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. (p. 20)


Accountability is perhaps the most important of the three goals envisioned by the committee because it is necessary to achieving the other two. Lack of accountability has contributed to the failure of the emergency care system to adopt these changes in the past. Without accountability, participants in the system need not accept responsibility for failures and can avoid making changes necessary to improve the delivery of care.

Accountability is difficult to establish in emergency care because responsibility is dispersed across many different components of the system; thus it is difficult even for policy makers to determine where system breakdowns occur and how they can subsequently be addressed. When hospitals lack transfer agreements, when providers receive no continuing pediatric education, and when pediatric specialists and on-call specialists are not available, no one party is to blame—it is a system failure. Ambulance diversion is another good example. When a city recognizes it has an unacceptably high frequency of diversion, whom should it hold accountable? EMS can blame the hospitals for crowding and excessively long off-loading times; hospitals can blame the on-call specialists or the discharge sites that are unwilling to take additional referrals; and both can blame the state public health department for inadequate funding of community-based alternatives or community physicians for excessive referrals of their patients to the ED.

The unpredictable and infrequent nature of emergency care contributes to the lack of accountability. Most people have limited exposure to the emergency care system—an ambulance call or a visit to the ED is a rare event. Therefore, the performance of the system is generally not in the forefront of public awareness. Further, public awareness is hindered by the lack of nationally defined indicators of system performance. Few localities can answer basic questions about their emergency care services, such as how well 9-1-1, dispatch, prehospital EMS, hospital emergency and trauma care, and other components of the system perform and how their performance compares with that in other regions and the rest of the nation. Consequently, few understand the present crisis facing the system. By and large, the public assumes that the system functions better than it actually does (Harris Interactive, 2004).

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