proposal is to be successful, the constituencies associated with established programs must not perceive that they are being politically weakened during the transition. The committee believes the proposed consolidation of agencies would enhance support for emergency and trauma care across the board, benefiting all current programs. But it also believes avoiding disruptions that could

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Hospital-Based Emergency Care: At the Breaking Point adversely affect established programs is critically important. Therefore, the committee believes legislation creating the new agency should protect current levels of funding and visibility for existing programs. The new agency should balance its funding priorities by adding to existing funding levels, not by diverting funds away from existing programs. The committee acknowledges the concern that removing medical-related emergency and trauma functions from DHS and DOT would create additional fragmentation. The committee believes the public safety aspects of emergency and trauma care must continue to be addressed as a core element of the emergency and trauma care system. But the primary focus of the system should be medical care and public health if the recognition, stature, and outcomes that are critical to the system’s success are to be achieved. SUMMARY OF RECOMMENDATIONS 3.1: The Department of Health and Human Services and the National Highway Traffic Safety Administration, in partnership with professional organizations, should convene a panel of individuals with multidisciplinary expertise to develop evidence-based categorization systems for emergency medical services, emergency departments, and trauma centers based on adult and pediatric service capabilities. 3.2: The National Highway Traffic Safety Administration, in partnership with professional organizations, should convene a panel of individuals with multidisciplinary expertise to develop evidence-based model prehospital care protocols for the treatment, triage, and transport of patients. 3.3: The Department of Health and Human Services should convene a panel of individuals with emergency and trauma care expertise to develop evidence-based indicators of emergency and trauma care system performance. 3.4: The Department of Health and Human Services should adopt regulatory changes to the Emergency Medical Treatment and Active Labor Act and the Health Insurance Portability and Accountability Act so that the original goals of the laws will be preserved, but integrated systems can be further developed. 3.5: Congress should establish a demonstration program, administered by the Health Resources and Services Administration, to promote coordinated, regionalized, and accountable emergency

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Hospital-Based Emergency Care: At the Breaking Point care systems throughout the country, and appropriate $88 million over 5 years to this program. 3.6: Congress should establish a lead agency for emergency and trauma care within 2 years of this report. The lead agency should be housed in the Department of Health and Human Services, and should have primary programmatic responsibility for the full continuum of emergency medical services and emergency and trauma care for adults and children, including medical 9-1-1 and emergency medical dispatch, prehospital emergency medical services (both ground and air), hospital-based emergency and trauma care, and medical-related disaster preparedness. Congress should establish a working group to make recommendations regarding the structure, funding, and responsibilities of the new agency, and develop and monitor the transition. The working group should have representation from federal and state agencies and professional disciplines involved in emergency and trauma care. REFERENCES AHA (American Heart Association). 2005. Sudden Cardiac Death: AHA Scientific Position. [Online]. Available: http://www.americanheart.org/presenter.jhtml?identifier=4741 [accessed February 15, 2006]. Asplin BR, Knopp RK. 2001. A room with a view: On-call specialist panels and other health policy challenges in the emergency department. Annals of Emergency Medicine 37(5):500–503. Bardach NS, Olson SJ, Elkins JS, Smith WS, Lawton MT, Johnston SC. 2004. Regionalization of treatment for subarachnoid hemorrhage: A cost-utility analysis. Circulation 109(18):2207–2212. Berenson RA, Kuo S, May JH. 2003. Medical malpractice liability crisis meets markets: Stress in unexpected places. Issue Brief (Center for Studying Health System Change) (68):1–7. Bravata DM, McDonald K, Owens DK. 2004. Regionalization of Bioterrorism Preparedness and Response. Rockville, MD: Agency for Healthcare Research and Quality. CDC (Centers for Disease Control and Prevention) National Center for Injury Control and Prevention. 2001. Web-based Injury Statistics Query and Reporting System (WISQARS). [Online]. Available: http://www.cdc.gov/ncipc/wisqars/ [accessed September 2004]. Chang RK, Klitzner TS. 2002. Can regionalization decrease the number of deaths for children who undergo cardiac surgery? A theoretical analysis. Pediatrics 109(2):173–181. Chiara O, Cimbanassi S. 2003. Organized trauma care: Does volume matter and do trauma centers save lives? Current Opinion in Critical Care 9(6):510–514. CMS (Centers for Medicare and Medicaid Services). 2005a. Report Number One to the Secretary, U.S. Department of Health and Human Services, from the Inaugural Meeting of the Emergency Medical Treatment and Labor Act Technical Advisory Group. Washington, DC: CMS. CMS. 2005b. Report Number Two to the Secretary, U.S. Department of Health and Human Services, from the Emergency Medical Treatment and Labor Act Technical Advisory Group. Washington, DC: CMS.

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