3
Building a 21st-Century Emergency and Trauma Care System

While today’s emergency and trauma 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 (Davis, 2003). To address these challenges and chart a new direction for emergency and trauma care, the committee envisions a system in which all communities will be served by well-planned and highly coordinated emergency and trauma care systems 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, emergency medical services (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 actively engaged in its operation through prevention, bystander training, and monitoring of system performance.

While these objectives will require substantial, systemwide change, they



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Emergency Medical Services at the Crossroads 3 Building a 21st-Century Emergency and Trauma Care System While today’s emergency and trauma 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 (Davis, 2003). To address these challenges and chart a new direction for emergency and trauma care, the committee envisions a system in which all communities will be served by well-planned and highly coordinated emergency and trauma care systems 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, emergency medical services (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 actively engaged in its operation through prevention, bystander training, and monitoring of system performance. While these objectives will require substantial, systemwide change, they

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Emergency Medical Services at the Crossroads are achievable. Early progress toward the goal of more integrated, coordinated, and regionalized emergency and trauma care systems became derailed over the last two decades (see Chapter 2). 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 problems are becoming more apparent, and this provides a catalyst for change. The committee calls for concerted, cooperative efforts at multiple levels of government and the private sector to finally break through and achieve these goals. This chapter describes the committee’s vision for a 21st-century emergency and trauma 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. The chapter then profiles current approaches of states and local regions that exhibit these features. Finally, the chapter 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 and trauma care system. IMPROVING COORDINATION Today’s emergency and trauma care system suffers from fragmentation along a number of different dimensions. As described in Chapter 2, EMS occupies a space that overlaps three major silos: health care, public health, and public safety. In most cases, these three systems are not aligned, and their means of communicating or coordinating with one another are highly limited. Within health care, there is considerable fragmentation along a number of dimensions relating to EMS. For example, coordination among 9-1-1 dispatch, prehospital EMS, air medical providers, and hospital and trauma centers is often lacking (NHTSA, 1996). EMS personnel arriving at the scene of an incident often do not know what to expect regarding the number of injured or their condition (McGinnis, 2005). They also are frequently unaware of which hospitals are on diversion status and which are ready to receive the type of patient they are transporting. Lack of coordination between EMS and hospitals can result in delays that compromise care. In addition, deployment of air medical services is often not well coordinated. While air medical providers are not permitted to self-dispatch, a lack of coordination at the ground EMS and dispatch level sometimes results in multiple air ambulances arriving at the scene of a crash even when all are not needed. Similarly, police, fire, and EMS personnel and equipment often overcrowd a crash scene because of insufficient coordination regarding the appropriate response.

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Emergency Medical Services at the Crossroads In addition, in many communities there is little interaction between emergency care services and community safety net providers, even though the two 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 compliance, and enhanced quality of care and patient satisfaction. Coordination between EMS and public health agencies could also be improved. Through their regular activities, EMS providers have information that could serve as a barometer for both illness and injury trends within the community, potentially assisting state and local public health departments. However, communication links between these agencies are often not well established. Moreover, although prevention activities are generally limited in the emergency care setting, utilization of emergency services represents an important opportunity for imparting information on injury prevention to patients. Emergency care providers could benefit from the resources and experiences of public health agencies and experts in establishing injury prevention activities. Finally, perhaps now more than ever, with the threat of bioterrorism and outbreaks of diseases such as avian influenza, 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. Emergency responders 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 partnership that allows for improved communication of information between emergency care providers and public health officials must first be in place. Movement Toward Greater Coordination The value of integrating and coordinating emergency and trauma care has long been recognized. For example, the 1966 National Academy of Sciences/National Research Council (NAS/NRC) report Accidental Death and Disability: The Neglected Disease of Modern Society called for better coordination of emergency and trauma care through community councils on emergency medical services, which 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). Although the drive toward system development waned when federal funding of EMS was folded into state block grants in 1981, the goal of system planning and coordination has remained paramount within the emergency and trauma care community. In 1996, the National Highway Traffic

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Emergency Medical Services at the Crossroads Safety Administration’s (NHTSA) 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 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) While the concept of a highly integrated emergency and trauma care system as articulated by NHTSA was not new, progress toward its realization has been slow. Nevertheless, there have been important successes in the coordination of emergency and trauma care services that point the way toward solutions to the problem of fragmentation. The most important example of such successes is the trauma system, which has developed a comprehensive and coordinated approach to the care of injured patients. Children’s hospitals have been successful in effecting regional coordination to ensure transport and appropriate care for children with specialized needs. The pediatric intensive care system is a leading example of regional coordination among hospitals, community physicians, and EMS providers (Gausche-Hill and Wiebe, 2001). These examples demonstrate the possibilities for enhanced coordination across the system as a whole. Importance of Communication Communication is critical to establishing systemwide coordination. An effective communications system is the glue that can hold together effective, integrated emergency and trauma 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 dispatchers to offer prearrival instructions to callers requesting an ambulance. An effective communications system also enables ambulance dispatchers to assist EMS personnel in directing patients to the most appropriate facilities based on the nature of their injuries and the facilities’ fluctuating capacity. Good communication is necessary to link EMS personnel with other public safety providers, such as police, fire and emergency management,

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Emergency Medical Services at the Crossroads and public health, and can facilitate coordination and incident command in disaster situations. Effective communication also facilitates medical and operational oversight and quality control within the system. In Chapter 5, the committee stresses the importance of fully integrated communications systems to link EMS with hospital, public safety, public health, and emergency management personnel. SUPPORTING REGIONALIZATION The objective of regionalization is to improve patient outcomes by directing patients to facilities with experience in and 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 of treatment for severely injured trauma patients in improving patient outcomes of care, reducing mortality from traumatic injury, and lowering costs (Jurkovich and Mock, 1999; MacKenzie, 1999; Mann et al., 1999; Mullins, 1999; Mullins and Mann, 1999; Nathens et al., 2000; Chiara and Cimbanassi, 2003; Bravata et al., 2004; MacKenzie et al., 2006), although the evidence here is not uniformly positive (Glance et al., 2004). Formal protocols within a region for prehospital and hospital care contribute to improved patient outcomes as well (Bravata et al., 2004). In addition, organized trauma systems have been shown to add value in facilitating performance measurement and promoting research. While regionalization of trauma services to high-volume centers is optimal when feasible, 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 the quality of care may be substantially better in such facilities than in those outside the system, and comparable to national norms. Inclusive trauma systems are designed to cover the entire continuum of care of the injured patient, from the site of injury through acute care and, when appropriate, rehabilitation. Such a system requires the committed involvement of all qualified medical facilities in the region. An efficient triage system, coupled with established transfer agreements, is required to ensure that patients receive the right care in the right place at the right time. In addition, all facilities caring for injured patients must be evaluated for standards of care and must contribute at least a minimal dataset to support systemwide quality/performance improvement programs. Regionalization may also be a cost-effective strategy for developing and training teams of response personnel. Regionalization benefits triage,

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Emergency Medical Services at the Crossroads medical care, outbreak investigations, security management, and emergency management. Indeed, both the Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC) have made regional planning a condition for preparedness funding (GAO, 2003a). Concerns About Regionalization The case for regionalization of emergency services is strong, but not absolute. Regionalization can adversely impact the overall availability of clinical services in a community if directing a large number of patients to a regional program leads to elimination of needed services at other facilities. For example, the loss of a profitable set of patients, such as those with suspected acute myocardial infarction (AMI), could result in the closure of a smaller hospital’s cardiac unit or even the entire hospital. The survival of small rural facilities may require the identification and treatment of patients who do not require the capacities and capabilities of larger facilities, as well as repatriation to a local facility for long-term care and follow-up after stabilization at a tertiary center. It is important to take a systems approach that considers the full effects of regionalization on a community. Determining the appropriate metrics for this type of analysis and defining the process for applying those metrics within each region raise significant research and practical issues. Nonetheless, in the absence of rigorous evidence to guide the process, planning authorities should take the above factors into account in developing regionalized systems of emergency and trauma care. Also, the committee is wary of regionalization that results in directing patients to specialty hospitals that do not provide comprehensive emergency services, as these facilities can drain financial resources from those hospitals that do provide such care (GAO, 2003b; Dummit, 2005). Configuration of Services The design of the emergency and trauma care system envisioned by the committee bears similarities to the inclusive trauma system originally conceived and first proposed and developed by CDC, and adapted and disseminated by the American College of Surgeons (ACS). Under this approach, every hospital in a community can play a role in the trauma system by undergoing state 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. In addition to trauma center verification, ACS, along with the American

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Emergency Medical Services at the Crossroads College of Emergency Physicians (ACEP), state EMS directors, NHTSA, HRSA, trauma nurses, and others, has developed the nascent Trauma Systems Consultation program. Under this program, on-site consultation is provided when requested by the lead agency of a region. The consultation is performed by a multidisciplinary team, which evaluates all components of the system and offers specific recommendations for raising the system to the next level, regardless of how embryonic or mature the system may be. An important feature of these consultations is that they cover the entire continuum of care. A number of regions have sought and received such a consultation. The committee’s vision expands the concept of an inclusive trauma system to encompass all illnesses and injuries, as well as the entire continuum of emergency care—including 9-1-1 dispatch, prehospital EMS, and clinics and urgent care providers that may take part in emergency care. All providers can play a role in supplying emergency care in their community according to their capabilities. Under the committee’s vision, providers would undergo a process by which their capabilities would be identified and categorized in a manner not unlike trauma verification and designation; the result would be a complete inventory of emergency and trauma care providers within a community. Initially, this categorization might simply be based on the existence of a service—for example, the availability of a cardiac catheterization laboratory or coverage by a neurosurgeon. Eventually, the categorization process might evolve to include more detailed information—for example, the availability of specific emergency procedures and on-call specialty care and indicators of quality, including both service-specific outcomes and general indicators, such as time to treatment, frequency of diversion, and ED boarding. Prehospital EMS could be similarly categorized according to ambulance capacity, availability, credentials of EMS personnel, advanced life support (ALS) and pediatric ALS, treat and release and search and rescue capabilities, disaster readiness (e.g., personal protective equipment), and outcomes (e.g., survival rate from witnessed cardiac arrest due to ventricular fibrillation). A standard national approach to the categorization of emergency and trauma care providers is needed. Categories should reflect meaningful differences in the types of emergency and trauma care available, yet be simple enough to be understood easily by the provider community and the public. 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 promote benchmarking of performance. 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

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Emergency Medical Services at the Crossroads 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 and trauma 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 understood, the basic classification system proposed above could 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. Debate continues over whether EMS personnel should perform ALS procedures in the field, or rapid transport to definitive care is best (Wright and Klein, 2001). The answer to this question likely 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. EMS responders who provide stabilization before the patient arrives at a critical care unit are sometimes subject to criticism because of a strongly held belief 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). 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, the scoop and run approach makes sense when a critical intervention needed by the patient can be provided only at the hospital. Decisions regarding the appropriate steps to take should be resolved using the best available evidence. Therefore, the committee recommends that the National Highway Traffic Safety Administration, in partnership

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Emergency Medical Services at the Crossroads 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 furnished to EMS personnel to support transport decisions. Development of an initial set of model protocols should be completed within 18 months of the release of this report. These protocols would facilitate much more uniform treatment of injuries and illnesses nationwide so that all patients would receive the current standard of care at the most appropriate location. The protocols might require modification to reflect local resources, capabilities, and transport times; however, they would acknowledge the fact that the basic pathophysiology of human illness is the same in all areas of the country. Once in place, the national protocols could be tailored to local assets and needs. The process for updating the protocols will also be important because it will dictate how rapidly patients will receive the current standard of care. The 1966 NAS/NRC report Accidental Death and Disability anticipated the need to categorize care facilities and improve transport decisions: The patient must be transported to the emergency department best prepared for his particular problem…. Hospital emergency departments should be surveyed … to determine the numbers and types of emergency facilities necessary to provide optimal emergency treatment for the occupants of each region…. Once the required numbers and types of treatment facilities have been determined, it may be necessary to lessen the requirements at some institutions, increase them in others, and even redistribute resources to support space, equipment, and personnel in the major emergency facilities. Until patient, ambulance driver, and hospital staff are in accord as to what the patient might reasonably expect and what the staff of an emergency facility can logically be expected to administer, and until effective transportation and adequate communication are provided to deliver casualties to proper facilities, our present levels of knowledge cannot be applied to optimal care and little reduction in mortality and/or lasting disability can be expected. (NAS and NRC, 1966, p. 20) These views were echoed in the 1993 Institute of Medicine (IOM) report Emergency Medical Services for Children, which stated that “categorization and regionalization are essential for full and effective operation of systems” (IOM, 1993, p. 171). Once the decision has been made to transport a patient, the responding ambulance unit should be instructed—either by written protocol or by on-line medical direction—which hospital should receive the patient (see Figure 3-1). This instruction should be based on developed transport

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Emergency Medical Services at the Crossroads FIGURE 3-1 Service configuration in a regionalized system. The figure illustrates some potential transport options within a regionalized system. The basic structure of current EMS systems is not altered, but protocols are refined to ensure that patients go to the optimal facility given their type of illness or injury, the travel time involved, and facility status (e.g., availability of ED and intensive care unit [ICU] beds). For example, instead of taking a stroke victim to the closest general community hospital or to a tertiary medical center that is farther away, there may be a third option—transport to a community hospital with a stroke center. Over time, based on evidence on the effectiveness of alternative delivery models, some patients may be transported to a nearby urgent care center for stabilization or treated on the street and released. Whichever pathway the patient follows, communications are enhanced, data collected, and the performance of the system evaluated and reported so that future improvements can be made.

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Emergency Medical Services at the Crossroads protocols to ensure that the patient is taken to the optimal facility given the severity and nature of the illness or injury, the status of the various care facilities, and the travel times involved. Ideally, this decision should take into account a number of complex and fluctuating factors, such as hospital ED closures and diversions and traffic congestion that hinders transport times for the EMS unit (The SAFECOM Project, 2004). In addition to using ambulance units and the EMS system to direct patients to the optimum location for emergency and trauma care, hospital emergency and trauma care designations should be posted prominently to improve patients’ self-triage decisions. Such postings can educate the public about the types of emergency services available in their community and enable patients who are not using EMS to direct themselves to the optimal facility. FOSTERING ACCOUNTABILITY Fostering accountability is perhaps the most important of the committee’s three goals because it is necessary to achieve the other two. Lack of accountability has contributed to the failure of the emergency and trauma care system to adopt needed changes in the past. Without accountability, participants in the system need not accept responsibility for their failures and can avoid making changes necessary to avoid them in the future. Accountability has failed to take hold in EMS systems because responsibility is dispersed across many different components of the system; thus it is difficult for policy makers to determine when a system breakdown occurs, much less where it is located or how it can be adequately addressed. EMS diversion is a good example. When a city recognizes it has an unacceptably high frequency of diversions, the locus of responsibility for the problem remains unclear. EMS can blame the ED for crowded conditions and excessively long off-loading times; EDs can blame their hospital for not transporting admitted patients to inpatient units promptly; hospitals can blame on-call specialists or the discharging physician, as well as long-term care facilities that are unwilling to take additional referrals; and all players in the system can blame the state public health department for inadequate funding of community-based alternatives or community physicians for failing to manage their patients adequately so as to keep them out of the ED. The unpredictable and infrequent nature of emergency and trauma care contributes to the lack of accountability. Most people have limited exposure to the emergency and trauma care system and consider it unlikely that they will ever require an ambulance transport. Consequently, public awareness of specific problem areas in the system is limited. In fact, however, Americans visit EDs more than 114 million times a year, and more than 16 million of these visits involve transport by ambulance (Burt et al., 2006).

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Emergency Medical Services at the Crossroads 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 medical care/public health 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 care/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. Because emergency and trauma care functions would be consolidated in a department oriented toward medical care and public health, there is a risk that public safety and emergency management components could receive less attention, stature, or funding. Therefore, the committee considers it important 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

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Emergency Medical Services at the Crossroads 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 should be established to determine the exact composition of the new agency and to coordinate an effective transition. 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

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Emergency Medical Services at the Crossroads 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 the Department of Defense (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, and with the involvement of the Office of Management and Budget and the 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 associated with the transition to and the new administrative overhead associated with the lead agency. In addition, Congress should add new funding for the offices of hospital-based

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Emergency Medical Services at the Crossroads 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 these 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 period. 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 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.

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Emergency Medical Services at the Crossroads Adapting the Legal and Regulatory Framework The way hospitals and EMS agencies deliver emergency care is shaped largely by federal and state laws—in particular, the Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986, the Health Insurance Portability and Accountability Act (HIPAA), and medical malpractice laws. The application of these laws to the actual provision of care is guided by sometimes baffling regulatory rules and advisories, enforcement decisions, and court decisions, as well as by providers’ understanding of the laws. EMTALA and HIPAA are discussed below. Emergency Medical Treatment and Active Labor Act of 1986 EMTALA was enacted to prevent hospitals from refusing to serve uninsured patients and “dumping” them on other hospitals. The act established a mandate for hospitals and physicians who provide emergency and trauma care to provide a medical screening exam to all patients and appropriately stabilize patients or transfer them to an appropriate facility if an emergency medical condition exists (GAO, 2001). EMTALA has implications for the regional coordination of care. The act was written to provide individual patient protections—it focuses on the obligations of an individual hospital to an individual patient (Rosenbaum and Kamoie, 2003). While it serves an important purpose, the statute is not clearly adaptable to a highly integrated regional emergency care system in which the optimal care of patients may diverge from conventional patterns of emergency treatment and transport. Until recently, EMTALA appeared to hinder the regional coordination of services in several specific ways—for example, requiring a hospital-owned ambulance to transport a patient to the parent hospital even if it is not the optimal destination for that patient, requiring a hospital to interrupt the transfer to administer a medical screening exam for a patient being transferred from ground transport to helicopter using the hospital’s helipad, and limiting the ability of hospitals to direct nonemergent patients who enter the ED to an appropriate and readily available ambulatory care setting or clinic. Interim guidance published by CMS in 2003 appeared to mitigate these problems (DHHS, 2003). This guidance established, for example, that a patient visiting an off-campus hospital site that does not normally provide emergency care does not create an EMTALA obligation, that a hospital-owned ambulance need not return the patient to the parent hospital if it is operating under the authority of a communitywide EMS protocol, and that hospitals are not obligated to provide treatment for clearly nonemergency situations as determined by qualified medical personnel. Further, hospitals involved in disasters need not adhere strictly to EMTALA if operating under a community disaster plan. Despite these changes, however, uncertainty sur-

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Emergency Medical Services at the Crossroads rounding the interpretation and enforcement of EMTALA remains a damper on the development of coordinated, integrated emergency care systems. In 2005, CMS convened a technical advisory group to study EMTALA and address additional needed changes (CMS, 2005a,b,c). To date, the advisory group has focused on incremental modifications to the act. While the recent CMS guidance and deliberations of the EMTALA advisory group are positive steps, the committee envisions a more fundamental rethinking of EMTALA that would support and facilitate the development of regionalized emergency systems, rather than simply addressing each obstacle on a piecemeal basis. The new EMTALA would continue to protect patients from discrimination in treatment while enabling and encouraging communities to test innovations in the design of emergency care systems, such as direct transport of patients to non–acute care facilities—dialysis centers and ambulatory care clinics, for example—when appropriate. Health Insurance Portability and Accountability Act HIPAA was enacted to facilitate electronic transmission of data between providers and payers while protecting the privacy of patient health information. In protecting patient confidentiality, HIPAA can present certain challenges for providers, such as making it more complicated for a physician to send information about a patient to another physician for a consultation. Regional coordination is based on the seamless delivery of care across multiple provider settings. Patient-specific information must flow freely between these settings—from dispatch to emergency response to hospital care—to ensure that appropriate information will be available for clinical decision making and coordination of services in emergency situations. In addition, retrospective patient-level data are needed to measure the performance of the system and to develop protocols based on outcomes of care across providers. Current interpretations of HIPAA would make it difficult to achieve the required degree of information fluidity. Recommendation Both EMTALA and HIPAA protect patients from potential abuses and serve invaluable purposes. As written and frequently interpreted, however, they can impede the exchange of lifesaving information and hinder the development of regional systems. The committee believes appropriate modifications can be made to both acts that would preserve their original purpose while reducing their adverse impact on the development of regional systems. The committee recommends that the Department of Health and Human Services adopt regulatory changes to the Emergency Medical Treatment and Active Labor Act and the Health Insurance Portability and Accountability

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Emergency Medical Services at the Crossroads Act so that the original goals of the laws will be preserved, but integrated systems can be further developed (3.6). Financing System Costs In addition to the above and other regulatory issues that should be addressed by the federal government, there are outstanding issues related to the financing of the emergency care system. While the establishment of the proposed federal lead agency would help rationalize the federal grant payments allocated to EMS and the emergency care system more broadly, these grants represent a small share of total payments to EMS providers. Payments for EMS are made primarily through public and private insurance reimbursements and local subsidies. A large percentage of EMS transports are for elderly patients, making the federal Medicare program a particularly important payer. EMS costs include the direct costs of each emergency response, as well as the readiness costs associated with maintaining the capability to respond quickly, 24 hours a day, 7 days a week—costs that are not adequately reimbursed by Medicare. In addition, by paying only when a patient is transported, Medicare limits the flexibility of EMS in providing the most appropriate care for each patient. Therefore, the committee recommends that the Centers for Medicare and Medicaid Services convene an ad hoc working group with expertise in emergency care, trauma, and emergency medical services systems to evaluate the reimbursement of emergency medical services and make recommendations with regard to including readiness costs and permitting payment without transport (3.7). A key objective of this working group would be to develop a strategy and a mechanism to ensure that federal, state, and local governments each would pay a fair share toward maintaining EMS readiness capacity. The working group would examine the role played by the Medicare and Medicaid programs in establishing a basic level of EMS readiness across the country and assess the extent to which local self-determination should be the basis for deciding whether to extend service beyond this level. In addition, the working group would consider whether pay-for-performance principles should be applied to EMS. Finally, the group would examine the costs and burden sharing required for local EMS systems to make needed upgrades in communications and information technology. 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 indi-

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Emergency Medical Services at the Crossroads viduals 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: Congress should establish a demonstration program, administered by the Health Resources and Services Administration, to promote coordinated, regionalized, and accountable emergency and trauma care systems throughout the country, and appropriate $88 million over 5 years to this program. 3.5: Congress should establish a lead agency for emergency and trauma care within 2 years of the release of this report. This 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 design and monitor the transition to its assumption of the responsibilities outlined above. The working group should include representatives from federal and state agencies and professional disciplines involved in emergency and trauma care. 3.6: 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.

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